A  CAJM  journal article.Objectives: A retrospective study of all children with a diagnosis of sciatic nerve injury managed at the University College Hospital, Ibadan, Nigeria over a 12 year period was carried out in order to determine predisposing factors to the nerve injury and highlighting practical preventive measures.
Design: The necessary data was collected from the case files of children seen at the hospital with a diagnosis of sciatic nerve injury, from 1988 to 1999.
Results: There were 27 children aged five months to 12 years with a diagnosis of sciatic nerve injury. Twenty (74%) of the children were aged five years or less. While seven patients (26%) presented within two weeks of development of foot drop consequent on intramuscular (IM) injection given on the buttock, 20 patients (74%) presented much later. Fever was the most common complaint for which the injection had been given. The identity of the drugs given was not known in 10 patients. In the remaining 17 patients drugs administered were specified and included Chloroquine,Novalgin, Paraldehyde, Procaine penicillin, and Sulfadoxine- Pyrimethamine. Most of the patients had received the injections in privately owned medical facilities where staff with minimal training are often allowed to administer IM injections.
Conclusion: It is suggested that the IM route for injection be strongly discouraged when a drug can be given by other routes. Only trained staff should be allowed to administer IM injections. Giving IM injections at sites other than the buttock maybe advantageous in children particularly those aged five years and below

Familusi, J.B.

Fatunde, O.J.

Central African Journal of Medicine

English

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Injection-induced sciatic nerve injury in Nigerian children
OJ FATUNDE, JB FAMILUSI
Abstract
Objectives: A retrospective study of all children with a diagnosis of sciatic nerve injury managed at the 
University College Hospital, Ibadan, Nigeria over a 12 year period was carried out in order to determine 
predisposing factors to the nerve injury and highlighting practical preventive measures.
Design: The necessary data was collected from the case files of children seen at the hospital with a diagnosis 
of sciatic nerve injury, from 1988 to 1999.
Results: There were 27 children aged five months to 12 years with a diagnosis of sciatic nerve injury. Twenty 
(74%) of the children were aged five years or less. While seven patients (26%) presented within two weeks 
of development of foot drop consequent on intramuscular (IM) injection given on the buttock, 20 patients 
(74%) presented much later. Fever was the most common complaint for which the injection had been given. 
The identity of the drugs given was not known in 10 patients. In the remaining 17 patients drugs administered 
were specified and included Chloroquine,Novalgin, Paraldehyde, Procaine penicillin, and Sulfadoxine- 
Pyrimethamine. Most of the patients had received the injections in privately owned medical facilities where 
staff with minimal training are often allowed to administer IM injections.
Conclusion: It is suggested that the IM route for injection be strongly discouraged when a drug can be given 
by other routes. Only trained staff should be allowed to administer IM injections. Giving IM injections at sites 
other than the buttock maybe advantageous in children particularly those aged five years and below.
Cent A frJ  Med 2001;47(2):35-8
Introduction
The sciatic nerve (roots L4,5,S1,2,3) enters the gluteal 
region through the lower part of the greater sciatic foramen 
and transverses the buttock under cover of the gluteus 
maximus in the interval between the greater trochanter of 
the femur and the tuberosity of the ischium. It ends half 
way down the back of the thigh by dividing into two 
branches — the common peroneal nerve which is lateral 
and the tibial nerve, which is medial.1 It is recommended 
that intramuscular (IM) injections into the buttock be
placed in the upper outer quadrant, so as to avoid the sciatic 
nerve.2 If the injection is given more medially than 
recommended or in the rare case of a sciatic nerve that is 
more laterally placed than usual, the sciatic nerve may be 
injured. Such injury mostly affects the more lateral fibres 
of the nerve, which are destined to form the common 
peroneal nerve in the thigh. The injury, therefore, produces 
a peroneal nerve palsy (foot drop)3 with or without sensory 
impairment.4'6 Injury to the sciatic nerve consequent on 
misplaced IM injection into the buttock should be rare 
when properly trained personnel administer such an
Department of Paediatrics 
University College Hospital 
Ibadan, Nigeria 
Correspondence to:
Dr OJ Fatunde 
Department o f Paediatrics 
University College Hospital 
Ibadan, Nigeria 
email: fat@skannet. com
Cent AfrJ Med 2001;47(2) 35
injection. We have noted at our centre however, that such 
injury to the sciatic nerve is not uncommon and in most 
cases could have been avoided. We report here on 27 cases 
of sciatic nerve injury encountered in children admitted to 
paediatric wards or seen in the paediatric neurology clinic 
of the University College Hospital Ibadan, Nigeria, during 
an 11 year period. Our study objective was to determine the 
predisposing factors to the nerve injury, and highlight 
practical preventive measures.
Materials and Methods
The records of all patients with a diagnosis of sciatic nerve 
injury admitted to the paediatric wards or seen in the 
paediatric neurology clinic of the University College 
Hospital (UCH), Ibadan, Nigeria during the period 1988 to 
1999 were reviewed. Note was taken of the age and sex of 
the patient at presentation, the presenting complaints, 
nature and site of the injection given, interval between 
injection administration and hospital presentation, findings 
on neurological examination, as well as the eventual 
outcome on follow up. Patients included in the study were 
mostly those that developed limb weakness and foot drop 
within hours (maximum 24 hours) of administration of an 
injection into the buttock. Two patients were neonates who 
were noted to have impaired dorsiflexion of the foot 
following discharge form the neonatal ward. Patients in 
whom there was a significant possibility of another 
diagnosis especially that of paralytic poliomyelitis were 
excluded form the study. All the patients were referred for 
physical therapy after the initial evaluation.
Results
There were a total of 27 children in the study; 16 males and 
11 females, giving a male: female ratio of 1.5:1. The ages 
ranged from five months to 12 years with a mean of 4.1 
years. Twenty of the patients (74%) were aged five years 
or less while seven were over five years old. The complaints 
for which IM injection had been given were stated as fever 
in 20patients(74%), fever and seizures in two patients and 
other complaints such as bone pains, respiratory distress, 
neonatal sepsis and prematurity in the remaining patients. 
The medications injected into the buttock were not known 
in 10 patients. In the other 17 patients, chloroquine was 
implicated in seven cases (41%), Novalgin in seven cases 
(41%), Paraldehyde in two cases (12%) and other drugs 
such as procaine penicillin and Sulfadoxine-pyrimethamine. 
Some patients received more than one medication.
The IM injection had been given into the buttock on the 
same side as that of the foot drop in 15 cases (56%), in both 
buttocks in seven cases (26%),while the side was not 
specified in five cases (19%). As shown in Table II, 12 of 
the patients (44%) had received their injections at private 
clinics or. hospitals, four patients at unspecified health 
facilities while three patients in each case had their injections 
at state government hospitals and university teaching 
hospitals. Two patients had injections at home given by
nurses living nearby and two others at local government 
maternity centres.
Table I: Intra-muscular medications implicated in 27 
children with sciatic nerve injury.
Medication No. %*
Chloroquine 7 26
Novalgin 7 26
Paraldehyde 2 7
Procaine penicillin 1 4
Others 4 15
Unknown 10 37
*Some patients had more than one medication.
Table II: Health facility where injections were given that 
precipitated sciatic nerve injury in 27 children.
Institutions No. %
Home (Itinerary nurse) 2 7
Local Government Maternity Centre 2 7
Private Hospital 12 44
State Hospital 3 11
Mission Hospital 1 4
University Teaching Hospital 3 11
Not Stated 4 15
Total 27 100
The interval between development of foot drop and 
presentation in hospital ranged between five days and one 
year, with a mean of 60 days. Although only seven patients 
(26%) presented in the early stage within two weeks of 
development of foot drop, 22 patients were seen within two 
months. Table III shows that of those seven seen in the 
early stage, three presented with severe pain of the affected 
limb.
Table III: Presenting symptoms and signs in 27 children 
with sciatic nerve injury.
Signs and 
symptoms
Acute phase (n=7) 
No. (%)
Late phase (n=20) 
No. (%)
Foot drop 7 (100) 20 (100)
Pain 3 (43) 2 (10)
Hyperaesthesia 2 (29) 2 (10)
Sensory loss 2 (29) 3 (15)
Muscle wasting 2 (29) 10 (10)
The affected leg was usually held with the hip and knee 
joints flexed (Figure I). Two patients in each case had 
demonstrable sensory loss, hyperaesthesia and evidence of 
some muscle wasting. Among the 20 patients seen later in 
their illness, three had sensory loss (dorsum of the foot in 
two cases and lateral leg in the other) Figure II. Muscle 
wasting was documented in 10 of these 20 patients (50%). 
The areas of maximal muscle wasting were the thigh in two 
patients, the calf and lower leg in seven others, while the 
area was not specified in one case.
Cent A frJ Med 2001;47(2) 36
Figure I .'Patient with right sided sciatic nerve injury in the 
acute phase, showing foot drop, evidence of pain and 
inability to stand on right leg.
Follow up was poor with only seven patients (26%) 
making further visits to the paediatric neurology clinic 
after the initial diagnosis. The period of follow up in the 
clinic ranged from two weeks to nine months. All the 
patients still had significant foot drop at follow up with a 
little improvement being recorded for one patient seen two 
months after the first visit.
Discussion
Most children in our environment are given IM injections 
at one time or another for fever (anti-malarials, antipyretics); 
seizures (anti-convulsants usually Paraldehyde) or infection 
(antibiotics usually penicillin or streptomycin). In addition, 
routine immunization with Diphtheria/Pertussis/Tetanus 
(DTP) vaccine is given via the IM route. While properly 
placed IM injections in the buttock should not normally 
cause sciatic nerve injury, damage occasionally results, 
especially in infants.7,8 This is why it is recommended that 
IM injections in little children should not be given into the 
buttock until the age of about three years when the child is
Figure [I: Patient with right sciatic nerve injury of several 
months duration, showing mild muscle wasting of right leg, 
foot drop and loss of sensation over shaded area.
walking and the gluteal muscles are well developed.8 In the 
smaller child, alternative sites recommended for IM 
injections include the vastus lateralis, the rectus femoris 
and the deltoid muscles.9 There is very little risk of injury 
to major blood vessels or nerves using these sites. Some of 
the cases reviewed in this study involved children over the 
age of three years although most of them were aged five 
years or less. It would seem as if the danger to the sciatic 
nerve in the child older than three years is still considerable.
All the patients in this review presented v/ith foot drop 
which is a consequence of the weakness of the dorsiflexors 
of the foot which are supplied by the common peroneal 
nerve.1 In addition, some patients reported sensory 
impairment in the first few days following the injection, 
while direct observation of the same was made in two of the 
seven cases that presented within two weeks of the inj ection. 
Aberration of sensation in the form of hyperaesthesia, 
dysaesthesia, hyperalgesia mechanical and thermal 
allodynia following peripheral nerve injury have been 
reported both in human and animal models.4-6 In two of our 
cases, the pain was so severe as to require hospitalisation 
for several days. Suggestions for treating such pain have 
included intrathecal administration of ketamine.10 However, 
our patients improved eventually with the use of the 
common analgesia, paracetamol. Sensory loss was not 
systematically looked for in the patients under, review but 
was recorded in five cases altogether. Areas affected were
the lateral aspect of the leg and/or parts of the dorsum of the 
foot. These are areas supplied by branches of the common 
peroneal nerve. Muscle wasting documented in 12 patients 
also occurred in muscles supplied by the common peroneal 
nerve. The main differential diagnosis of injection- 
associated sciatic nerve injury in our environment, is 
paralytic poliomyelitis. One of the main distinguishing 
factors, however, is that muscle weakness or paralysis in 
poliomyelitis is often very extensive in the early phase, 
often involving the loss of already acquired motor 
milestones. It is on recovery that paralysis may be localized 
to one or more limbs. In addition, although IM injections 
are known to facilitate paralysis in patients with acute 
poliomyelitis infection, such paralysis will not be immediate 
as is noted in that of sciatic nerve injury. Further, disorders 
of sensation already described in traumatic peripheral 
nerve injury, are not associated with paralyticpoliomyelitis. 
Several other patients with a history and physical findings 
suggestive of sciatic nerve injury were encountered during 
this review but such cases were not included in the present 
analysis whenever there was even a remote possibility of 
paralytic poliomyelitis.
Prognosis of sciatic nerve injury depends on the 
magnitude of the trauma inflicted on the nerve.11 In general, 
injection-induced trauma would be expected to carry a 
good prognosis since in most cases; the trauma is probably 
caused by the nearness of a hypertonic solution to the nerve 
rathcr than a direct trauma to the nerve. Sixteen of 21 
neonatal cases reviewed by Ramos Fernandez et aP obtained 
total recovery, with time of recovery ranging from four to 
14 months. Follow up among our patients was poor, most 
of the cases seen in the clinic did not report back for 
subsequent scheduled visits. However, it is noteworthy 
that many patients had had their foot drop for several 
months before presenting in our hospital. This would 
indicate that total recovery (if it occurs) would probably 
take several months. In addition, the late presentation of 
many of our patients with foot drop suggests that there may 
be several more children with less pronounced muscle 
weakness going about the streets without reporting at all to 
a hospital. The problem of sciatic nerve injury is therefore 
probably much bigger than would be suggested by the 
number of patients reviewed in this study.
Most of the patients in this review had IM injections at 
privately owned health institutions. It is well known that 
many such institutions do not employ adequately trained 
nurses and often make use of auxiliary staff whose training 
is often deficient. The use of properly trained staff may be 
expected to reduce the incidence of wrongly placed IM 
injections. The most common condition for which IM 
injections were given to children in this review was fever. 
Where specified, the drug given was mostly chloroquine 
and the same drug was probably administered in the cases 
where specification was not given. Chloroquine is a drug 
that is known to be rapidly effective when given by the oral 
as well as the subcutaneous routes and IM administration 
was probably unnecessary in most of these cases. Also, 
antibiotics administered for presumed infections can usually
be given safely by the oral route. Most of the IM injections 
given to children in this review, therefore, \yere unnecessary 
and the undesirable side effect of sciatic nerve injury could 
have been avoided. Other workers have made the same 
observations about unnecessary IM injections.1'2
It is suggested, in order to reduce the morbidity caused 
by IM injections given to children, that only properly 
trained staff should administer such inj ections. In addition, 
alternative sites such as the vastus lateralis, rectus femoris 
or the deltoid muscles should be used in children at least up 
to the age of five years. Whenever possible, routes other 
than IM (oral, subcutaneous) should be used for the 
administration of drugs in children.
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Cent AfrJ  Med 2001';47(2) 38
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Injection-induced sciatic nerve injury in Nigerian children

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Injection-induced sciatic nerve injury in Nigerian children

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