Epidemiology and Treatment of Paediatric Patients with Post-injection Paralysis

Background: Post-injection paralysis (PIP) is paralysis that occurs distally in a limb immediately after an injection is given proximally in the same limb, without any other possible cause for the paralysis. In Uganda, iatrogenic injection injury is a major cause of disability in children as injections are commonly given by trained and untrained providers. Sciatic nerve injury that does not self-resolve, with or without supportive treatment, often results in a chronic foot deformity. This study investigates the epidemiology and treatment of PIP in Uganda, with aims to increase and prevent this debilitating, iatrogenic condition.

Methods: Health records of pediatric patients surgically treated for PIP at one hospital from 2013 to 2018 were retrospectively reviewed. Pre-operative demographics, perioperative management, and outcome were coded and analyzed with descriptive statistics, chi-square for categorical and linear models for continuous variables.

Results: 403 pediatric patients underwent 492 total surgical procedures within a six-year period. On average, patients received the inciting injection at 3.49 years of age. The average age at initial presentation to the hospital was 9.12 years old. There was a widespread geographic distribution of patient hometowns, with 34.24% of all patients living within 40 km from the hospital. 83% of reported injection indications were for febrile illness. 25% of reported injections explicitly stated quinine as the agent. Those who lived further from the facility had longer times between the inciting injection and initial hospital presentation (p=0.0216) and were more likely to be lost to follow-up (p=0.0042). Although 26 different procedure combinations were performed, achilles tendon lengthening, triple arthrodesis, tibialis posterior and anterior tendon transfers composed 83% of all conducted surgeries. Amongst 5 different foot deformities, equinus and varus were most likely to undergo soft tissue and bony procedures, respectively (p=0.0223). 18.6% of patients received two or more surgeries. 67% of patients achieved a plantigrade outcome; 13.61% had not by the end of the study period; 19.3% had unreported outcomes.

Conclusion: Over 490 surgical procedures were performed, emphasizing the immense time and resources allocated to manage this serious, iatrogenic disability that occurs throughout Uganda. In lower-income regions, the commute to healthcare facilities may pose a substantial barrier to care, as evidenced by greater loss of follow-up in patients who lived farther away from the hospital. This study reports that 80% of injection indications were due to febrile illness, supporting prior observations that intramuscular injections are usually recommended for children with febrile illnesses, including malaria. The lack of injection regulation and easy accessibility to injections may further explain the high prevalence of PIP in Uganda. Prevention strategies are imperative, as over 400 children were surgically treated within just six years at one hospital in Uganda.