Intramuscular injections and a missed opportunityTalenie de BruynSeptember 2012

Clinical case• 15 yr old netball player• Presents pain over left buttock with decreased movement in

left leg due to pain• Presented on Wednesday• Had Voltaren imi on Monday, Tuesday x 2 and Wednesday

morning before presenting to enable participation in tournament

• Injections given by assistant coach• Pain only increased• Took Myprodol in between injections to alleviate pain and

discomfort• No known chronic diseases• Invited to Free State U/18 netball trials the following week

Examination

• Overall healthy• Antalgic gait – favouring the left leg• Tender over gluteus medius and piriformis• Haematoma lateral aspect left buttock• Haematoma lateral aspect right buttock• Haematoma medial-inferior aspect left buttock• Haematoma middle of right buttock• 1+ oedema lower limbs• Urine test 1+ protein and 2+ blood• Pain with extension and adduction of hip

Special investigations

• Advised to have UK+E done• Pt did not go for blood tests

3 Stage assessment

• Biological: multiple haematomas on buttocks

probable kidney involvement

repetitive gluteus injuries

• Psychological: will miss FS netball trials due to injuries and Voltaren overuse – decreased self confidence

• Social: pressure from mother and coach to compete despite

injuriessocial standing dependant on netball performanceSelf image reliant on netball performance

Differential diagnosis

1. Repetitive muscle strain

2. Muscle damage due to injections

3. Kidney compromise by high dose anti-inflammatories

4. Nicolau syndrome

Diagnosis

• Muscle strain gluteus medius• Haematoma gluteus muscles• Kidney involvement not proven

Problem list

• Active:Gluteus injury – old and neglected Haematomas both buttocksProbable kidney function deterioration

• Passive: Performance pressure from mother and coachSelf image build on netball identityLack of knowledge re management of muscle

injuries

Discussion

• NSAID’s provide analgesic, antipyretic and anti-inflammatory relief

• Available OTC• Lay persons expect some gastric side effects but little

else• Adverse reactions include: GIT bleeds/ulcers, blood

dyscrasias, allergic reactions, liver function changes and nephrotoxicity

• Nephrotoxicity especially in states of fluid depletion

( Nakahura et al, 1998)

•

Discussion (2)• Mechanism of action NSAID’s:Inhibit COX 1 and 2 with inhibition of PG synthesis from

arachidonic acidInhibits migration, aggregation and neutrophile and

macrophage functionsInhibits COX 2 which locally is overexpressed in inflammation

– PG synthesis from this supports lesional processAlters natural healing process

( Ziltener, Leal and Fournier, 2010)

Nephrotoxicity • reduced renal perfusion as seen in various forms of cardio-

renal disease, dehydration, and the aging kidney• the adequacy of renal prostaglandin production mediated

predominantly by cyclooxygenase-1 (COX-1) and, potentially, by COX-2 enzyme activity becomes of major significance in the activation of compensatory renal hemodynamics.

• Inhibition of renal prostaglandin production by the use of NSAIDs in these circumstances can potentially lead to the emergence of several distinct syndromes of disturbed renal function: fluid and electrolyte disorders, acute renal dysfunction, nephrotic syndrome/ interstitial nephritis, and renal papillary necrosis.

• blunting the homeostatic renal effects of prostaglandins, NSAIDs can adversely influence blood pressure control, particularly during the use of angiotensin-converting enzyme (ACE) inhibitors, diuretics, and Beta-blockers.

• (Whelton, 1999)

Discussion (3)

• NSAID’s should be used lowest possible dose for shortest period just to alleviate pain

• Prevent long term side effects on kidneys, GIT and repair of ligamentous and muscular injury

• Parental vs oral administration more systemic toxicity (Ziltener, Leal and Fournier, 2010)

Discussion (4)

• This case study focusses on intra muscular injections

• Muscle subjected to trauma with weakening of muscle fibres

• Creates inflammatory process in muscle fibres • Detrimental effect cell regeneration phase• Inhibit extracellular matrix synthesis with decreased

collagen turnover and muscle regeneration• Increases fibrosis at injured site (Brukner and Khan,

2012)

Discussion (5)• Important that imi injections be given correctly• If intradermal or subcutaneous decreased drug

absorption and greater possibility of local complications• WHO determines skin must be stretched flat between

fingers and needle injected at 90 angle on ⁰superolateral aspect of buttock

• Aspiration must be done to determine whether blood vessel was punctured

• Needle inserted to hilt• Buttocks various amounts of fat which determines

whether injected in subcutaneous fat or intra muscularly

Correct injection site

Discussion (6)

• Study by Chan et al in 2006 using a 30mm 23G needle followed by CT scan determined the following:

32% intramuscularly68 % subcutaneous fatSubcutaneous fat injections lead to higher incidence

of abscesses and granulomas

True imi injection

Subcutaneous injection

Discussion (7)• People not trained to inject people may inadvertently inject into

a bloodvessel• Can lead to tissue necrosis 2 to damage to an end-artery with ⁰

resultant massive inflammation• Starts as intense pain and pallor at site• Then erythema evolves into livedoid bluish reticular patch• Becomes haemorrhagic and then necrotic• Complications: neurological injury, extensive necrosis, limb

ischaemia, sepsis sometimes resulting in death• Nicolau syndrome: livedo-like dermatitis or embolia cutis

medicamentosa• Clinical improvement with anticoagulation therapy, intravenous

steroids and vaso-active therapy (Uri and Arad, 2008)

Nicolau syndrome

Skin ulcer secondary to incorrect injection technique

Gluteal injection site granulomas

Subcutaneous abscess

Management

• Advise regarding NSAID use• Avoidance of intramuscular injections during sport

tournaments and by persons not trained to give imi• POLICE • Increased fluid intake during sporting events• Rehabilitation of gluteus muscle group after

recovery of injury• Monitor kidney function and increase fluid intake

Prognosis

• If she follows recuperation plan and avoids further NSAID use: good prognosis

• Attitude of mother and coach makes this highly unlikely

• If continues to play and use NSAIDs indiscriminately: kidney failure and severe muscular injury

Importance

• Most pts only aware of possible GIT side effects• Little known in lay population about nephrotoxicity

an impact on healing processes• Our responsibility to educate people and colleagues

regarding these issues

References 1. Brukner and Khan. Clinical sports medicine. 4th edition.

McGraw and Hill. Sydney. 2012.2. Chan, V.O., Colville, J. et al. Intramuscular injections into the

buttocks: Are they truly intramuscular? European journal of radiology. Vol 58. 2006. Elsevier. p.480- 484.

3. Nakahura, T. et al. Nonsteroidal Anti inflammatory drug use in adolescence. Journal of adolescent health. Vol 23. 1998. p 307 – 310.

4. Uri and Arad. Skin necrosis after self-administered intramuscular diclofenac. Journal of plastic, reconstructive and aesthetic surgery. 2010:63, e4-5.

5. Whelton, A. Nephrotoxicity and NSAIDs: Physiological foundation and clinical implications. American journal of medicine. Vol 106. 1999. p 13S – 24S.

6. Ziltener, J.L., Leal,S. Fournier, P.E. Non-steroidal anti-inflammatory drugs for athletes: An update. Annals for physical and rehabilitation medicine. Vol 53. 2010. Elsevier Masson. p 278-288.