The intramuscular injections are the most common cause leading to fibrosis of quadriceps in developing countries, also in Cambodia, the injections are applied most health care providers in the country. The complications are not exceptional.

1. Treatment of Quadriceps Fibrosis
After Intramuscular Injections
1
HENG Sophea and al.
National Pediatric Hospital
Department of Surgery
2015
21st Annual Conference of Cambodian Society of Surgery

2. Intramuscular Injections
HengS,SCC Pediatric Surgery
Conference2015
2

3. Outline
I. Introduction
II. Materials et Methods
III. Discussion
IV. Conclusion and recommendation
HengS,SCC Pediatric Surgery
Conference2015
3

4. I- INTRODUCTION
 Quadriceps fibrosis after injections
 Myofibrosis to the quadriceps muscles,
 resulting from fibrofatty replacement of
the quadriceps muscles
 iatrogenic sequelae of multiple/repeated
injections.
4HengS,SCC Pediatric Surgery
Conference2015

5.  Fibrosis of the quadriceps is found among
the child after intramuscular injections of
the drug products
 In the treatment of pathologies among
infants and small children.
 By the staffs of health insufficiently form,
or by inadequate/unsafe technique.
 Incidence : fairly frequent in tropical
area: in Africa, in Asia
5HengS,SCC Pediatric Surgery
Conference2015

6.  In Cambodia,
 Incidence : unknown
 the practice of intramuscular injections is
frequently carried out everywhere at once in
the public hospital and at the same time in the
private clinic.
 The World Health Organization (WHO,2007)
estimates that of the 12 billion injections
administered worldwide annually,
 50% are unsafe and
 75% are unneccessary.
6Journal of Medicine and Rehabilitation; Vol 1, No 1, May/June 2007

7. II- MATERIELS - METHODS
 Retrospective studies
 Surgical department, National Pediatric Hospital
 Duration of Study : Jan 2009 – October 2015
 141 patients (200 cases) admitted
 with quadriceps fibrosis after intra-muscular injections,
 characterized by progressive limited flexion of knee
 Age : 24 month – 18 years old.
7HengS,SCC Pediatric Surgery
Conference2015

8. Objectives
 Analyzing retrospectively the results of
quadriceps fibrosis after intramuscular
injections, diagnosed and treated in our
surgical department, NPH
 Alert to health staffs in order to know its
complications and reduce drug usage in
this way.
8HengS,SCC Pediatric Surgery
Conference2015

9.  Inclusion Criteria
 Limited knee flexion after intramuscular
injections
 Patients treated by surgical release, with
regularly follow-up.
 Exclusion Criteria
 Limited knee flexion secondary to other
causes (congenital, syndromic)
 Sciatic paralysis secondary to intramuscular
injections.
9HengS,SCC Pediatric Surgery
Conference2015

10. Criteria for Diagnosis
 History
 Repeated intramuscular injections
 Timing after injections : many months to many
years,
 progressive development of limited flexion.
 Physical Exam
 Painless gait
 Hypotrophy of affected thigh
 Limited knee flexion (in prone position) +++
10HengS,SCC Pediatric Surgery
Conference2015

11. 11
Results
HengS,SCC Pediatric Surgery
Conference2015
Female
85
60%
Male
56
40%
Distributing Chart of Sex
(n=141)
Female
Male

12. Distributing Chart of Affected
Knee
12HengS,SCC Pediatric Surgery
Conference2015
50
35%
32
23%
59
42%
Distributing Chart of Affected Knee
(n=200)
Left
Right
Bilateral

13. Geographic Distributing Chart
13HengS,SCC Pediatric Surgery
Conference2015
25 25
22
19 18
14
4 4 3 3 2 20
5
10
15
20
25
30
PATIENTS
CITY - PROVINCE
GEOGRAPHIC DISTRIBUTING CHART
(N=141)

14. 14HengS,SCC Pediatric Surgery
Conference2015
The Degree of Knee Flexion
(Pre-op)

15. 15HengS,SCC Pediatric Surgery
Conference2015

16. The Degree of Knee Flexion
(Pre-op)
16HengS,SCC Pediatric Surgery
Conference2015
36
18%
100
50%
55
27%
9
5%
Distributing Chart of Degree of Knee Flexion
(n=200)
0-20
21-50
51-90
91-120

17. Treatment
 All patients : 200 cases
 Treated at our surgical
department
 By surgical release
 Operative procedures :
 Percutaneous
tenotomy
 V-Y quadriceps
lengthening
 Z quadricepsplasty
 Followed by casting with
knee flexion 90*
 Percutaneous
tenotomy : for 10-15
days
 V-Y or Z plasty : 3
weeks.
 Rehabilitation : early
after removal of cast
HengS,SCC Pediatric Surgery
Conference2015
17

18. Operative Procedures
18HengS,SCC Pediatric Surgery
Conference2015
37
18%
1
1%
162
81%
Distributing Chart of Operative Procedures
(n=200)
V-Y Plasty
Z-Plasty
Percutaneous
Tenotomy

19. Evaluation of Results
19HengS,SCC Pediatric Surgery
Conference2015
4
2%
14
7%
182
91%
Distributing Chart of Knee Flexion at Final
Follow-up (n=200)
Fair <90
Satisfactory 90-120
Good >120

20. Complications
(Final results)
20HengS,SCC Pediatric Surgery
Conference2015
10
12
1
3
6 5
2
0
2
4
6
8
10
12
14
Patients
Complications
Distributing Chart of Complications
(n=200)

21. Case N*1
 V.S, 7y/F, Kratia
 Gradually limited left knee flexion
 History : repeated IM injections, started
since 3 years before admission
 Flexion of left knee : 60*
 Treatment : Percutaneous tenotomy
21HengS,SCC Pediatric Surgery
Conference2015

22. 22HengS,SCC Pediatric Surgery
Conference2015
Fibrofatty Tissue Fibrofatty Tissue
Percutaneous TenotomyLimited Knee flexion (60*)

23. 23HengS,SCC Pediatric Surgery
Conference2015
Percutanous Tenotomy Good result in final FU

24. Case N*2
 SP, 5y/F, Kg Chhnang
 Progressive limited flexion of right knee : 0-5*
 Painless knee, elevated patella
 History : repeated injections since infant
 Medications : unknown, by physician at
province
 Reasons : respiratory infections, diarrhea
 Treated by «V-Y» quadriceps lengthening
 Result 1 year after surgery
 Flexion 125°- 130*
 Large scar. 24HengS,SCC Pediatric Surgery
Conference2015

25. 25
Elevated PatellaKnee Stiffness in ExtensionHengS,SCC Pediatric Surgery
Conference2015

26. 26
V-Y quadriceps plasty
Casting with knee flexion 90*
Good result at final FUHengS,SCC Pediatric Surgery
Conference2015

27. Case N*3  PN, 10y/M, Kandal
 R-quadriceps fibrosis (F=50*)
 History : repeated injections
 Treated by percutaneous
tenotomy, followed by
rehabilitation.
 Result : complete flexion
27HengS,SCC Pediatric Surgery
Conference2015

28. III- DISCUSSION
1. Discussion – Diagnosis
Late
Due to unrecognized the disease by
physician and also patients
Neglected management due to
unrecongnized center to care this
problem
Socio-economic conditions
28HengS,SCC Pediatric Surgery
Conference2015

29.  Frequency
IM injections carried out everywhere at once
in the public hospital and at the same time in
the private clinic.
Habit, easily way for children.
Lack of education focus on its complications.
 Drug products
Mostly in studied series in Africa : quinine and
antibiotics
Our series, difficult to precise exactly : AB,
antipyretic, analgesic, Vit K, ascorbic acid,
unknown drugs. 29HengS,SCC Pediatric Surgery
Conference2015

30. 2. Discussion – Methods of treatment
 Physiotherapy :
Early stage but still incertain and
ineffective
Some patients started with physiotherapy,
finally require a surgical release.
 Surgical release followed by
rehabilitation to get :
Better ROM
Muscle strength.
30HengS,SCC Pediatric Surgery
Conference2015

31. 3. Discussion – Operative
procedures
 Indications
 Mild/moderate contracture :
percutaneous tenotomy
 Severe contracture : V-Y or Z plasty or
Judet’s quadriceps release
31HengS,SCC Pediatric Surgery
Conference2015

32.  Hematoma (1.5%)
 Extensive release
 Lack of hemostasis
 Fractures (1%)
 Excessive passive
mobilization of knee
32
4. Discussion – Complications
HengS,SCC Pediatric Surgery
Conference2015

33.  Infection : (0.5%)
 Less chance to get infection : respect asepsis
in OT.
 Residual contracture (3%):
 Severe cases
 Lack of physiotherapy
 Lack of follow-up
 Require secondary release
33HengS,SCC Pediatric Surgery
Conference2015

34.  Hypertrophic scar (5%) and wound
break (6%)
 Severe case with limited flexion < 20 degree
 Treated by V-Y quadriceps lengthening
 2 cases require skin graft and 1 for flap
34HengS,SCC Pediatric Surgery
Conference2015

35. IV- CONCLUSION -
RECOMMENDATION
 Intramuscular injection is a widespread drug use,
which can be serious consequences, called iatrogenic
complications.
 It could cause a stiffness of the knee in extension
installing aesthetic and functional problem, motor
disability.
 The surgery followed by an early rehabilitation
remains the most effective method to restore the
function of the knee.
35HengS,SCC Pediatric Surgery
Conference2015

36.  A public health issue and preventable.
 From this day, we recommend
 Help to share the knowledge about quadriceps
fibrosis and it complications to all health
officers,
 Improve the way how to diagnose,
 A alternative systematic use of forms (oral,
rectal and intravenous), to avoid such a long
life iatrogenic impairment complications.
36HengS,SCC Pediatric Surgery
Conference2015

37. REFERENCES
1. Onimus M, Brunet L, Gaudeuille A, Issa Mapouka A- Le traitement des séquelles
d'injections intramusculaires de sels de quinine en milieu africain. Med Trop,
2007; 67: 267-273.
2. Soumah ML, Sylla AI, Toure MR, Camara T, Kama T, Kma ML, Diallo MB, Cisse A –
Fibrose du quadriceps : Séquelles d’injection intramusculaires de la cuisse, à
propos de 92 cas au CHU IGNACE DEEN DE CONAKRY. Med Trop 2003 ; 63 : 49-52.
3. Pradip k. Mukherjee,M.S.(Cal.) and A.K.Das, FRCS., MB.,FRCSE, West Bengal, India
- Injection fibrosis in the quadriceps femoris muscle in children. JBJS, april 1980;
vol.62-A, 4 : 453-456.
4. EZEUKWU AO INJECTION-INDUCED SCIATIC NERVE INJURY AMONG CHILDREN
MANAGED IN A NIGERIAN PHYSIOTHERAPY CLINIC: A FIVE-YEAR REVIEW, Journal
of Medicine and Rehabilitation; Vol 1, No 1, May/June 2007.
5. PK Mukherjee and AK Das - Injection fibrosis in the quadriceps femoris muscle in
children, J Bone Joint Surg Am. 1980;62:453-456.
6. EV Alvarez, M Munters, LS Lavine, H Manes and J Waxman - Quadriceps
myofibrosis. A complication of intramuscular injections, J Bone Joint Surg Am.
1980;62:58-60.
37

38. អរគុណ - សំណួ រ
38HengS,SCC Pediatric Surgery
Conference2015

39. រួមគ្នា ដ ើមបីដោគជ័យ និងការរ ីកចំដរ ីន !
39
Thank All of You
HengS,SCC Pediatric Surgery
Conference2015