Intramuscular Injection Site Injuries Masquerading As Pressure Ulcers
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Presentation
Case 1. A 47-year-old Caucasian woman was referred to the author’s facility for the treatment of “bed sores.” Five months prior to being seen at the author’s facility, the patient suffered a fracture of the right hip, which was treated with a hip prosthesis. Postoperatively, she developed a small area of skin breakdown on the right posterio-lateral buttock area. Hospital records showed that this was a stage 1 pressure ulceration of the right hip. It was treated with moist wound care and healed. Despite healing of the skin, the area of the breakdown continued to be painful and hard. Examination showed an area of induration of the right buttock at the site of the previous skin disruption. The hardness was at least 2cm below the surface of the skin. There was no overlying skin defect. No redness of the skin or other problems were noted. Magnetic resonance imaging (MRI) scan was interpreted as showing an abscess in the subcutaneous tissues of the right buttock just to the right of the midline (Figure 1). There was evidence of surrounding edema. Extending superiorly from the lesion was a track that involved the posterior medial aspect of the gluteus maximus and the posterior right sacrum. These findings were suspicious for a right gluteal abscess and osteomyelitis of the sacrum. A bone scan showed only mild increased activity in the right sacrum; this activity was not intense enough to be osteomyelitis but suggested a low-grade infection. The patient had a diagnostic aspiration of the mass. No abscess was found, and cultures were negative. The patient was treated with antibiotic medication and had some relief of her symptoms. As soon as the antibiotic medication was stopped, the discomfort recurred and the subcutaneous mass enlarged to 4cm in diameter.
Case 2. An 81-year-old Caucasian woman with multiple medical problems was referred to the author’s clinic for treatment of a “pressure ulcer” of her right presacral area, which had been present for nearly four months. Home health nurses had been treating the ulcer with hydrogel dressings. At the time of the author’s evaluation, the patient had a painful stage 4 ulceration of the right ileal area that was 5cm in diameter and full of necrotic tissue (Figure 2).
Case 3. A 57-year-old Caucasian woman came to the author’s clinic for treatment of an abscess of her right iliac fossa area. Over the years she had developed multiple “hard knots” on her hips, which were occasionally painful and would drain pus. The patient noted that, at times, one of the areas would open and a hard “rock” would come out after which the area would become less tender. Examination showed that the patient had multiple areas of subcutaneous calcification on both lateral hip areas. There was a subcutaneous abscess on the right hip with a surrounding area of cellulitis (Figures 3A and B).
Diagnosis
Case 1. A review of the patient’s hospital record at the time of her hip operation revealed that she had received an intramuscular (IM) injection of promethazine in the right buttock area in the postoperative period for symptoms of nausea.
Case 2. On close questioning of the patient, it was discovered that the “ulcer” had occurred at the site of an IM injection of an antibiotic she had received for treatment of cellulitis of her right leg. The type of antibiotic and the dosage were not known.
Case 3. The patient related that she had severe migraine headaches thirty years previously at the time of a family disaster. She had been treated by her physician with multiple IM injections of pentazocine. These had been given repeatedly at the site of the current problem.
Diagnosis. Each patient was diagnosed as having complications due to IM injections of medication.
Discussion
Universal symbols frequently associated with physicians are the stethoscope and the hypodermic syringe and needle.
References
1. Howard-Jones N. A critical study of the origins and development of hypodermic medication. J History Med 1947;2:201–49.
2. Howard-Jones N. The origins of hypodermic medication. Scientific American 1971;224:96–102.
3. Greenblatt D, Divoll-Allen M. Intramuscular injection-site complications. JAMA 1978;240(6):542–44.
4. Hay J. Complications at site of injection of depot neuroleptics. BMJ 1995;311:421.
5. Hanson D. Intramuscular injection injuries and complications. GP 1963;27:109–15.
6. Robb D, Kanji Z. Comparison of two needle sizes for subcutaneous administration of Enoxaparin: Effects on size of hematomas and pain on injection. Pharmacotherapy 2002;22(9):1105–9
7. Williams AW, Montgomery GL. Chemical injury of arteries. J Pathol 1959;77:63.
8. Gaspar MR. Acute arterial lesions due to drug abuse. In: Haimovici H (ed.). Vascular Emergencies. New York, NY: Appleton-Century-Crofts, 1982;241–50.
9. Gammel JA. Arterial embolism: An unusual complication following the intramuscular administration of bismuth. JAMA 1927;88:998–1000.
10. Knowles J. Accidental intra-arterial injection of penicillin. Amer J Dis Child 1966;111:552–6.
11. Kolb LC, Gray SJ. Peripheral neuritis as a complication of penicillin therapy. JAMA 1946;132:323–6.
12. Broadbent TR, Odom GL, Woodall B. Peripheral nerve injuries from administration of penicillin. JAMA 1949;140:1008–10.
13. McKain CW, Urban BJ. Pain and cluneal neuropathy following intragluteal injection. Anesth Analg 1978;57:138–41.
14. Clark K, Williams P, Willis W. Injection injury of the sciatic nerve. Clin Neurosurg 1969;17:111–24.
15. Brown B. Sciatic injection neuropathy. Calif Med 1972;116:13–6.
16. Napiontek M, Ruszkowski K. Paralytic drop foot and gluteal fibrosis after intramuscular injection. J Bone Joint Surg (Br) 1993;75(1):83–5.
17. Jain JK, Markowitz A, Khilanani PV, Lauter CB. Localized mucormycosis following intramuscular corticosteroid: Case report and review of the literature. Am J Med Sciences 1978;275(2):209–16.
18. Waisbren BA, Smith MD. Hypersensitivity to Meperidine. JAMA 1978;239(14):1395.
19. Zelman S. Abscesses from parenteral injection. JAMA 1978;240(1):23.
20. Svendsen O. Intramuscular injections and muscle damage: effects of concentration, volume, injection speed, and vehicle. Arch Toxicol 1984; 7:472–5.
21. Steiness C, Svendsen O, Rasmussen F, Nielsen P. Prediction of local damage after intramuscular injection. Drug Design and Adverse Reactions. Alfred Benzen Symposium X. Munksgaard, Copenhagen, 1977.
22. Steiness E, Rasmussen F, Svendsen O, Nielsen P. A comparative study of serum creatine phosphokinase (CPK) activity in rabbits, pigs, and humans after intramuscular injection of local damaging drugs. Acta Pharmacology 1978.
23. Donkersgoed JV. Injection site scars. Canadian Cattlemen’s Association. Accessed at www.cattle.ca/business/qsh/pdffiles/injsitescarsfactsheet.pdf. Accessed May, 2000.
24. Indong O, Smith J, Spencer G, et al. Fibrous contracture of muscles following intramuscular injections in adults. Clinical Orthop 1977;127:214–9.
25. Hang YS, Miller JW. Abduction contracture of the shoulder. Acta Orthop Scand 1978;49:154–5.
26. Cozen LN. Pentazocine injections as a causative factor in dislocation of the shoulder. J Bone Joint Surg 1977;59A:7.
27. Brodersen M. Deltoid fibrosis. Accessed at: www.emedicine.com/orthoped/topic481.htm. Accessed June, 2002.
28. Chen SS, Chien Ch, Yu HS. Syndrome of deltoid and/or gluteal fibrotic contracture: and injection myopathy. Acta Neurol Scand 1988;78(3):167–76.
29. McCloskey JR, Chung SM. Quadriceps contracture as a result of multiple intramuscular injections. Am J Dis Child 1977;131:416–7.
30. Gunn DR. Contracture of the quadriceps muscle. J Bone Joint Surg 1964;46B:492–7.
31. Loyd-Roberts GC. The etiology of quadriceps contracture in children. 1964;46B:498–502.
32. Lee JH, Girffiths WJ, Bottomley RH. Extraosseous osteogenic sarcoma following an intramuscular injection. Cancer 1977;40(6):3097–101.
33. Weinbren K, Salm R, Greenberg G. Intramuscular injections of iron compounds and oncogenesis in man. BMJ 1978;1(6114):683–5.
I had surgery over 3 weeks ago for a ruptured implant. The surgery went fine. I got an injection of phenergan in the recovery room for nausea and the nurse jabbed me in the lower part of my thigh. The next day or so I noticed an extremely numb area in my thigh. Over the next few days and weeks my entire thigh from my knee up to about a hand's length from my hip bone, my thigh is burning. There is ONE spot where it feels like there is a pin inside! I know there's not but that's what it feels like. Below the skin on my entire thigh it is hyper-sensitive. I thought I might have had a blood clot so I went to the ER and they did a sonogram-no blood clot. The doc there put me on neurontin and I've been taking advil but nothing is helping. My plastic surgeon doesn't believe me when I told him they jabbed me in the lower thigh (I called the hospital-they said they gave me an injection in the thigh but, of course, they're not going to admit that they didn't give it in the right place) so he won't help. I am trying to get into my internist or my neurologist...I can't see either of them until the end of the month. I wonder if there is any danger in waiting? Nothing looks odd on my skin but, right underneath the skin, it feels like it's on fire...ugh....SO frustrating. It feels like she injected acid into my thigh...I can do weight bearing exercises and bicycle but it's very uncomfortable to walk and, by the end of the day, I'm limping. I fell the other day too. I'm really worried about my leg...
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