Uganda Be Kidding Me: Iatrogenic Pediatric Orthopaedic Injuries in Kumi, Uganda

Kristin Alves

Resident in Harvard Combined Orthopaedic Surgery Program

PGY5

Uganda Be Kidding Me: Iatrogenic Pediatric Orthopaedic Injuries in Kumi, Uganda

I began traveling to Uganda in the Fall of 2015 to begin to assess and help address two pediatric orthopaedic disabilities I had never heard of or seen in medical school or during my orthopaedic surgery residency.  My retrospective cohort study in Northeast Uganda in 2015 demonstrated that over 40% of children seen for any musculoskeletal disease in clinic at Kumi Hospital were diagnosed with one of the two disabilities I am working on.

These disabilities are common in Sub-Saharan Africa, and may be increasing in incidence.  We believe that these disabilities are iatrogenic and completely preventable impairments, this burden becomes even more alarming.  So what are these disabilities?  

One of these disabilities is post-injection paralysis (PIP).  Children with PIP suffer an injury to the sciatic nerve and develop loss of motor and sensory function of the sciatic nerve distal to the injection.  There seems to be a number of cases of PIP in Uganda and there is a need for further research.  The strong temporal association with the onset of PIP and the injection leaves the causation up for little debate.  Further research though is needed to understand what injection practices may be contributing to the development of PIP.  There are many factors that may be at play including technique, medication used, health of the patient, etc. 

The other disability is gluteal fibrosis (GF). GF is a fibrotic contracture of the gluteal muscles that cause significant functional limitations with a swinging out of the leg with any hip flexion.  These children for example have their knees go out over 180 degrees apart with attempts at squatting. Such alteration in hip biomechanics for affected children impacts their ability to go to school and to perform ADLs in their homes and communities.  The current hypothesis is that these children develop a buttock abscess after an injection which can then lead to muscle necrosis, fibrosis and gluteal contracture. Interestingly, while PIP patients have been seen throughout the country, GF patients have anecdotally been noted to primarily be seen in northeast Uganda which leads me to believe that an additional exposure is acting as an effect modifier of the injections in this region.

Treatment of GF is surgical resection of the fibrotic contracture while treatment of PIP has a variety of surgical and non-surgical options depending on the clinical presentation.  This large burden of disease that requires surgical management but could likely be prevented has not yet been addressed in Uganda.

This leads me to my current work in Uganda. I am in country to do a qualitative study to try to understand what is causing these two disabilities. This study will cascade into my next case control study to allow for a mixed methods study to assess causation of the disabilities. My study focuses on individuals involved in the administration of injections (physicians, nurses, health care workers, and community practitioners), individuals involved in the preparation of injections (pharmacies and health care staff), and individuals with knowledge of injection practices in Uganda (district health officers).  My study involves key informant and focus group interviewing to attempt to get a better understanding of what may be causing both of these disabilities.

I am currently in Kumi District with my team who are a part of the project including an orthopaedic surgeon, community based outreach health and social worker and research coordinator.

 

While we are getting set up to do the actual study we have gone out into the community to meet with the children suffering from these disabilities  

It’s been a powerful start to what I expect to be a really fruitful month. My month will include not only this research project, but I will also have exposure both clinically and surgically to pediatric orthopaedic diseases seen in Kumi and Kampala, Uganda.  It will be an amazing month with much to report in my next post!