Jack Ayres, MD
PM&R Resident Physician
Walter Reed National Military Medical Center
Rockville, Maryland, United States
Nicholas Fethiere, MD
Resident Physician
Walter Reed National Military Medical Center
Washington, District of Columbia, United States
Edward A. Dolomisiewicz, MD
Program Director
National Capital Consortium PM&R Residency Program
Bethesda, Maryland, United States
Partial transection of the right sciatic nerve
Case Description:
A 31-year-old male U.S. marine sustained an artillery blast injury resulting in polytrauma significant for severe right lower extremity neurovascular injuries, a few of which required emergency surgery. After transfer to a U.S. hospital for definitive care, PM&R was consulted to evaluate the extent of suspected nerve damage. On exam, the patient exhibited loss of dorsiflexion and eversion, along with numbness of the anterolateral leg, dorsal foot, and first web space. CT imaging revealed a retained metallic foreign body in the proximal posteromedial thigh. Bedside ultrasound demonstrated evidence of retained shrapnel limiting visualization of the sciatic nerve at the level of the infragluteal fold with increased perineural anechoic signal tracking distally. Together, these findings suggested sciatic nerve injury isolated to the common peroneal division. Intraoperative findings confirmed both the location and extent of injury. The patient has since undergone foreign body removal and is awaiting a nerve graft procedure.
Discussions:
This case highlights the utility of neuromuscular ultrasound in evaluation of peripheral nerve injury. CT was the primary imaging modality for evaluation in this patient due to MRI being contraindicated. The limitations of CT in assessing nerve injury are well known. Bedside ultrasound, however, provided information vital to lesion localization and surgical planning. Obtaining optimal images of the sciatic nerve and assessing axonal continuity near the level of injury was challenging due to artifact; however, our findings raised concern for perineural hematoma which increased suspicion for proximal nerve injury which was confirmed intraoperatively.
Conclusions:
Bedside ultrasound is an invaluable tool for neuropathy evaluation, particularly when other modalities are unavailable or contraindicated. This case displays the massive diagnostic potential of ultrasound use in polytrauma evaluation in the future.
