Introduction

Although sciatic mononeuropathy is rare in children, its involvement is the most common type as far as traumatic peripheral nerve injuries are concerned [1]. The etiology usually involves direct cutting of the nerve, compression, vascular diseases, malignancy, and infections [1,2]. In this report, we present a 2-year-old child who suffered an unexpected sciatic nerve injury due to direct cutting by glass. During follow-up, he was also found to have periosteal involvement in addition to the deep soft tissue injuries. We discuss the role of ultrasound examination in monitoring this patient and the rehabilitation challenges that he faces.

Case

Ethical statements: Informed consent for this case report was obtained from the patient’s legal guardian.

One year ago, a 2-year-old patient was examined 3 weeks after surgery (left sciatic nerve coaptation and hamstring muscle repair) to repair a severed sciatic nerve resulting from a traumatic glass injury (falling on a glass vase while playing/running). He was prescribed home-based exercises and an ankle-foot orthosis. Electrodiagnostic evaluations 4 months after the surgery had revealed severe axonal injury to the left sciatic nerve. Range of motion, ankle stretching, and lower limb strengthening exercises were gradually added to the rehabilitation protocol.

One year after surgery, physical examination during a control visit showed improved strength in the gastrocnemius and plantar flexor muscles, as well as the sensation of the plantar surface. Repeat electrodiagnostic evaluations revealed denervation potentials and neurogenic motor unit action potentials in the tibialis anterior and gastrocnemius muscles. Ultrasound examination (Fig. 1, Supplementary Video 1) was performed on the sciatic nerve, which was significantly swollen and irregular compared with the right side (cross-sectional areas of 155 mm² and 19 mm², respectively). While scanning the peroneal and tibial branches (which were normal), a cortical/periosteal spur-like lesion was incidentally detected on the lateral side (Supplementary Video 2), which did not cause any compression of the sciatic nerve. Radiographs confirmed the diagnosis of periostitis ossificans progressiva (Fig. 1). An outpatient physical therapy program, including neuromuscular electrical stimulation of the left sciatic nerve-innervated muscles, was initiated, along with strengthening exercises. The patient is still undergoing conservative follow-up, and further surgical intervention is not currently being considered.

Discussion

Sciatic nerve injury is the most common type of traumatic neuropathy in children [3]. Depending on the extent of trauma, the scenario can turn into a complex injury involving nearby soft tissues. Considering its numerous advantages (high resolution, lack of radiation, dynamic imaging, etc.), ultrasound examination appears to be the paramount initial approach for uncovering any nerve or adjacent pathology. Owing to its patient friendliness and the possibility of dynamic assessment, ultrasound improves the examination, especially in children, where imaging would otherwise necessitate additional techniques/medications [4]. One of the main purposes of this report was to draw attention to the role of ultrasound examinations in pertinent cases, particularly during long-term follow-up, when repeat evaluations might be required. As a side note, ultrasound also led us to recognize another complication while scanning the healing sciatic nerve [5]. Indisputably, the need for extra imaging should always be part of the agenda in case sound waves fail to provide the “complete picture.” Radiography was performed to image the periosteum, cortex, and bone to identify additional pathologies. Certain ossifications can be detected by ultrasound even before radiography or computed tomography [6].

The second aim for presenting this patient was to describe a nontrivial scenario of (extensive) trauma, in which rehabilitation was lengthy and challenging. However, despite the fact that nerve and soft tissue healing is better in children than in adults, compliance with orthotic use during daily life or electrical stimulation during physical therapy may be significantly lower in children. Nonetheless, the patient's favorable progress with conservative treatment precluded additional surgery.

To the best of our knowledge, a direct/complete sciatic nerve cut due to a traumatic glass injury has not been reported in the relevant literature. Therefore, in this rare (but otherwise possible) case, we call attention to the need for prompt and thorough imaging during the acute care and long-term follow-up of extensive traumatic lesions. Last but not least, for children, ultrasound examinations might be the “sous chef” while “baking.”

Article information

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Author contributions

Conceptualization: AFÇ, LÖ; Formal analysis, Supervision: LÖ; Writing-original draft: BY, HO, LÖ; Writing-review & editing: BY, LÖ.

Supplementary materials

Supplementary Video 1.

Long-axis imaging of the left sciatic nerve (from proximal to distal, and vice versa) shows fusiform swelling at the site of coaptation. The nerve is morphologically normal proximally and distally.

Supplementary Video 2.

Short-axis imaging (from proximal to distal, and vice versa) shows a cortical spur on the femur.

Fig. 1.

(A) Axial imaging for cross-sectional area measurement (1.55 cm²) shows the edematous, irregular, and anechoic sciatic nerve (green tracing) on the left side. (B) Axial imaging for cross-sectional area measurement (0.19 cm²) shows the normal sciatic nerve (yellow tracing) on the right side. (C) Anteroposterior radiograph of the left femur (frog leg position) shows the periosteal lesion (arrow).

References

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Figure & Data

References

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