Medial Rectus Muscle Incarceration in Pediatric Medial Orbital Wall Trapdoor Fractures

Pediatric orbital fractures

PURPOSE OF REVIEW

The aim of this study was to summarize current evidence on the clinical presentation, evaluation, and management of pediatric orbital fractures. Recent trends in management strategies as well as emerging surgical techniques for pediatric orbital fracture repair are presented.

RECENT FINDINGS

Although somewhat limited, growing bodies of evidence support a conservative approach with close follow up in pediatric orbital fractures. For those patients necessitating surgical repair, resorbable implants are increasingly preferred given their lack of donor site morbidity and a minimal impact on the developing craniofacial skeleton. There are emerging data reporting the use of three-dimensional (3D) printing-assisted approaches and intraoperative navigation; however, more research is needed to assess their applicability in the pediatric population.

SUMMARY

There are few studies with large patient cohorts and long-term follow up given the rare incidence of pediatric orbital fractures, which restricts the generalizability of research on the topic. The studies available increasingly suggest that fractures without clinical evidence of entrapment can be managed conservatively with close follow up. A variety of reconstructive implants are available for those fractures necessitating repair. Donor site morbidity, availability, and need for additional procedures should all be factored into the reconstructive decision-making process.

Case report on combined approach for delayed orbital floor repair

"White-eyed blowout" fractures in pediatric patients can be presented with fewer clinical symptoms; therefore, immediate diagnosis and surgery is essential. In cases where early surgery was performed, rapid recovery and better postoperative outcomes were noted regardless of the configuration of fracture. In pediatric patients, due to changes in the orbital volume, autograft is recommended. Although there are different approaches to orbital floor, transantral approach provides enhanced illumination and accessibility to orbital floor. This case report portrays a pediatric case of white-eyed blow out fracture which went unnoticed for about 1 month and was managed at a later date. Combined mid-tarsal and transantral approaches using iliac crest graft was used to repair the orbital blow-out fracture.

Isolated paediatric orbital fractures: a case series and review of management at a major trauma centre in the UK

Purpose

Paediatric orbital fractures are rare. Existing literature demonstrates wide variation in estimates of incidence, aetiology, management protocols and outcomes. Despite this, it is generally acknowledged that orbital fractures with entrapment of the extraocular muscles constitute a surgical emergency due to the potential for persistent diplopia secondary to muscle ischaemia and necrosis.

Methods

This retrospective study was conducted to determine the characteristics and outcomes of management of orbital fractures amongst the paediatric population. It involved patients presenting to a major trauma unit in London between 2010 and 2020.

Results

Thirteen patients with isolated orbital fractures presented to our unit in this period. The average age was 13 years. Surprisingly the predominant aetiology was interpersonal violence. The most common fracture pattern involved the orbital floor and medial wall. One medial wall fracture case was missed in the emergency department.

Eight patients required surgical intervention due to diplopia caused by muscular entrapment of extraocular muscles; the final patient had a large defect resulting in enophthalmos requiring a large titanium plate. A transconjuctival approach was preferred for surgical access and resorbable sheet was used in the remaining cases. Five patients had nausea, vomiting or bradycardia associated with the oculocardiac reflex. Surgical intervention occurred within 24–48 h of injury in 6 cases. Resolution of diplopia occurred in 7 patients within 6 months.

Conclusion

Paediatric patients with orbital fractures should be assessed on the day of injury by a maxillofacial surgeon. Due to the risk of persistent diplopia, urgent surgical intervention in patients with entrapment of extraocular muscles should occur as soon as possible.

Paediatric orbital trapdoor fracture misdiagnosed as a head injury: a cautionary tale!

Trapdoor fractures, otherwise known as 'white-eyed blowout' fractures, occur predominantly in the paediatric cohort and have a male predilection. Patients commonly present with acute fractures to the emergency department, and delayed diagnosis can result in significant morbidity. A lack of external signs, such as oedema or ecchymosis, often misleads physicians into underestimating the seriousness of the injury. It can be initially misdiagnosed as a head injury due to the oculocardiac reflex, nausea, vomiting, poor patient compliance and a failure to examine the eye appropriately. The incarcerated muscles may become necrotic because of ischaemia, resulting in ocular motility problems. Immediate surgery is recommended for symptomatic persistent diplopia or clinical evidence of muscle entrapment. The authors present the case of a 16-year-old male adolescent initially diagnosed with a head injury due to his nausea and vomiting following trauma to his orbit. This resulted in a delay to surgery. This article highlights the importance of performing an ophthalmic assessment to detect other features of a trapdoor fracture in children presenting with orbital trauma. It also reinforces the importance of knowledge of the oculocardiac reflex as its association with orbital injuries is well documented.

Orbital Disease in Neuro-Ophthalmology

Many abnormalities of the orbit present with neuro-ophthalmic findings, such as impaired ocular motility or alignment, and sensory changes, including optic neuropathy. Comprehensive coverage of all orbital diseases is beyond the scope of this article. This review focuses on diagnosis and management of the most common and the most vision- or life-threatening orbital conditions as well as more recently discovered entities and points of active controversy. These conditions include orbital trauma, vascular disease, inflammatory and infectious diseases, and neoplasms. Common presenting symptoms and associated neuro-orbital diseases also are summarized.

Pediatric Orbital Medial Wall Trapdoor Fracture with Normal Computed Tomography Findings

With advances in diagnostic technology, radiologic diagnostic methods have been used more frequently, and physical examination may be neglected. The authors report a case of pediatric medial orbital trapdoor fracture in which the surgery was delayed because computed tomography (CT) findings did not indicate bone displacement, incarceration of rectus muscle, or soft tissue herniation. A healthy 6-year-old boy was admitted to the emergency room for right eyebrow laceration. We could not check eyeball movement or diplopia, because the patient was irritable. Thus, we performed facial CT under sedation, but there was normal CT finding. Seven days later, the patient visited our hospital due to persistent nausea and dizziness. We were able to perform a physical examination this time. Lateral gaze of right eye was limited. CT still did not show any findings suggestive of fracture, but we decided to perform exploratory surgery. We performed exploration, and found no bone displacement, but discovered entrapped soft tissue. We returned the soft tissue to its original position. The patient fully recovered six weeks later. To enable early detection and treatment, thorough physical examination and CT reading are especially needed when the patient shows poor compliance, and frequent follow-up observations are also necessary.

Different onset pattern of oculocardiac reflex in pediatric medial wall blowout fractures

PURPOSE

We report the 2 pediatric patients who had radiographic confirmation of a rare case of medial orbital wall "trapdoor" fracture with extraordinary symptoms of oculocardiac reflex (OCR).

METHODS

This was a small interventional case series.

RESULTS

This is the retrospective report of 2 boys (13 and 10 years old) who developed diplopia, pain, nausea/vomiting, and general malaise following blunt trauma. However, the onset pattern of OCR was absolutely different: delayed onset of OCR just following therapeutic forced duction test to treat the orbital content herniation in the first case and a sudden onset after injury in the second case. In both cases, urgent surgery led to complete normalization of ocular motility.

CONCLUSIONS

Prompt diagnosis and proper treatment are critical to maximize clinical outcome for this rare and critical trauma.

Orbital trapdoor fractures

Orbital trapdoor fractures are commonly encountered in children. Awareness of trapdoor fractures is of particular importance. This is because early recognition and treatment are necessary to prevent permanent motility abnormities. In this article, we will provide a brief overview of orbital fractures. The clinical and radiographic features of trapdoor fractures will then be reviewed, followed by a discussion on their proper management.

White-eyed medial wall blowout fracture mimicking head injury due to persistent oculocardiac reflex

White-eyed medial wall blowout fracture associated with muscle entrapment is rare. It may present with symptoms consistent with an intracranial injury, delaying the diagnosis and putting the patient at risk for permanent damage. A case of an isolated white-eyed medial wall fracture associated with persistent bradycardia on abduction secondary to oculocardiac reflex as well as limited abduction mimicking sixth-nerve weakness is presented. Patients with white-eyed medial wall blowout fracture with muscle entrapment can present with oculocardiac reflex symptoms, pain, diplopia, and strabismus in the absence of any signs on ocular examination except for abnormal motility. Computed tomography imaging of the orbit should be performed to confirm the diagnosis, followed by immediate surgical intervention to avoid ischemia and permanent injury.

Medial wall fracture: an update

This article is a review of the literature and update for management of medial orbital wall fractures. A retrospective review of the literature was performed via PubMed to review the diagnosis and management of medial wall orbital fractures. Medial wall orbital fractures though commonly accompanying orbital floor fractures can also occur alone. There are two primary theories explaining the pathophysiology of medial wall fractures: the hydraulic theory and buckling theory. Most fractures do not require treatment. "White-eyed" trapdoor fractures necessitate immediate surgery to reduce the risk of muscle fibrosis. Trapdoor fractures are more common in the pediatric population. The vast majority of nondisplaced fractures without entrapment do not require surgery. Evaluating patients with medial wall fractures requires evaluation of muscle motility and relative enophthalmos. Patients with entrapped muscles require immediate treatment to prevent permanent injury to the muscle.

Evaluation and management of pediatric orbital fractures in a primary care setting

OBJECTIVE

To review and evaluate the management of white-eyed blowout fractures (WEBOF) from Emergency Department (ED) triage through surgical repair.

METHODS

Retrospective chart review of consecutive cases of pediatric orbital blowout fracture requiring surgical repair at a large ophthalmologic referral center. The characteristics of patients with WEBOF and those with conventional orbital blowout fractures were compared, including: mechanism of injury, clinical presentation, ED management and referral patterns, and time to definitive treatment.

RESULTS

Sixteen patients comprised the WEBOF study group, and 14 patients with conventional blowout fractures comprised the control group. All WEBOF had pain with eye movement, limited ductions and diplopia, and 75% had nausea and vomiting. These symptoms were present in significantly lower frequencies in control patients (64%, 64%, 7%, 14%, respectively). Compared to controls, WEBOF patients were younger; had injury more often resulting from sports and play; were less likely to undergo orbital imaging in the ED; were more likely to be diagnosed with concussion in the ED; were less likely to be seen urgently by an ophthalmologist; and were told to follow-up with an ophthalmologist 4-5 days later than control patients.

CONCLUSIONS

WEBOF is a clinical diagnosis consisting of vertical diplopia, gaze restriction and nausea and/or vomiting in the setting of peri-orbital trauma in the pediatric and young-adult age group. The paucity of external signs of trauma may lead to initial misdiagnosis and delay in treatment. All patients who meet WEBOF criteria should undergo dedicated orbital CT as part of the ED evaluation. If WEBOF is suspected, a prompt referral to an ophthalmologist should be made.

Blow-out fractures in children: six years’ experience

OBJECTIVES

To present and analyze our experience in treating blow-out fractures in children, over a 6-year period.

STUDY DESIGN

The study was retrospective with 16 consecutive cases of blow-out fractures in children aged 5 to 15 years. All patients presented with impairment of eye motility and diplopia together with radiological findings. Treatment included fracture reduction, release of entrapped periorbital soft tissues, and placement of an alloplastic membrane on the orbital floor. Fractures were linear in 11 cases (trapdoor) and severe or comminuted in 5 cases.

RESULTS

Clinical symptoms subsided in all cases. Complete recovery of eye motility was achieved after surgical procedure in 13 cases; 2 patients presented late but had full recovery, and 1 patient, 4 years postoperatively, still had slight motility impairment.

CONCLUSIONS

Surgical treatment of blow-out fractures, including periorbital tissue release and placement of a membrane lining on the orbital floor, presented satisfactory results in our cases.

Adult medial orbital wall trapdoor fracture with missing medial rectus muscle

We report the case of a 28-year-old man presenting with a medial orbital wall trapdoor fracture with a missing medial rectus muscle. We believe this to be the first case report of an adult medial orbital wall trapdoor fracture. Trapdoor fractures most commonly occur in the pediatric population, and those involving the medial orbital wall generally occur in areas with less developed ethmoid air cells. Since the present case followed neither pattern, a different injury mechanism was considered. The ethmoid air cells in this case were well developed, which may have played an important role in the pathogenesis of this adult medial orbital wall trapdoor fracture. Based on our findings, we propose a possible mechanism for a medial orbital wall trapdoor fracture in an adult. The cellular frames enable the medial bone to shift just minimally, regardless of the high orbital pressure during a blow. The excess volume of the orbital content escapes into the cells through narrow cracks; therefore, after a blow, it cannot move back completely into the orbit. Consequently, it pushes the shifted bone towards the orbit, becoming trapped in a manner similar to that of a check-valve mechanism.

Isolated Medial Orbital Wall Fractures With Medial Rectus Muscle Incarceration

PURPOSE

To retrospectively review and analyze cases of isolated medial orbital wall fractures with medial rectus muscle incarceration presenting to a tertiary ophthalmic plastic surgery practice from 1997 to 2005.

METHODS

Retrospective chart review and literature review.

RESULTS

Nine cases of isolated medial wall fracture with medial rectus muscle incarceration are presented. The most frequently encountered clinical feature was adduction deficit on the affected side. Extraocular motility improved in all patients who underwent surgery, and mean postoperative enophthalmos was minimal.

CONCLUSIONS

Isolated medial orbital wall fractures with medial rectus muscle incarceration are rare. Ocular motility abnormalities were the only indication of underlying fracture in the majority of our cases. Clinicians should be alerted to the anticipated presentation of medial wall fractures with incarceration of the medial rectus muscle, including the possibility of a "white eye" and normal abduction of the traumatized eye.