Muscle Entrapment Research Articles

Surgical Intervention on Pediatric Orbital Floor Fractures Improves Enophthalmos but Does Not Affect Visual Outcomes

INTRODUCTION: Isolated orbital floor fractures are common in the pediatric population. While guidelines such as fracture size greater than 2 sq cm. have been used to dictate surgical intervention in adults, less is known about the relative indications for surgery in the pediatric population.1,2 Therefore, the aim of the current study is to review the presentation, management, and outcomes for children with isolated orbital floor fractures in an effort to refine operative indications and prevent complications. METHODS: A retrospective review was performed on 72 children with isolated orbital floor fractures at a tertiary pediatric hospital from 1994 to 2010. RESULTS: Seventy-two patients with 76 fractures were identified. The average age at the time of injury was 8.41 +/- 3.8 years. Follow-up time was 14.2 +/- 4 months. The majority (50%) of patients suffered minimally displaced fractures, while 18% (13/72) suffered blowout fractures and 6% (4/72) suffered trapdoor fractures. Nineteen percent (14/72) of children presented with decreased visual acuity. Patients who were assaulted had a significantly increased risk for decreased visual acuity (RR: 3.25, CI:1.82-5.81, p<0.05). Eight percent (6/72) had enophthalmos on presentation when assessed by an Ophthalmologist. Patients with increasing defect widths had a significantly increased risk for developing enophthalmos after adjusting for age, surgery, and mechanism of injury (RR:1.8, CI:1.11-2.96, p<0.05). Thirty-three percent (24/72) underwent surgery with the most common indication for surgery being size of the fracture followed by muscle entrapment. Eighty-three percent (20/24) received either medpore or titanium implants, with the remaining 4 patients receiving autologous bone. Patients who underwent surgical intervention had statistically greater defect widths compared with their conservatively managed counterparts (20.7mm vs. 7.7mm, p<0.05). Additionally, patients who underwent surgical intervention had statistically greater defect/orbital width ratios when compared with than their conservatively managed counterparts (0.54 vs. 0.32, p<0.05). Surgery was not associated with improved visual outcomes; however, patients who received operative intervention displayed significantly decreased rates of enophthalmos on follow-up (RR:0.02, CI:0.00-0.49, p<0.05) (Table 1).Table 1: Statistical evaluation of endpoints.CONCLUSIONS: Isolated pediatric orbital floor fractures are common injuries and the majority should be managed conservatively. Patients with decreased visual acuity on presentation should be cautioned that surgical intervention does not improve visual outcomes. Greater defect width is associated with the development of enophthalmos and this is improved with surgical correction.

Nylon Foil (Supramid) Orbital Implants in Pediatric Orbital Fracture Repair

To present the authors experience with the nylon foil (Supramid) implant as a safe and effective method to repair pediatric orbital wall fractures. A retrospective chart review of all pediatric patients (≤18 years) that underwent orbital wall fracture repair with an unsecured 0.4-mm Supramid implant between 2007 and 2010. Outcome variables were diplopia and surgical complications. This study was carried out with IRB approval. A total of 59 orbits in 57 patients underwent orbital fracture repair using solely the 0.4-mm Supramid implant that were included in this retrospective chart review with the average age being 12 years. Trauma related to daily activities (42.1%) was the most frequent cause of orbital fractures. Eight patients (14.0%) had associated ocular/orbital injuries. Thirty-one patients (54.8%) were symptomatic at presentation with the most common presenting symptom being diplopia (n = 19, 33.3%). The most common fracture pattern sustained was combined orbital floor and medial wall fractures, which occurred in 21 patients (36.8%). Of the 3 patients (5.3%) that required immediate intervention due to extraocular muscle entrapment resulting in vasovagal responses, all returned to full and normal extraocular motility. There were 2 postoperative complications without any permanent sequelae; no patient developed postoperative enophthalmos recognizable by both physician and parents, and diplopia improved in all the 6 patients who suffered from immediate postoperative diplopia (10.7%). The nylon foil implant is a safe and effective method to repair pediatric orbital wall fractures given the low complication rate.

Versorgung isolierter Orbitabodenfrakturen – Rekonstruktion mit präfabriziertem Titanmesh

Concerning safety and efficiency in surgery of isolated orbital floor fractures, several treatment modalities are being discussed. It is a matter of recent interest that prefabricated titanium meshes provide significant advantages. The purpose of this study was to review the usability of the MatrixORBITAL® plate. In a prospective study we evaluated 10 patients (June 2011 to November 2013) with an isolated orbital floor fracture. All patients in the study group had undergone reconstruction with the MatrixORBITAL® plate. For purposes of analysis were recorded: age, gender, fracture category according to Jaquiéry et al. (2007), duration of surgery, complications, globe motility (Harms wall), exophthalmometry, function of the infraorbital nerve, evaluation of facial symmetry and aesthetic as well as personal contentment of the patient. A reference group received a PDS® sheet, an antral balloon or other materials. In the study group (2 women and 8 men aged between 26 and 83 years) all cases presented a large disruption of the orbital floor (> 2 cm2 bony defect; category II-III). Volume changes were universally associated with diplopia, but only in two cases with an entrapment of the inferior rectus muscle. The mean duration of the operation was 110 minutes (minimum 50, maximum 135 minutes). Postoperatively diplopia was decreasing in all cases. None of the patients had a significant impairment of visus and no reoperation was necessary. The analysis of functional outcomes between the groups mesh, PDS sheet and antral balloon revealed no significant differences. Based on this experience and due to good intraoperative handling, the authors recommend the prefabricated titanium plate in the treatment of isolated orbital wall fractures or in combination with the medial wall despite the material costs.

Superior Oblique Muscle Entrapment in Orbital Fracture Presenting as Acquired Brown-Like Syndrome

Pediatric orbital trauma with fracture involving the junction of roof and medial wall leading to superior oblique entrapment is rare. Here the authors report a case of orbital fracture at the junction of roof and medial wall with entrapment of the superior oblique muscle presenting clinically as canine tooth syndrome which was surgically released. Postoperatively, the ocular motility improved, and the patient was relieved of diplopia. They recommend early surgical exploration in such cases, which lead to successful resolution of diplopia.

Infraorbital nerve block for isolated orbital floor fractures repair: review of 135 consecutive cases.

Background:Orbital blowout fractures can be managed by several surgical specialties including plastic and maxillofacial surgery, otolaryngology, and ophthalmology. Recommendations for surgical fracture repair depend on a combination of clinical and imaging studies to evaluate muscle/nerve entrapment and periorbital tissue herniation.Methods:The aim of this study was to verify the applicability of regional anesthesia when repairing orbital floor fractures. A retrospective chart review was performed for isolated orbital floor fractures treated at the Department of Maxillofacial Surgery in Florence between May 2011 and July 2012. The study included 135 patients who met the inclusion criteria: 96 subjects were male (71%) and 39 were female (29%). The mean age was 45.3 years, ranging from 16 to 77 years.Results:The results revealed that isolated anterior orbital floor fractures can be safely repaired under regional and local anesthesia. Regional and local anesthesia should be combined with intravenous sedation when the fracture involves the posterior floor. The surgical outcome was comparable to the outcome achieved under general anesthesia. There was a lower rate of surgical revisions due to concealed malposition or entrapment of the inferior rectus muscle (19% vs 22%). However, this result was not statistically significant (P > 0.05).Conclusions:There are several advantages to surgically repairing isolated orbital floor fractures under regional and local anesthesia that include the following: surgeons can check the surgical outcome (enophthalmos and extrinsic ocular muscles function) intraoperatively, thereby reducing the reoperation rate; patient discomfort due to general anesthesia is eliminated; and the hospital stay is reduced, thus decreasing overall healthcare costs.

Management of Pure Medial Orbital Wall Fracture With Autogenous Bone Graft

The orbit is an irregular conical cavity formed from 7 bones including the frontal, sphenoid, zygomatic, maxillary, ethmoid, lacrimal, and palatine bones. Fractures of the internal orbit can cause a number of problems, including diplopia, ocular muscle entrapment, and enophthalmos. Although muscle entrapment is relatively rare, diplopia and enophthalmos are relatively common sequelae of internal orbital fractures. Medial orbital wall fracture is relatively uncommon and represents a challenge for its anatomical reconstruction. In this context, autogenous bone graft has been the criterion standard to provide framework for facial skeleton and orbital walls. Therefore, it is possible to harvest grafts of varying size and contour, and the operation is performed through the bicoronal incision, which is the usual approach to major orbital reconstruction. Thus, this article aimed to describe a patient with a pure medial orbital wall fracture, and it was causing diplopia and enophthalmos. The orbital fracture was treated using autogenous bone graft from calvarial bone. The authors show a follow-up of 12 months, with facial symmetry and without diplopia and enophthalmos. In addition, a computed tomography scan shows excellent bone healing at the anterior and posterior parts of the medial orbital wall reconstruction.

Timing of operation for blowout fractures with extraocular muscle entrapment

Many authors have advocated early surgical intervention to avoid muscle degeneration in patients with blowout fractures with evidence of extraocular muscle entrapment imaged under computed tomography. However, there is still no golden standard with regard to the target timing of operations for releasing extraocular muscle. Between January 2002 and December 2011, the authors treated eight cases of blowout fracture with extraocular muscle entrapment. Notes from presumed cases of blowout fracture were retrospectively reviewed for information relating to surgical treatment and prognosis. In this series, a patient who was operated on 7 hours after injury showed the quickest recovery from diplopia. In contrast, a patient who was operated on 18 days after injury showed persistent diplopia for 2 years. Nevertheless, in patients who were operated on 3–11 days after injury, there was no obvious correlation between the outcome and the number of days between injury and the operation. It is concluded that, when emergency surgical intervention within several hours is not possible, it should be performed as soon after the injury as possible in order to prevent the increase of predictive fibrosis around the extraocular muscle.

The omohyoid muscle entrapment of the internal jugular vein. A still unclear pathogenetic mechanism

To evaluate the role of the omohyoid muscle anatomic variants as a possible reversible cause of internal jugular vein extrinsic compression. We describe a chronic cerebro-spinal venous insufficiency patient, who presented a omohyoid muscle entrapment of the internal jugular vein, confirmed by both magnetic resonance venography and ultrasound investigation. A omohyoid muscle surgical transection together with a patch angioplasty was performed. The surgical procedure led to both IJV flow restoration and neurological improvement. The omohyoid muscle compression on the internal jugular vein seems to be a possible cause of venous obstruction, but several anatomical and patho-physiological aspects need further investigations. Such picture might cause balloon venous angioplasty inefficacy and needs to be preoperatively considered.

‘White-eyed’ blowout fracture: a case series of five children

The ‘white-eyed’ blowout fracture is an orbital injury in children that is commonly initially misdiagnosed as a head injury because of predominant autonomic features and lack of soft-tissue signs. We...

Oculocardiac reflex in a medial orbital wall fracture without clinically evident entrapment

In this report, we describe a patient with a medial wall orbital fracture, who presented with vasovagal-like symptoms secondary to an oculocardiac reflex. This case is unusual because the patient had no other clinical evidence of muscle entrapment. A 15-year-old male presented with daily 5-10 min episodes of dizziness, light headedness, and nausea consistent with a vasovagal reaction. On examination, the patient had full extra ocular motility and was orthotropic in all fields of gaze. On computed tomography a comminuted medial orbital wall fracture was identified. The adjacent medial rectus muscle was in normal position, but was “rounded” relative to the contralateral side. The patient underwent fracture repair with immediate resolution of all symptoms. Symptoms related to a vasovagal response may occur with orbital fractures despite normal extra ocular motility. Presumably this relates to tension or pulling on an extra ocular muscle, which is not to a degree that alteration in function is appreciable clinically.

Minimally invasive plate osteosynthesis of distal tibial fractures: a comparison of medial and lateral plating

PurposeThe hypothesis of this study was that lateral minimally invasive plate osteosynthesis (MIPO) would be comparable with medial MIPO with regard to clinical and radiographic results. The purpose of this study was to compare the results of medial and lateral MIPO for treatment of distal tibial fractures. Materials and methodsBetween June 2005 and February 2009, 24 patients with a distal tibia fracture were treated using MIPO. Patients were divided into two groups according to the MIPO methods used; 12 patients were fixated by medial MIPO (group M) and the other 12 patients by lateral MIPO (group L). These two groups were compared with regard to time to union. Clinical results were assessed by use of the IOWA ankle-rating system and the range of ankle motion at last follow-up. Mean operation time and postoperative complications were evaluated by chart review. Radiographic results were assessed on the basis of tibial angulation and shortening at last follow-up. ResultsRadiological evidence of bony union was observed for all study subjects. Mean union time was not significantly different between the two groups. Mean IOWA score, range of ankle motion, and operation time were no different between the two groups. No significant difference in angulation and shortening was observed between the groups, and no patient had an angular deformity >5° or tibial shortening >10mm at the last follow-up. Skin irritation was encountered in one case in group M and limited motion because of entrapment of the tibialis anterior muscle was observed in one patient in group L. ConclusionBoth medial and lateral MIPO produced good clinical and radiological results for distal tibial fractures. Lateral MIPO may be an effective option when soft tissue condition on the medial side of the distal tibia is poor or when the fracture line is close to the ankle joint.

Oculocardiac Reflex Induced by an Orbital Floor Fracture: Report of a Case and Review of the Literature

There are very few indications for the urgent treatment of facial fractures, in particular orbital floor fractures. Confirmed entrapment of an extraocular muscle is a well-known indication, and ruling out entrapment is an essential part of the assessment of orbital trauma.1 An uncommon, yet arguably more emergency indication for orbital floor fracture repair is a dysrhythmia associated with the oculocardiac reflex (OCR). The OCR, also known as the Aschner phenomenon,2-4 is a physiologic response to physical stimulation of the eye or adnexa.

Fracture du plancher de l’orbite chez l’enfant, étude rétrospective à propos de 34 cas

Orbital fractures represent 30 % of children facial fractures. Nausea and vomiting are more predictive of entrapment than local trauma stigmatisms. Entrapment and diplopia are more frequent in adults. Delay for surgery is unclear in literature varying from 6 hours to days. The aim of this study is to summarise the aspects of orbital floor fractures in children with regard to clinical and radiological presentation, management, and outcomes. We conducted a retrospective study including 34 children presenting isolated orbital floor fracture. Clinical, radiological, ophthalmological, surgical data and outcomes were analyzed. Mean age was 9.4 years. In 15% of cases, no local stigmatism of trauma was present. Entrapment fracture was the most frequent, with 81% of fat or muscles entrapment. In all, 27% of the patient had residual diplopia. Residual diplopia developed after trap-door fracture with muscle entrapment and a more than 24 hours delay for surgery. Trap-door fracture is frequent in childhood population. Clinical diagnosis can be difficult. However, surgical treatment should be considered before 24 hours to avoid complication as residual diplopia.

Medial Orbital Wall Fractures and the Transcaruncular Approach

We review the literature on medial orbital wall fractures and perform a meta-analysis on outcomes with the transcaruncular approach. The reported incidence for this injury ranges widely, although diagnosis can be made effectively with clinical examination and computed tomography. Clinical sequelae can include rectus entrapment or herniation, enophthalmos, and diplopia. Local injuries occurring in high concordance include concomitant fractures of the orbital floor and nasal fractures, although anterior cranial fossa extension, ocular trauma, other craniofacial injuries, and polytrauma must be ruled out. Indications for operative intervention include large defects, early or persistent enophthalmos particularly if causing diplopia, and rectus muscle entrapment.Various surgical approaches to the medial orbit have been described; however, the transcaruncular approach offers direct, reliable access without creating a cutaneous scar on the central face. A meta-analysis was performed on all studies reporting outcomes of the transcaruncular approach. A total of 228 cases were pooled, finding a favorable overall complication rate of 2.6%. Half of these complications required surgical correction and half resolved nonoperatively.Medial orbital wall fractures are an increasingly appreciated injury requiring clinical and radiologic assessments. When indicated, reconstruction of the medial orbital wall can be safely and effectively performed with the transcaruncular approach. Additional prospective outcomes studies are required to elucidate (1) the incidence of medial orbital wall fractures, (2) indications for operative versus nonoperative management, and (3) outcomes analysis of the transcaruncular approach compared with other approaches.

Transzygomatic Kirschner wire fixation for the treatment of blowout fracture

Total orbital floor reconstruction with sheet-shape materials is available for the treatment of extensive and crushed-type blowout fractures. Simple blowout fractures, on the other hand, require only manual reduction without fixation. Although several types of blowout fractures do not require total reconstruction, some fixation is usually necessary. Eighteen cases of blowout fracture were treated with transzygomatic Kirschner wire fixation between 2002 and 2009. This technique was applied to simple fracture cases in which periorbital soft tissue re-herniated through the floor defect into the maxillary sinus after manual reduction, despite improvement of the extra-ocular muscle entrapment. The wire was used to directly support the fracture segment in five cases and used together with a maxillary sinus anterior wall bone graft in 13 cases. Mean follow-up was 12.5 months. Mild diplopia remained as a subjective symptom in one case. None of the cases developed major complications or conspicuous scars on the cheek. Transzygomatic Kirschner wire fixation for blowout fracture has the advantages of precise and rigid fixation of all parts of the inferior floor, minimal morbidity without requiring an orbital approach and long-term safety without artificial remnants. This technique can be applied for the treatment of simple blowout fractures.

Transient pseudo-Duane syndrome after lateral orbital trauma

Duane syndrome is a dysinnervation disorder that frequently involves secondary anomalous eye movement, in particular, ocular retraction and the narrowing of the palpebral fissure on the adduction. Pseudo-Duane syndrome is caused by a mechanical restriction that produces clinical findings similar to those of Duane syndrome. Most patients with pseudo-Duane syndrome have restrictive pathologies on the medial side of the globe, such as entrapment of the medial rectus muscle. We report the case of a 44-year-old man with pseudo-Duane syndrome in whom we identified a lateral orbital wall fracture and entrapment of the soft tissue surrounding the lateral rectus muscle by computed tomography. To the best of our knowledge, this etiology of pseudo-Duane syndrome has not been previously reported.

Ischio femoral impingement in an 11-year-old girl

Ischiofemoral impingement (IFI) is the entrapment of the quadratus femoris muscle (QFM) between the trochanter minor of the femur and the ischium-hamstring tendon. Patients with IFI generally present with hip pain, which may radiate toward the knee. Although there is no specific diagnostic clinical test for this disorder, the presence of QFM edema/fatty replacement and narrowing of the ischiofemoral space and the quadratus femoris space on magnetic resonance imaging (MRI) are suggestive of IFI. The optimal treatment strategy of this syndrome remains obscure. Patients may benefit from a conservative treatment regimen that includes rest, activity restriction, nonsteroidal anti-inflammatory drugs, and rehabilitation procedures, just as with other impingement syndromes. Herein we report an 11-year-old girl with IFI who was successfully treated conservatively. To our knowledge, our case is the youngest patient reported in the English literature. MRI remains an important tool in the diagnosis of IFI, and radiologists should be aware of the specific features of this entity.

Delayed Immediate Surgery for Orbital Floor Fractures: Less Can Be More

Orbital floor fractures can result in diplopia, enophthalmos, hypoglobus and infraorbital dysthesia. Currently, the most common treatment for orbital floor fractures is immediate surgical intervention. However, there are a number of well-documented cases of unoperated orbital floor fractures in the literature, culminating in diplopia or enophthalmos in few patients. of these, none reported the diplopia or enophthalmos to be bothersome. As reported previously in the ophthalmology literature, most orbital floor fracture-induced diplopia resolves as the swelling settles, and the few patients with remaining diplopia can successfully be treated with surgery on the uninvolved eye. It has also been commented that most patients with enophthalmos are asymptomatic. The authors’ institution has more than 50 surgeon-years experience with delaying immediate surgery for two weeks to allow time for the swelling-induced diplopia to resolve. In the authors’ experience, true entrapment of the inferior rectus muscle is rare. The present article describes a study of late follow-up (average 945 days) of 11 nonoperated patients with orbital floor fractures. In the eight patients who initially presented with diplopia, there was resolution of functionally limiting double vision. Only one patient had asymptomatic, but measurably significant, enophthalmos at −3 mm. All patients had full restoration of extraocular movements and resolution of infraorbital dysthesia. None of the patients were exposed to the operative risks of ectropion, infection, implant extrusion, bleeding or blindness. The present study provides level IV evidence that delaying surgery up to two weeks after orbital floor fracture may avoid unnecessary surgical risks and inconveniences in many patients with orbital floor fracture.

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.

Facial Injury- Football

HISTORY: A 22-year-old University of Toledo defensive end was struck in the face by an opposing player. During a conference game this defensive lineman was rushin g the quarterback when he came into contact with the offensive tackle. The offensive tackle's left hand came through the defensive player's face mask and his thumb struck directly below the defensive player's eye. The player fell to the ground and subsequently ran off the field with his hand over his facemask. He reported severe eye and facial pain, as well as nausea and dizziness. PHYSICAL EXAMINATION: Sideline exam revealed a player in significant distress, unable to open his left eye. Procaine drops were administered without success. When the athlete's eye was opened it revealed that he was looking inferiorly, unable to look laterally or superiorly. Athlete was severely nauseated and displayed vertigo and diplopia upon exam. Athlete displayed immediate swelling and tenderness around orbital bones on the left side of his face. DIFFERENTIAL DIAGNOSIS: 1. Orbital Fracture 2. Ruptured Globe 3. Traumatic Optic Neuropathy 4. Retrobulbar Hemorrhage TEST AND RESULTS: CT brain without contrast: -No acute intracranial hemorrhage, infarct, or mass effect. Ventricles normal in size and position. Gray and white matter interface normal. -Left periorbital soft tissue swelling with intra orbital gas. Fracture of left orbital wall. CT facial without contrast: -Depressed fractures of the left orbital floor as well as the medial wall of the left orbit. -Orbital fat extends through the floor defect with partial entrapment of the inferior rectus muscle. Medial rectus muscle is displaced medially and is swollen. -Fluid/hemorrhage in the left maxillary sinus and also the left ethmoid air cells. FINAL WORKING DIAGNOSIS: 1. Left orbital floor fracture 2. Left medial orbit fracture with orbital contusions 3. Entrapment of the left inferior rectus muscle TREATMENT AND OUTCOMES: 1. ORIF of the left orbital floor fracture 2. ORIF of the left medial orbit and nasal wall fracture 3. Return to light exercise and activity at 3 weeks 4. Return to practice and contact exercise at 4 weeks 5. Game play at four and a half weeks with enclosed face mask and eye shield