Endoscope-Assisted Repair of Pediatric Trapdoor Fractures of the Orbital Floor

Abstract

Trapdoor fractures of the orbital floor revealed a high incidence of persistent diplopia associated with extraocular muscle and soft tissue entrapment in the pediatric population, but actual entrapment of the muscle belly was confirmed in only 27.8% of patients endoscopically. Temporary hypertropia (31.2%) occurred in trapdoor fractures of the orbital floor but improved after 2 months of follow-up in every patient. Marked motility restriction and nausea/vomiting are predictive of trapdoor fractures. Prompt surgical intervention is needed in patients with such symptoms.

Pediatric orbital floor fractures

“…This symptomatology has been reported as highly suggestive of inferior rectus or orbital soft-tissue entrapment in the setting of known periocular trauma and can be considered an indication for immediate surgery. 14,19,30 An average of 1 in 4 children with serious entrapment requiring surgery will present with nausea and vomiting (range, 14.7% to 55.6%) as well as restricted extraocular motility. 9,10,12,14 The presence of nausea and vomiting has been reported to have a positive predictive value of 75% for a trapdoor fracture.…”

“…14,19,30 An average of 1 in 4 children with serious entrapment requiring surgery will present with nausea and vomiting (range, 14.7% to 55.6%) as well as restricted extraocular motility. 9,10,12,14 The presence of nausea and vomiting has been reported to have a positive predictive value of 75% for a trapdoor fracture. 23 Furthermore, nausea and vomiting had a reported positive predictive value of 83.3% for inferior rectus entrapment in the presence of a documented trapdoor fracture.…”

“…Carroll et al 33 Recovery times tend to increase with increasing delays in surgery. Kim et al 14 Prompt surgery is recommended for patients with marked restricted motility and experiencing nausea and vomiting.…”

“…Between 44% and 100% of children with entrapment had severely limited extraocular motility (Figure 1). [9][10][11][12][13][14][19][20][21][22][23][24][25][27][28][29][30][31][32][33] Diplopia can be caused by entrapment of extraocular muscles, direct damage to the muscles during the initial injury, swelling and hemorrhage, or injury to branches of motor nerves. Direct damage and injury to the nerve may be irreversible and result in persistent diplopia.…”

“…[9][10][11] Among all pediatric orbital floor fractures, the subset of trapdoor fractures make up a large proportion and have been reported to comprise from 27.8% to 93% of cases. 9,10,[12][13][14] Conversely, adults are more often found to have comminuted, or "open-door," fractures, without tissue entrapment, that can be observed for 2 weeks prior to repair. 13 The difference between adult and pediatric injury is attributable to variations in the facial anatomy of children versus adults.…”