Do Not Fall for This; Diagnostic Challenges in Orbital Floor Fractures With Extraocular Muscle Entrapment

Abstract

Extraocular muscles that are entrapped in orbital fracture sites require emergent surgical treatment. Muscle entrapment can present with subtle findings or mimic other conditions, contributing to delays in diagnosis.Here, we present two cases of extraocular muscle entrapment that were not immediately identified. By discussing the diagnostic challenge in these cases, we aim to increase the comfort of all physicians in identifying muscle entrapment in the emergency department.

Isolated medial rectus hematoma following blunt trauma-a novel case report

“…5 Increased intracranial pressure from intracranial hemorrhage often leads to papilledema and usually bilateral 6th nerve palsy. 7 In 6th nerve palsies, as a characteristic of paralytic incomitant strabismus, the forced duction test is negative, and is therefore one of the leading differential diagnoses in our case, and it should be kept in mind that it can occur in the absence of cranial or orbital fracture. Trauma is the most common cause of isolated 6th nerve palsy in children, with skull base fractures being the most frequent pathology.…”

“…Therefore, a meticulous diagnostic approach is essential to guide appropriate therapeutic interventions and safeguard visual function in affected individuals. [5][6][7] The 6th cranial nerve is vulnerable to trauma due to its long intracranial path. Trauma-related 6th nerve palsy, which manifests as limitations in eye abduction, esotropia, and horizontal diplopia.…”

“…Children's bones, with more osteocytes and less calcified tissue, are more flexible and less prone to fragility, contributing to the distinct characteristics of trapdoor fractures in this age group. 7 The weaker bony adhesions of the periosteum in children also make them susceptible to subperiosteal hematoma after trauma, regardless of an orbital fracture. 4,10 In our case, the absence of a positive forced duction test and no orbital fractures on CT ruled out a trapdoor fracture or soft tissue entrapment.…”

“…3 Prompt surgical intervention is crucial for entrapment of extraocular muscles or soft tissue in an orbital bone fracture due to the risk of severe complications, including bradycardia, persistent diplopia, and mortality, making it a top priority in differential diagnosis. 7 Subperiosteal orbital hematomas pose a management challenge, as they may require conservative treatment or urgent surgery if there's a risk of compartment syndrome and optic nerve damage. Typically located in the upper orbital wall, these hematomas present with proptosis, hypoglobus, limited upward gaze, and reduced visual acuity.…”