 I don't know me yet, I'm Teresa Long, I'm a BGY2 resident, and I'm really excited to present to you a case, I'm giving away all of the story, but a case of a 12 year old boy that I saw who was entrapped on call, and so as a resident this was the first time that I had ever seen entrapment, and it was an exciting case and a good learning case for me. So we had a 12 year old male, he presented a primary children's ED after he was referred from an outside emergency room, and he was playing flag football and his friends head collided with his right eye. He had no loss of consciousness, he immediately had double vision after the injury, went home with his parents after the injury, iced his eye for about two and a half hours, had an episode of vomiting, and then his parents said well maybe he had a concussion, let's bring him back to the ED. And then outside of the emergency room they discovered that he couldn't, he had no changes in his vision, but at the outside emergency room they basically did a CT scan and then sent him to primaries. So really his dad had keratoconis, his uncle had a lazy eye, but no significant past medical history or surgical history. His vision was great, he had no APD, but his extra-ocular movements he was minus three and a half and in production in that right eye and minus four in soup production, and otherwise his examination was completely normal. And then on slip-life examination he had some mild eyelid edema in the right eye, there was no sub-conjunctable hemorrhage, and the posterior examination was within normal limits as well. So we reviewed the CT scans, I said oh my gosh he cannot move his eye, this must be what entrapment looks like. And then just highlighting some images, I have a pointer, no I don't. So you can just see that on the inferior floor there's a very very thin trapdoor fracture which explains his vision and then one more image here I think this is probably the most obvious. So radiologically it looks like he's also entrapped as well as clinically. So we have a 12-year-old boy has a right inferior trapdoor fracture, he has no evidence of open glove compartment syndrome or traumatic hyfema or posterior segment injury, but he's entrapped. So what do we do now? So I kind of had some questions, how soon does my patient need to go to the OR, does the timing of his operative intervention affect his long-term outcomes, and then what post operative complications can be expected as we go forward as some learning points for me. So orbital floor fractures in children just a brief review, so they're 35, 3 to 45% of all pediatric facial fractures and pediatric orbital injuries have unique patterns. So interestingly in kids less than 7 involvement of the orbital roof is more common and then once they get past 7 they tend to have more floor and medial wall injuries and this is because as kids grow their sinuses fill with air and their anatomy changes and so the pattern of injury tends to be different and then typically children can have diplopia or ocular motility limitations and without evidence of pardon me globe trauma and so this is this term that I hadn't heard before learning this case of the white-eyed blowout fracture. So kids are less likely to present with subcontamorges and q-mosis and externally they look like they're normal but that doesn't mean that they couldn't have a big problem. They talk about the ocular cardiac reflex, several papers have talked about this as a triad but typically the ophthalmic division of the trigeminal nerve is affected and the visceral motor nucleus of the vagus nerve are connected and that causes bradycardia. The presence of nausea and vomiting has a positive predictive value of 83% for an inferior rectus entrapment in the presence of an op-documented trapdoor fracture. So asking about nausea and vomiting in a kid is really important when assessing fractures and adults you know in contrast tend to have a ton of swelling, bruising, subcontamorage and double vision when they present it's not quite as obvious. So if you don't follow the pediatric literature this paper just came out in December and I'm really excited to have a lot of information on this slide but it was a great review it was really comprehensive so this is a retrospective review of pediatric patients less than 18 years old. Over a 15-year period this was done in India and they documented the cause of injury, imaging findings, clinical features and management. You can see the outcomes that they measured. They had 52 patients in this study interestingly 75% of them were male pediatric patients and their mean age of presentation was about 11 years old so about the same age as our patient. The most common cause of injury in this study 35% of them was road traffic accidents which is interesting because in India they talked about how seat belts and car seats are not as commonly used but the patterns of injury changed so as the pediatric patients got older injury from assault tended to be more common and injury from sports was more common in males than females. Then the orbital floor was the most common site of injury and trapdoor fracture was seen in almost half of the patients with the pediatric population. Most of them had double vision. The majority of patients presented with no or mild visual impairment and a lot of them 81% of them had some degree of ocular motility restriction. Fomening was the most common systemic complaint and then they tracked how many patients went to the surgery so entrapment was the most common cause for them to go to the OR and there was a discussion of implants and how to repair but that is a big topic that needs more time than today. So their outcomes was 2020 to NLP and it was interesting is the visual acuity that the kids presented with tended to be the visual acuity that they finished with after surgery so the damage was kind of done from the initial injury. The NLP eyes there were like two or three and they were really traumatic like bilateral injuries for these patients. If they're conservatively managed their diplopia decreased they not found most persisted in all patient's traumatic atosis improved and they all patients in general got better so and then they noticed that if they had surgical intervention within 15 days they had complete resolution of their diplopia. So what about trapdoor fractures specifically? So typically a trapdoor fractures a linear medially hinged but minimally displaced fracture that classically runs along the infor orbital canal. They have been compromised known to compromise about 27 to 93 percent of cases of pediatric orbital floor fractures and the big thing is you have worry about ischemia of the entrapped intraocular muscle and that down the road can lead to Volkman's ischemic contracture something that orthopedic surgeons often note. There's two theories of how this happens the hydraulic mechanism and the buckling mechanism. So the hydraulic mechanism this increased interorbital pressure puts direct compression on the fracture of the bony floor or the buckling mechanism where the force is transmitted posteriorly through the orbital rim and then transiently buckles and fractures the orbital floor. So why do we get trapdoor fractures in kids? Well they have more elastic bones essentially and so the you have the fracture that happens with the force transduction backwards and then the bone automatically snaps back so much quicker and this is different when adults because you have mineralized bone they're more fragile and then you get open door fractures with herniation of tissues. So when do we take kids to the OR? Obviously entrapment is one of the biggest ones. They have ocular motility restriction causing double vision. They have a positive ocular cardiac reflex. Early enough almost a large defect or if long later down the road they have non-resolving double vision. So what postoperative complications so double vision is the most common one that I was worried about for my patient and they noted that in children with trapdoor fractures double vision may be more common. Probably due to the ischemic injury that happens and then there are some more infrequent injuries. So I look back and I was like well this is really interesting. Dr. Patel always tells us you have to know where you've been before you have to know where you're going to go. So Smith and Reagan in 57 first described this isolated fracture of the orbital floor with an intact orbital rim and this was of course you know before the time of imaging. So in 78 Puttermann hypothesized that the extra ocular muscle pathology was due to contusion and this would resolve with time and this was this was they recommended observation for orbital blowout fractures in adults. And there's some note in the literature that this became misinterpreted as the need to observe orbital floor fractures. In the 80s we got CT scans. In 1991 Damien was the first to buy immediate surgery from pediatric orbital floor fractures with positive forced-duction tests. And then in 1998 this is where the terminology came from with Jordan for the white-eyed blowout fracture in pediatric patients. So you don't have this basically in this study they noted faster improvement in ocular motility than kids that were operated and kids that were operated in two to four days as opposed to two weeks and so they said hey maybe you need to take them to the OR sooner in two days. A lot of information on this slide but essentially from 2000 to now 2011 you can see the trend. So less than two weeks and we're going to seven days and then now surgical intervention as soon as the diagnosis is made within 24 hours within 48 hours. So the trend is taking patients to the OR sooner at least in the last 15 years or so. This study was one that actually objectively measured. It also came out this year in 2018 and it was a plastic and reconstructive surgery journal but they actually objectively measured patients post-operative motility and they put 28 children with unilateral orbital floor fractures with entrapment into two groups. Those that went to the OR in 24 hours and those that went to the OR after 24 hours. ENT ophthalm and facial plastic surgeries all took care of this patient which makes sense with an academic institution. CT was performed in all children and what did they find? So essentially there was no statistically significant difference in resolution of vertical motility deficits but patients that had surgery within 24 hours had more fully recovered at the first and final post-op endpoints. So increased likelihood of recovery of motility deficits if they went to the OR sooner within 24 hours. The last thing that I found Dr. Marx has sent this paper to the residents when we are learning but what about CT imaging in the pediatric population? So it's really underestimates extracular muscle and soft tissue entrapment and so Parbu found that more than 50% of children with orbital fracture had entrapment when they went to the OR that was not appreciated by the radiologists. So this really suggests that entrapment is very much a clinical diagnosis. You have to examine the patient, you have to look at their extracular movements and so that's something that in all patients that we see at primaries we need to be seeing them and checking their EOMs if the ED doc doesn't do a good job. In adults though in contrast CT is really highly sensitive and specific and then down here I have some information on the concordance rates. So what were the key learning points for me from this case? This is my first case of entrapment. So orbital fractures with entrapment are more likely to occur in children than adults with the elasticity of the bones. They're more likely to present with a white eyed blowout fracture so just because the kid looks normal it doesn't mean that they don't have a problem. CT scans may underestimate a fracture especially in children so clinical exam and ophthalmology consultation is essential. The presence of nausea and vomiting is a sensitive symptom for EOM entrapment in the presence of a fracture. And then to the ED doc I would say I found another paper that said up to a third of pediatric facial trauma patients basically the they presented with the the oculocardiac reflex and this went under recognized by the ED doctor so if they have bradycardia if they're having symptoms is something that ED doc needs to be aware of and they need to think about consulting ophthalmology and not attributing them to a concussion. And then timely repair is important so surgery within 24 hours may lead to better outcomes. I think I'm interested to see what further studies occur in my career. So what happened to our patient? So he was taken to the OR for repair of his orbital floor trapdoor fracture with placement of metaphor barrier sheet. He went within 24 hours. We got him to the OR the next morning and as you can see so I have post op one day one two three post op week two and post op month one is his depot layer resolved and his extracurricular movements are improved so here are my references. What questions do you have? So we got a few player from ocular plastics. Here we go leave start surgery. The old debate the old debate used to be that in these young children that if you just relieved it you don't necessarily have prosthesis in and that the tissues would often bounce back and so where are we in regards to that debate? Is it there still those who feel that you can just relieve these and I have to put a prosthesis here essentially is sticking in something always happening with these pediatric young trapdoor injuries? Absolutely so in those fractures where there's a true trapdoor right this is why it's really this is why I always say to you send me a copy of the scans you have to look at the scans yourself don't rely on radiology report it's no fault of the radiologist you should spend the day with the radiologist and see what they have to read everything from head to toe and these are things that are often missing so if you have a true trapdoor fracture I tend to release it through a post op test on the table and then decide whether you put it in one turn or not if there is an open space then I will put a thin thinner in front of usual but that applies you don't always need an implant and we mustn't forget putting a porous foreign body in the orbit carries a certain amount of infection and so on and one of the things you didn't bring up is anytime you see a fracture in someone less than 16 definition of children is very good for country to country below 16 the thing to look for is upcase if you see any evidence of them closing their eyes as they look up in upcase or they get nausea nausea is an indication for immediate surgery that's where you get a trapdoor with pulling on the innovation of the erectus which gives you that face away response if you get some limitation I disagree with that 24-hour rule there is a tendency in ocular plastics to operate operate too quickly many of these patients will have a bruised muscle and the movement goes back to normal within 24-48 hours so what Dr. Olson is talking about in the old days they used to say observe them for two weeks not necessarily true that you have to wait for two weeks but do allow the edema from trauma and if you're not sure just have somebody eat you really hard on one biceps and then carry two heavy pales within an hour or two hours you can carry the big one but the first few hours you're not able to muscle does get bruised so I think this early surgery remember if you operate on them quickly you'll never find out how many of them could have got better and this is where converse papers from the 1960s and 70s are very useful they actually follow these patients without doing surgery the problem with their papers is the mixture of adults and children and the Indian paper you mentioned which which I happened to review it's very good paper but some of the objections there were some of them had surgery too soon even with very slight limitation movement in the so-called practical practice you'll never find out that child could have gotten better of them finally don't forget finances the minute you take a patient like this to see everybody from start to finish pre-op post-op visits costs come to something like 45 to 50 thousand dollars in this country and it's really hope not to operate on children who don't need surgery so my approach with these is if you have nausea I operate on them immediately if they have any kind of a basal vagal response with or without nausea I operate on them immediately otherwise I give them anything up to a week and then decide whether certain things are enough this way you avoid unnecessary surgery we have a large series and I think what we will do is we will pull up papers because the number of patients I don't operate on is very substantial so we should be able to review paper like this thank you thank you