Surgical treatment of blow-out fracture in a pediatric patient

Case Report

Abstract

Introduction: Among the fractures that affect the orbit, blow-out fractures are those in which bone fragments enter the maxillary sinus, and in those classified as trapdoor, the fragment returns to its usual position, herniating content into the maxillary sinus, affecting more pediatric patients. Trapdoor blow-out fractures are more common in children, as their bones are more flexible and therefore, when they fracture, they tend to return to their original position, resulting in linear fractures with consequent entrapment of soft tissue and the inferior rectus muscle. Case Description: This was a 4-year-old male pediatric patient with a history of a head-on collision with another child. He was admitted to the Oral and Maxillofacial Surgery and Traumatology department of the João XXIII Hospital, located in Belo Horizonte (Minas Gerais), oriented, eupneic and walking. Clinical examination revealed limited upper gaze, i.e. limited supine movement, nausea and pain in the area affected by the trauma. A computerized tomography (CT) scan carried out at the hospital revealed a trapdoor blow-out fracture of the orbital floor in the right orbit. The patient was surgically approached 36 hours after the trauma by the Oral and Maxillofacial Surgery and Traumatology team. During surgery, subpalpebral access was used to expose the fracture and the inferior rectus muscle, which was trapped, was removed from the fracture line, which was reduced and fixed with a 1.5 system titanium mesh, placed at the lower edge, to provide support for the eyeball and act as a barrier to prevent herniation of intra-orbital contents into the maxillary sinus. Subsequently, intradermal suturing was performed and, at the end of the surgical procedure, a forced ocular motility test (forced duction test) was carried out, which confirmed the return of ocular motility in the right eye and the success of the surgical treatment proposed by the hospital's Oral and Maxillofacial Surgery and Traumatology team. Results: In the immediate postoperative period, the child had preserved eye movements, excellent visual acuity, as well as edema compatible with the surgery and good general health. It is essential to note that the literature mentions that blepharohematoma and blepharoedema are uncommon in pediatric patients, so the absence of these factors is not enough to rule out the diagnostic hypothesis of trapdoor fracture in children. On the other hand, some symptoms are relevant and can be caused by trapdoor fractures in children, such as vomiting, syncope, loss of permanent ocular motility, severe diplopia and even tissue necrosis. It is important to note that in some cases, muscle entrapment may not be seen on CT scans, so it is essential to carry out a clinical examination and observe the patient's complaints so that the correct diagnosis can be reached by the professional. Conclusion: This case report aims to demonstrate that anamnesis, clinical examination and computed tomography are essential for the correct diagnosis and better prognosis of pediatric patients with trapdoor blow-out fractures. The studies in this case report prove that immediate surgical intervention is essential to achieve satisfactory post-operative results that ensure health and quality of life for children affected by this type of fracture.