What is the best course of action for a 28-year-old male patient with suspected orbital fracture and possible muscle entrapment due to trauma?

Management of Suspected Orbital Fracture with Muscle Entrapment

Non-contrast orbital CT should be performed immediately for this 28-year-old male patient with suspected orbital fracture and possible muscle entrapment to evaluate fracture pattern, muscle entrapment, globe integrity, and potential intracranial extension. 1, 2

Imaging Approach for Orbital Trauma

Primary Imaging Modality

• Non-contrast orbital CT is the gold standard for orbital trauma evaluation with:
  • Thin-section axial imaging
  • Multiplanar reconstructions
  • High sensitivity (94.9%) for detecting fractures, soft tissue injuries, hemorrhage, and foreign bodies 1, 2

Why CT is Superior for This Case

• Provides detailed visualization of:

  • Bony orbital walls and fracture patterns
  • Muscle entrapment (critical finding requiring urgent intervention)
  • Globe integrity
  • Air in the orbit (indicating communication with sinuses)
  • Potential intracranial extension 1, 2

• Radiographs are insufficient and have been largely replaced by CT for orbital trauma 1

Clinical Implications of Imaging Findings

Urgent Surgical Indications

• Muscle entrapment in fracture (particularly trap door fractures)
• Evidence of oculocardiac reflex (bradycardia, nausea, syncope)
• Globe subluxation or injury
• Optic nerve compression
• Large floor fractures with hypoglobus 2

Complications of Delayed Treatment

• Permanent diplopia and restricted ocular movement
• Muscle ischemia and necrosis
• Persistent enophthalmos or hypoglobus
• Oculocardiac reflex (potentially life-threatening) 3, 4

Important Clinical Considerations

Entrapment Recognition Challenges

• Entrapment occurs when any orbital tissue (muscle or fat) is trapped in the fracture site 3
• Radiologic reports often fail to comment on possible entrapment (missed in 53% of cases in one study) 3
• Adult patients with muscle entrapment may not present with oculocardiac reflex, unlike children 4

Consultation Recommendations

• Ophthalmology consultation should be obtained urgently if CT reveals:

  • Muscle entrapment
  • Large orbital floor fractures
  • Significant enophthalmos or hypoglobus
  • Evidence of globe injury 2

• Neurosurgical consultation if:

  • Pneumocephalus is present
  • Orbital roof fracture with intracranial extension
  • Evidence of optic nerve compression 2

Pitfalls to Avoid

• Relying solely on radiographs, which may miss subtle fractures or foreign bodies
• Delaying imaging when muscle entrapment is suspected
• Failing to recognize that entrapment can involve muscle or fat
• Waiting for oculocardiac reflex symptoms in adults before diagnosing entrapment
• Premature surgical intervention without proper imaging assessment 2, 3, 4

Non-contrast orbital CT provides the most critical diagnostic information to guide management decisions in this case, with the potential to prevent vision loss and preserve orbital function.