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Muscle entrapment is a rare but serious complication of certain medical procedures, most notably sinus balloon expansion for maxillary sinus fracture. It can also occur as a result of orbital fractures, which are typically caused by blunt periocular trauma and are one of the most common types of facial fractures. In the case of sinus balloon expansion, muscle entrapment occurs when a muscle becomes displaced into the fracture and trapped as the sinus is expanded and then deflated. This can result in severe fibrosis of the damaged and incarcerated muscle. Early diagnosis and treatment of muscle entrapment are crucial to prevent serious complications and ensure the best possible outcome for the patient.
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What You'll Learn
Muscle entrapment in children
Muscle entrapment is a rare but serious medical condition that requires urgent surgical correction. It occurs when a muscle becomes trapped within a fracture site, leading to potential complications such as bradycardia, syncope, nausea, permanent diplopia, or even death. While muscle entrapment can happen to people of all ages, this response will focus on muscle entrapment in children, as requested.
In children, muscle entrapment most commonly occurs in the eye region, specifically as an extraocular muscle entrapment in orbital fractures. This type of entrapment involves the muscles that control eye movement becoming trapped within the fracture site. It is considered a pediatric trauma and can result in severe fibrosis of the damaged and incarcerated muscle.
A case study described a 12-year-old male who presented to the emergency department after a physical assault resulting in blunt trauma to the face. Another case study involved a 9-year-old girl with a severe up-gaze deficit from a left-sided nondisplaced orbital floor fracture with entrapment of the inferior rectus muscle. This particular type of entrapment is rare in adults but has been reported almost exclusively in children.
Diagnosing muscle entrapment in children can be challenging, especially when it comes to assessing extraocular movements (EOM). These movements may be difficult to evaluate in children, particularly in those with significant facial soft tissue edema, lacerations, or chemosis. Therefore, it is crucial to have a thorough physical examination of the patient, which may include a CT scan, to aid in the diagnosis.
Treatment for muscle entrapment in children typically involves urgent surgical intervention to release the entrapped muscle and repair the fracture. This can lead to a full recovery of muscle function, as seen in the case of the 12-year-old male patient who fully recovered his range of extraocular muscle movement in the affected eye following surgery.
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Sinus balloon expansion
Muscle entrapment is a potential complication of sinus expansion by balloon catheterization. This procedure is used to treat compressed sinus fractures. During the procedure, a healthcare provider slowly inflates a tiny balloon within the sinus cavity, enlarging the space so that mucus can drain more easily. This treatment is typically recommended when symptoms of chronic sinusitis last more than 12 weeks and medications have failed to improve them.
In the case of muscle entrapment, the muscle becomes displaced into the fracture when the sinus is expanded, allowing its entrapment by some deflation. High intraorbital pressure due to active bleeding into the orbit may further increase the displacement of the muscle through the bony fracture.
Balloon sinus expansion should be approached with caution or avoided entirely when an orbital floor fracture is present. If it is employed, inflation should be slow and gradual, and deflation should be avoided. The balloon may be left in place until the fracture has completely healed.
Other procedures that may be considered include open-system or endoscopic procedures, which allow for direct visualisation of the surgical site. Endoscopic sinus surgery is another option for treating chronic sinusitis, but it is more invasive than balloon sinus expansion.
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Orbital floor fracture
The anatomy of the orbital floor also predisposes it to fracture. The orbital floor is composed of the frontal, ethmoidal, sphenoid, zygomatic, and lacrimal bones. The infraorbital neurovascular bundle, which includes the infraorbital nerve and artery, is located within the bony floor of the orbit. The bone overlying this bundle is very thin, making it a frequent site of isolated orbital floor fractures.
The signs and symptoms of an orbital floor fracture can vary significantly. Some patients may be asymptomatic with only minimal bruising and swelling, while others may experience diplopia, enophthalmos, hypo-ophthalmia (hypoglobus), and hypoesthesia of the cheek and upper gum on the affected side. Patients with diplopia and/or pain during vertical eye movements after blunt midfacial trauma are highly suspected of having an orbital floor fracture.
The diagnosis of an orbital floor fracture without entrapment typically requires radiological imaging, such as computed tomography (CT) scans, which have become the preferred modality for evaluating orbital trauma. Magnetic resonance imaging (MRI) is also useful for evaluating soft tissue masses and optic nerve pathology, but it is not recommended for patients with intraocular ferromagnetic foreign bodies due to the risks associated with the magnetic field.
The treatment approach for orbital floor fractures depends on the degree of injury. The goal is to restore both physiologic function and aesthetic appearance to the affected area. In some cases, a conservative approach may be warranted, while more invasive interventions, such as surgery, may be necessary in other situations. Rigid internal fixation techniques, such as plating and biocompatible implants, have gained widespread acceptance in the repair of orbital floor fractures. Early referral to an ophthalmologist or orbital specialist may be necessary for further evaluation and treatment planning.
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Nerve entrapment
The signs, symptoms, causes, and locations of nerve entrapment vary widely. Localised or referred pain is the most common symptom, but other symptoms such as dry thin skin can also occur in chronic cases of motor and sensory nerve entrapment. Neurological pain can be challenging to diagnose accurately, and it is crucial to determine whether the symptoms originate from the central nervous system (CNS), the spinal cord or nerve root compression, or the peripheral nervous system.
To diagnose nerve entrapment, a physician may administer a local anaesthetic in the symptomatic area, and if symptoms disappear, it may indicate nerve entrapment syndrome. Electrodiagnostic testing (EDS) can also be used to confirm the diagnosis, although there is no consensus on the best diagnostic imagery.
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Surgical treatment
Muscle entrapment, also known as nerve entrapment, occurs when a peripheral nerve loses mobility, flexibility, or becomes compressed by surrounding tissues, blood vessels, or bones. It can be both ischemic or mechanical in nature. Ischemic entrapment occurs when blood flow to a nerve is restricted, and mechanical entrapment occurs when a nerve is compressed by surrounding tissues, blood vessels, or bones. Nerve entrapment can cause neuropathic or neurogenic pain that can be either acute or chronic.
In cases of orbital muscle entrapment, where the extraocular muscles become trapped within an orbital bone fracture, urgent surgical intervention is often required. The surgical procedure involves exploring the orbital floor and releasing the entrapped tissue. In some cases, an orbital implant may be placed to repair the fracture. Early intervention is crucial, as delayed treatment can lead to complications such as ischemia, contracture, and compromised muscle function. Even before ischemic damage occurs, muscle entrapment can cause bradycardia or asystole, known as the Dagnini-Aschner phenomenon, which can be life-threatening.
For nerve entrapment in the upper limbs, such as carpal tunnel syndrome, cubital tunnel syndrome, and radial tunnel syndrome, surgical treatment options are available but are typically considered after non-operative measures have been explored. Surgical approaches may include decompression surgery, which restores neurovascular blood flow and relieves compression on the affected nerve. Early surgical intervention is associated with better postoperative function and recovery of nerve function.
In rare cases, sinus balloon expansion for maxillary sinus fracture can lead to entrapment of the inferior rectus muscle within the orbital floor fracture. Surgical treatment involves exploring the orbital floor and releasing the entrapped muscle. Endoscopic procedures may be preferred as they allow direct visualization of the surgical site.
Urgent surgical disincarceration is recommended for lateral rectus muscle entrapment in orbital fractures to avoid serious ophthalmologic complications. Early extrication can help preserve oculomotricity and prevent permanent diplopia.
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Frequently asked questions
Muscle entrapment is when a muscle becomes trapped within a fracture. This can occur when a muscle is displaced into a fracture and becomes trapped as the bone fragment moves back into place.
The symptoms of muscle entrapment can vary depending on the muscle involved and the location of the entrapment. Some possible symptoms include pain, nausea, and loss of function in the affected area. In some cases, muscle entrapment can also result in severe fibrosis of the damaged muscle.
The treatment for muscle entrapment depends on the specific circumstances of the entrapment. In some cases, surgery may be required to release the entrapped muscle. Other treatments may include suctioning blood from the affected area, administering medications, or repairing fractures with plates and screws.
