A child after blunt facial trauma has enophthalmos, restriction of upgaze, and inferior rectus entrapment on CT scan through an orbital floor fracture with a small defect ('white-eyed blowout'). Nausea and bradycardia are also noted. The appropriate management is:

• A Urgent surgical release within 24-48 hours due to trapdoor fracture with muscle ischemia and oculocardiac reflex ✓
• B Conservative observation for 2 weeks before surgical repair
• C Enucleation to prevent sympathetic ophthalmia
• D MRI first; then elective repair within 2 weeks

Explanation

Pediatric orbital floor fractures often cause 'trapdoor' fractures — the bone springs back after impact, trapping inferior rectus and orbital fat through the small defect. This causes muscle ischemia progressing to fibrosis if not released promptly. The oculocardiac reflex (nausea, vomiting, bradycardia from traction on orbital tissues/CN V) confirms muscle entrapment. This is a surgical emergency in children requiring repair within 24-48 hours to prevent permanent restriction and diplopia. In adults, observation for 2 weeks is appropriate if there is no significant entrapment. The 'white-eyed blowout' term reflects the incongruous minimal external injury with severe internal entrapment in children.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.