Orbital fractures in children: clinical features and management outcomes

Is Surgery Needed for Diplopia after Blowout Fractures? A Clarified Algorithm to Assist Decision-making

Diplopia is a common symptom after blowout fractures, with an incidence of 43.6%–83%. Although there is some consensus toward surgical correction, diplopia is not always resolved by surgery. Thus, there is a clinical dilemma for surgeons with regard to performing surgery at a specific time. This review aimed to create an algorithm to support accurate and effective decision-making.

Does Early Treatment of Paediatric Orbital Fracture Offer Any Advantage in Terms of Post-Operative Clinical Outcomes

Background

Trapdoor fractures commonly occur in children below 6 years of age. The high resiliency of bone, pneumatisation of sinuses and other factors lead to entrapment of muscle and/or soft tissue which undergoes ischaemic changes leading to residual diplopia. The timing of intervention in children ranges from 24 h to greater than 2 weeks. Early surgical intervention is particularly indicated in cases of Oculocardiac reflex.

Methods

A Prisma guided systematic review of literature was conducted with no filters on language till September 2020. Studies on paediatric orbital fractures with data on timing of intervention and clinical outcomes were considered eligible for the review. The Oxford Level Of Evidence was used to assess the strength of individual studies.

Results

A total of 19 studies (18 English, 1 French) were selected; except for one study all were retrospective series. The timing of intervention ranged from 24 h to more than 1 month. Most of the studies agreed that orbital fractures in children should receive early intervention preferably within 2 weeks. In case of white-eyed blowout fracture, oculocardiac reflex and trapdoor fractures with muscle entrapment surgical intervention should be carried out within 24-48 h.

Discussion

Children presenting with facial injuries should be thoroughly examined for signs of muscle entrapment, diplopia, nausea, vomiting and bradycardia. If present these should receive early intervention. In cases with no signs of oculocardiac reflex and muscle entrapment a treatment within 2 weeks is recommended. If diplopia is mild or resolving with minimal hypoglobus and enophthalmos a wait and watch policy should be carried out.

Resorbable Versus Titanium Hardware for Rigid Fixation of Pediatric Upper and Midfacial Fractures: Which Carries a Lower Risk Profile?

PURPOSE

Titanium associated risks have led to interest in resorbable hardware for open reduction and internal fixation (ORIF) of pediatric facial fractures. This study aims to systematically review and compare the outcomes of titanium/resorbable hardware used for ORIF of upper/midfacial fractures to determine which hardware carries a higher complication rate in the pediatric patient.

METHODS

Studies published between 1990 and 2020 on the ORIF of pediatric upper/midfacial fractures were systematically reviewed. A retrospective institutional review was also conducted, and both arms were compiled for final analysis. The primary predictor value was the type of hardware used and the primary outcome was the presence of a complication. Fisher's exact test and 2-proportion 2-tailed z-test calculations were used to determine statistical significance, which was defined as a P value < .05. The low quality of published evidence precluded meta-analysis.

RESULTS

Systematic review of 23 studies identified 659 patients, and 77 patients were identified in the institutional review. A total of 736 patients (299 resorbable, 437 titanium) were included in the final analysis. Total complication rate was 22.8%. The titanium group had a higher complication rate (27 vs 16.7%; P < .01), and more often underwent elective hardware removal (87.3 vs 0%, P < .01). In each hardware subgroup, the incidence of complications was analyzed by fracture site. In the titanium group, complication incidence was higher when treating maxillary fractures (32.8 vs 22.9%, P = .03). When comparing the 2 hardware groups by fracture site, maxillary fractures had a higher rate of complications when treated by titanium hardware compared with resorbable hardware (32.8 vs 18%, P < .01).

CONCLUSIONS

Upper/midfacial pediatric fractures requiring ORIF, especially maxillary fractures, may be best treated with resorbable hardware. Additional hardware-specific outcomes data is encouraged.

Surgical treatment of enophthalmos in children and adolescents with pure orbital blowout fracture

PURPOSE

This study evaluated outcomes of surgical treatment for enophthalmos after pediatric orbital blowout fracture. Associations of fracture type, fracture site, time from injury to treatment, and type of surgical procedure with treatment outcomes were assessed.

METHODS

The medical records of 200 children and adolescents (38 girls and 162 boys) with orbital fractures treated in the authors' department from 1975 to 2015 were reviewed retrospectively. The main causes of injury were accidental blows to the orbit and sports injuries. This study included only patients with fracture of the floor and/or medial wall of the orbit, which is referred to in the English literature as pure, or internal, blowout fracture. Patients with fracture of the orbital rim, lateral wall, or roof were excluded. Surgical treatment was performed for 178 patients; the other 22 children were treated conservatively.

RESULTS

In the surgically treated group, treatment outcomes did not differ in relation to the severity of post-traumatic enophthalmos. The setting of the eyeball improved in 83% of patients.

CONCLUSION

The severity of post-traumatic enophthalmos was not associated with surgical outcome in children.