Evaluation and treatment of pediatric orbital fractures

Surgical indication analysis according to bony defect size in pediatric orbital wall fractures

Background

Orbital fractures are the most common pediatric facial fractures. Treatment is conservative due to the anatomical differences that make children more resilient to severe displacement or orbital volume change than adults. Although rarely, extensive fractures may result in enophthalmos, causing cosmetic problems. We aimed to establish criteria for extensive fractures that may result in enophthalmos.

Methods

We retrospectively reviewed the charts of patients aged 0–15 years diagnosed with orbital fractures in our hospital from January 2010 to February 2019. Computed tomography images were used to classify the fractures into linear, trapdoor, and open-door types, and to estimate the defect size. Data on enophthalmos severity (Hertel exophthalmometry results) and fracture pattern and size at the time of injury were obtained from patients who did not undergo surgery during the follow-up and were used to identify the surgical indications for pediatric orbital fractures.

Results

A total of 305 pediatric patients with pure orbital fractures were included–257 males (84.3%), 48 females (15.7%); mean age, 12.01± 2.99 years. The defect size (p= 0.002) and fracture type (p= 0.017) were identified as the variables affecting the enophthalmometric difference between the eyes of non-operated patients. In the linear regression analysis, the variable affecting the fracture size was open-door type fracture (p< 0.001). Pearson’s correlation analysis demonstrated a positive correlation between the enophthalmometric difference and the bony defect size (p= 0.003). Using receiver operating characteristic curve analysis, a cutoff value of 1.81 cm² was obtained (sensitivity, 0.543; specificity, 0.724; p= 0.002).

Conclusion

The incidence of enophthalmos in pediatric pure orbital fractures was found to increase with fracture size, with an even higher incidence when open-door type fracture was a cofactor. In clinical settings, pediatric orbital fractures larger than 1.81 cm² may be considered as extensive fractures that can result in enophthalmos and consequent cosmetic problems.

Pediatric orbital wall fractures: Prognostic factors of diplopia and ocular motility limitation

OBJECTIVES

To investigate the factors affecting recovery of diplopia and limited ocular motility in pediatric patients who underwent surgery for orbital wall fracture.

DESIGN

Retrospective observational case series.

METHODS

In this retrospective observational case series, 150 pediatric patients (1-18 years old) who were diagnosed with orbital medial wall or floor fracture and underwent corrective surgery between 2004 and 2016 at Seoul National University Bundang Hospital were included. The medical records of patients with orbital medial wall or floor fracture were reviewed, including sex, age, diplopia, ocular motility, preoperative computed tomographic finding, and surgical outcomes. Factors affecting recovery of diplopia and ocular motility limitation were analyzed.

RESULTS

Of the 150 patients (134 boys; mean age, 14.4 years) who underwent corrective surgery for orbital wall fracture, preoperative binocular diplopia was found in 76 (50.7%) patients and limited ocular motility in 81 (54.0%). Presence of muscle incarceration or severe supraduction limitation delayed the recovery of diplopia. In case of ocular motility limitation, presence of muscle incarceration and retrobulbar hemorrhage were related with the delayed resolution. Multivariate analysis revealed supraduction limitation (Hazard ratio [HR] = 1.74, 95% confidence interval [CI] = 1.19-2.55), larger horizontal orbital floor defects (HR = 1.22, 95% CI = 1.07-1.38), and shorter time interval to first visit (HR = 0.73) as negative prognostic factors for the recovery of diplopia. In addition, muscle incarceration (HR = 3.53, 95% CI = 1.54-8.07) and retrobulbar hemorrhage (HR = 3.77, 95% CI = 1.45-9.82) were found as negative prognostic factors for the recovery of motility limitation.

CONCLUSIONS

Presence of muscle incarceration and retrobulbar hemorrhage, horizontal length of floor fracture, supraduction limitation, and time interval from trauma to first visit were correlated with the surgical outcomes in pediatric orbital wall fracture patients. These results strengthen that the soft tissue damage associated with bony fracture affects the orbital functional unit. When managing children with orbital wall fracture, meticulous physical examination and thorough preoperative computed tomography based evaluation will help physicians to identify damage of orbital functional unit.

Inaugural Survey on Practice Patterns of Orbital Floor Fractures for American Oral and Maxillofacial Surgeons

PURPOSE

In recent years, several studies have reported on practitioners' preferences for the treatment of orbital floor fractures, showing widely varying practice patterns. The purpose of the present study was to identify the practice patterns among oral and maxillofacial surgeons involved in the management of orbital floor fractures in the United States and compare them with the available published data.

MATERIALS AND METHODS

An anonymous survey was created and electronically mailed to surgeons. We also reviewed the published data on orbital floor fractures using a PubMed and MEDLINE search. The responses to the survey were analyzed using descriptive statistics.

RESULTS

The factors that had the greatest influence on the surgeon's decision to operate were a defect size > 2 cm2, enophthalmos, entrapment, and persistent diplopia. The most common surgical approach reported was a preseptal transconjunctival approach (32.0%), followed by the subciliary (27.9%) and postseptal transconjunctival (26.2%) approaches. The most commonly reported implant for orbital reconstruction was titanium (65.4%), followed by Medpor (43.7%) and composite Medpor and titanium (26.4%). The review of the published data showed a consensus among many of the operative indications mentioned, including a large defect size, enophthalmos, clinical entrapment, and persistent diplopia.

CONCLUSIONS

Oral and maxillofacial surgeons in the United States have a wide range of practice habits in the management of orbital floor fractures. Although the quality of the available evidence is poor, it supports a consistent approach to the management of orbital floor fractures in terms of the indications and surgical approach. The choice of reconstructive material and timing of repair remain more controversial. A clear need exists for improvement in the available data to help guide and set standards of care for the specialties managing orbital floor fractures.

Isolated orbital floor fractures in the paediatric patient: case series and review of management

Orbital injuries warranting surgical intervention are infrequent in the paediatric population, but 'blowout, trap door' fractures are unique in children and may constitute a relative surgical emergency. A retrospective review of isolated orbital floor fractures at the Royal Children's Hospital of Melbourne over a 10-year period was undertaken to evaluate the outcome of those patients who required surgical exploration. Twenty-two patients with documented isolated orbital floor injuries were studied. Preoperative signs and symptoms including diplopia, ocular motility, paresthesia, enophthalmos, hypoglobus, and the presence of nausea and vomiting were recorded. Thirteen patients underwent non-surgical management and nine patients underwent surgical exploration of the orbital floor via a trans-subconjunctival approach to reduce any entrapped soft tissue. Postoperative follow-up of these patients varied between 1 month and 18 months and none had any visual disturbance or diplopia in central gaze; however, two patients experienced diplopia in upward gaze at follow-up, although this did not impair the quality of life. Due to the risk of permanent soft tissue damage from the entrapment of the periorbita with or without extraocular muscle tissue, it is recommended that exploration be undertaken as soon as possible to minimize the risk of persistent diplopia due to impaired ocular motility.