2015 HSC Section 1 Book of Articles

Boyette

MCT can be assessed by pulling the eyelids laterally while palpating over the medial canthal region. Normally, the MCT creates an area of tautness (bowstring sign), which may still be present if the MCT is not completely avulsed from the bone. Therefore, bimanual palpation of the medial orbital wall using an intranasal instrument should be performed to test for mobility of the entire complex. The management of NOE fractures is primarily surgical with open reduction and in- ternal fixation. However, some authors advocate for closed reduction and extraction of the impacted nose if the reduced nasal pyramid feels stable. 1 Open reduction and internal fixation is commonly approached through existing brow lacerations or via a coronal approach. The primary goals are to restore nasal dorsal height and to restore medial canthal attachments and contour. However, bony fragments are often very small and not amenable to screw fixation. Transnasal wiring to stabilize the MCTs or MCT-bearing bone fragments may be necessary, along with cantilevered bone grafts for support at the nasal dorsum. The initial surgery is often the best chance to restore normal positioning, because revision NOE surgery is difficult. 34 The normal narrowing and convexity at the medial canthal region is difficult to re-establish; there- fore, external bolsters are recommended to help coapt the overlying soft tissue and splint the underlying bony fragments. Typically these are made from petroleum gauze and secured with transnasal wires or sutures to be left in place for as long as possible (usually 4–6 weeks). Nguyen and colleagues 34 have shown excellent results after long- term bolsters caused ulceration that was allowed to heal secondarily. Stenting of the nasolacrimal system is generally not necessary during the immediate repair, and long- term complaints of epiphora are rare. 35 Ultimately, there are few long-term studies examining outcomes of NOE fracture repairs in children, but the need for revision surgery is common, especially in the growing child. 36 Orbital Fractures Orbital fractures are common in children, but treatment strategies remain controver- sial. It is important to again emphasize that greenstick “trapdoor” fractures with mus- cle entrapment are more common in children and to be aware of the “white eye” orbital fracture ( Fig. 1 ). In general, after 5 years of age orbital floor fractures become more common than orbital roof fractures. 14 Ophthalmology evaluation is warranted in all cases of pediatric orbital injury. Traumatic optic neuropathy may be discovered, which

Fig. 1. Computed tomography of left orbital floor blowout fracture. Note the greenstick fracture pattern with entrapment of the inferior rectus muscle. ( From Fraioli RE, Branstetter BF, Deleyiannis WB. Facial fractures: beyond Le Fort. Otolaryngol Clin N Am 2008;41:67; with permission.)

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