2017 Sec 1 Green Book

Volume 137, Number 4 • Management of Orbital Fractures

at a high-volume ophthalmologic trauma referral

center with the goal of analyzing outcomes and bet-

ter understanding when intervention is warranted.

PATIENTS AND METHODS

Institutional reviewboardapprovalwasobtained

to conduct a retrospective review of patients in the

prospectively maintained pediatric trauma registry

(0 to 18 years) at the Wilmer Eye Institute of Johns

Hopkins Medical Institutions who were diagnosed

with orbital fractures by

International Classification

of Diseases, Ninth Revision

codes 802.4, 802.6, 802.7,

and 802.8. The medical records were reviewed for

each patient who was diagnosed with an orbital

fracture between the years 2003 and 2013. Patients

were excluded from this study if records did not

include a full ophthalmologic examination imme-

diately after presentation or if they did not follow-

up after their injury. Data were extracted from each

medical record for information about demograph-

ics, mechanism of injury, physical examination at

presentation, surgical intervention, and final out-

comes. Patients were excluded if they had any facial

fractures outside of the orbit, with the exception of

nondisplaced zygoma and frontal bone fractures

representing the continuation of orbital fractures.

The

test and Mann-Whitney

test were used

for statistical comparison of dichotomous groups

for normally and nonnormally distributed vari-

ables, respectively. Univariate logistic regression

was used to examine the impact of individual fac-

tors on the development of particular complica-

tions, with multivariate regression for possible

confounders. All statistical tests were two-sided,

and significance was set to the level of

< 0.05.

RESULTS

Demographics

One hundred fifty patients met the selection

criteria. The average patient age at the time of

trauma was 12.6 ± 4.3 years. One hundred six-

teen patients (77 percent) completed all recom-

mended follow-up and were discharged from

care, with an average follow-up time of 309 days.

The majority of patients were male [110 (73.3 per-

cent)], and the most common causes were sports

(34 percent) and assault (32 percent) (Table 1).

Fracture Characteristics

One hundred twenty-seven patients (85 per-

cent) had orbital fractures including the orbital

floor. Fifty-eight (39 percent) had medial wall

involvement, 12 (8 percent) included the roof,

and five (3 percent) had lateral wall involvement.

The subset of patients without floor involvement

(

= 23) was much less likely to undergo surgical

management (30.4 percent versus 78.7 percent;

< 0.001). Similarly, patients with evidence of

extraocular muscle restriction on examination

were much likelier to have a floor component of

their orbital fracture (OR, 5.2;

= 0.001).

Twelve patients had extension of their fractures

outside the orbit. Five had extension of a roof frac-

ture into the frontal bone and four had zygoma

involvement, all of which were nondisplaced.

Three patients had nasoorbitoethmoid fractures:

two with Markowitz-Manson type 1 fractures and

one with a Markowitz-Manson type 2 fracture.

On presentation, 43 patients (29 percent)

showedevidenceof radiographicmuscleentrapment

(i.e., herniation of a portion of the inferior rectus

muscle belly into the defect) on computed tomog-

raphy. Lack of diplopia and extraocular movement

restriction on initial presentation were relatively

sensitive for ruling out muscle entrapment on imag-

ing (sensitivity, 95 percent; specificity, 45 percent;

95 percent CI, 84.2 to 99.4 percent). Twenty-two

patients (15 percent) showed evidence of enoph-

thalmos preoperatively, 19 of whom developed it in

the acute fracture period. Of the remaining three

patients, two were initially managed conservatively

but developed enophthalmos, and one had surgery

delayed because of ophthalmologic sequelae (i.e.,

commotio retinae and traumatic iritis).

Surgical Cohort

Overall, 107 patients (71 percent) underwent

surgery for their fracture. Of these, 96 (90 per-

cent) underwent repair within the acute period

(

≤

3 weeks), whereas 11 (10 percent) underwent

delayed fracture repair (22 to 1399 days; median,

49 days). Thirty-nine patients (37 percent) had

surgery within the first 48 hours after their injury.

Patients received surgical or conservative treat-

ment based on their relative indications (Fig. 1),

with the exception of the previously mentioned

patients presenting with major eye injuries.

Table 1. Mechanisms of Injury (

= 150)

No. (%)

Sports

50 (33.8)

Assault

47 (31.8)

Play

18 (12.2)

Fall

13 (8.8)

Motor vehicle accident

10 (6.8)

ATV/motorbike

5 (3.4)

Other

5 (3.4)

ATV, all-terrain vehicle.