2017 Sec 1 Green Book

Volume 137, Number 4 • Management of Orbital Fractures

Despite this, there is little in the way of consensus

regarding the full breadth of indications that war-

rant surgical repair. At least four different surgical

specialties manage these injuries, and recommen-

dations for treatment vary across the literature.

The greatest areas of disagreement focus on (1)

optimal timing of surgery, for both entrapped

and nonentrapped fractures; (2) ophthalmologic

symptoms necessitating intervention; and (3) frac-

ture characteristics that warrant early intervention

before the development of globe malposition.

We sought to specifically answer the question

of surgical intervention in orbital fractures with

an emphasis on the outcomes of surgical versus

conservative treatment. Although it represents

the largest series of isolated pediatric orbital

fractures and the largest operative series in the

literature, our cohort is also unique in that we

excluded patients with any other type of facial

fracture or injury that could potentially confound

the decision to operate. Thus, patients were strat-

ified between surgery and conservative manage-

ment cohorts based on their clinical indications.

Both cohorts also included only patients who

returned after their injury, with nearly 80 per-

cent of patients completing their recommended

follow-up visits and released to follow-up on an

as-needed basis. Limitations of our study include

the potential for bias by excluding patients who

did not return for follow-up. Our results may also

have limited generalizability to high-energy cra-

niofacial trauma with multiple concomitant facial

fractures.

We previously reported a large cohort of pedi-

atric orbital roof fractures, with a significant rate

of intracranial injury and multisystem trauma.

These patients (who were not included in this

series) were admitted to the Johns Hopkins Pedi-

atric Trauma Center and had high rates of multi-

ple trauma by means of high-energy mechanisms.

In contrast, the patients in this series were man-

aged through the state-designated Wilmer Eye

Institute Ocular and Orbital Trauma Center and

were, by inclusion criteria, isolated injuries. This

is congruent with the low incidence of roof frac-

tures seen in this series. Examination of the demo-

graphics and fracture patterns of the two groups

offers an interesting comparison between low- and

high- energy facial injuries in the pediatric popu-

lation. Unlike the high rate of operative repair in

this series, less than 10 percent of patients with

orbital roof fractures had surgery,

and their

management is typically more analogous to a skull

fracture than an orbital floor fracture. Trapdoor

fractures are much less common in high-energy

injuries, contributing to a paradoxically elevated

rate of surgical intervention in orbital fracture

patients with low energy mechanisms.

Losee et al. reported a series of 74 pediat-

ric orbital fracture patients, 25 of which were

isolated orbital fractures.

Only three of the 25

patients (12 percent) underwent surgical treat-

ment, two of which were because of entrapment.

Mild detectable enophthalmos was seen in one of

the surgically treated fractures (33 percent) and

three of the conservatively treated fractures (14

percent). However, among “significant fractures”

(

= 12), defined as fractures that involved more

than 50 percent of the area or displacement mea-

suring greater than three times the cortex width,

the enophthalmos rate was 30 percent with con-

servative treatment. The authors questioned the

practical significance of mild enophthalmos and

advocated a conservative approach to manage-

ment in the absence of entrapment or early globe

malposition. This is clearly an area where surgeon

preference and informed consent by parents as to

the risks and benefits of intervention versus obser-

vation is essential.

Attempts to correlate radiographic fracture

size with the development of late complications

began shortly after the widespread adoption of

computed tomographic scanning. In 1983, Hawes

and Dortzbach postulated that a greater than

50 percent defect of the orbital floor on computed

tomographic scan was necessary to cause enoph-

thalmos.

This number has been widely adopted

as a standard for “critical fracture size” in the

ophthalmology literature. For example, Hatton

et al. published a series of 96 pediatric patients,

inclusive of multiple facial fracture patterns, from

the Massachusetts Eye and Ear Hospital following

this criterion.

Forty-nine patients (51 percent)

underwent surgery; however, only four patients

(4 percent) had surgery based on the size of the

fracture.

Bansagi and Meyer published a review of a

34-patient experience, of which eight were trap-

door fractures.

They noted that this subset of

patients had better recovery of ocular motility if

operated on immediately (within 48 hours) ver-

sus later (3 to 14 days after injury). Specifically,

these patients demonstrated long-term limitation

in supraduction. In contrast, Egbert et al.

con-

cluded that delay of up to 1 week was acceptable.

In our experience, these patients tend to do bet-

ter the earlier they undergo reduction. Accord-

ingly, our preference is to perform surgery for this

subgroup within 24 hours of presentation when-

ever possible.