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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.
10
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,
10
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.
2
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”
(
n
= 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.
11
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.
12
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.
13
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.
14
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.
27