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Plastic and Reconstructive Surgery
• April 2016
In the oral surgery literature, Gerber published
a series of 24 patients, of which 22 were operated
on (92 percent).
3
Seven patients (32 percent) had
long-termgaze restriction or diplopia, with one case
of enophthalmos. Based on these results, they pro-
posed that all operative pediatric orbital fractures
should be repaired within 3 days; however, we have
not seen evidence that this is necessary to obtain
good outcomes, and it may make the repair proce-
dure unnecessarily difficult because of edema.
In any pediatric facial trauma cohort, there is
always significant clinical heterogeneity between
the extremes of infants with highly immature cra-
niofacial skeletal structures and “nearly adult”
16-year-olds. If orbital fractures themselves were
randomly distributed in our cohort by age, we
would expect to see a roughly even distribution
of fracture patients by each year of life; instead,
there is a sharp increase in frequency after the age
of 12. We hypothesize that this is a combination
of increasing environmental exposure to trauma
and increasing anatomical predilection to orbital
(as opposed to skull or maxillary) fractures.
15
Even
factoring this in, however, increasing age still cor-
related with a higher operative rate. We attribute
this to a combination of a higher threshold for
intervention in very young children with signifi-
cant remaining orbital growth and a lower rate of
symptomatic fractures in these patients.
Our patients who underwent surgery fell into
three groups. Group I (
n
= 43) had definite evi-
dence or suspicion of muscle entrapment based
on a combination of clinical examination and
computed tomographic imaging, a clear indi-
cation for early open reduction and internal
fixation, which we try to accomplish as soon as
possible. Of the patients who were not operated
on for muscle entrapment, group II (
n
= 18)
demonstrated early enophthalmos, typically
from a relatively large defect, which represents
a second generally accepted indication for sur-
gery, although this can be performed in a more
delayed fashion.
Group III (
n
= 46) included patients with
neither entrapment nor acute globe malposition
who required surgery for other reasons (Fig. 2).
These patients represent the most challenging
evaluation, and the main indications for sur-
gery can broadly be divided into two categories:
(1) to preserve conjugate gaze or (2) to avoid late
enophthalmos or other sequelae resulting from
changes in orbital anatomy. Persistent diplopia
in central gaze or extraocular muscle movement
restriction after 1 to 2 weeks when edema has
mostly resolved will generally prompt us to inter-
vene, especially when there is evidence of orbital
fat herniation into the orbital defect on imaging.
The importance of ophthalmologic symptoms
tends to be underestimated in patient evaluation.
After swelling has largely abated at 1 to 2 weeks,
the continued presence of diplopia in central gaze
is concerning for alterations in orbital volume
and structure. This is less concerning if computed
tomographic imaging suggests the possibility of
transient impairment of extraocular muscle func-
tion (e.g., an extremely swollen inferior rectus or
intramuscular hematoma). Similarly, if the dip-
lopia is not present on central gaze but only on
vertical upgaze or downgaze, we have a greater
tendency toward observation.
Fig. 2.
Indications for surgery among group III patients (
n
= 46). Totals exceed
100 percent because some patients had two relative indications. “Other fracture”
indicates nasoorbitoethmoid or orbital roof.
EOM
, extraocular movement.
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