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Volume 137, Number 4 • Management of Orbital Fractures
Fracture characteristics that warrant acute
repair are likely the area of greatest controversy
in the management of these patients. Loss of sup-
port of the orbital contents is difficult to measure
quantitatively, and we generally avoid applying a
strict size measurement threshold except for the
rare patient who presents with an extremely large
defect where the majority of the orbital floor is
gone. Instead, we assess the apparent structural
changes (e.g., rounding of the inferior rectus
muscle, significant fat herniation) and clinical
symptoms coupled with the suspected structural
instability from the fracture. Displaced two-wall
fractures that include the medial transition zone
can result in a defect that appears deceptively
small. However, comparison to the opposite orbit
often reveals that only a few millimeters of dis-
placement of this large fragment can create a sig-
nificant orbital volume increase, and we manage
these operatively (Fig. 3). In these cases, we have
had good results with the use of prefabricated
anatomical titanium orbital plates.
Our absolute percentage rate of surgical inter-
vention is significantly higher than in other series.
As a state-designated ophthalmology referral
center and the primary pediatric trauma center
for the state of Maryland, there is undoubtedly a
strong referral bias present in our series. We gen-
erally advise outside physicians that they do not
need to transfer patients if the fracture is clearly
nonoperative (e.g., small and nondisplaced),
ocular motility is full, and the dilated ophthalmic
examination is normal. In addition, focusing on
isolated orbital fractures likely causes selection
bias toward “symptomatic” orbital fractures by
excluding incidental findings on patients imaged
for other facial fractures. Although these factors
prevent direct comparison of operative rates, they
do offer the advantage of a uniquely higher acuity
cohort with a greater proportion of cases where
management is not obviously nonoperative.
Even with referral bias considered, our crite-
ria still represent a lower threshold for operative
repair of pediatric orbital fractures compared
with most previous authors. As a high-volume cen-
ter, routinely performing these procedures offers
advantages in familiarity and favorable outcomes,
with a less than 5 percent rate of complications.
Importantly, in our experience, the long-term
ocular outcomes of these patients tend to be supe-
rior when significant disturbances in the anatomy
of the orbit are corrected.
Most series focus on the primary outcome of
globe malposition, which is evident on routine
Fig. 3.
A 14-year-old patient with a two-wall fracture that included the medial
transition zone who was managed operatively. Despite a deceptive lack of com-
minution or severe displacement (
above
,
left
), the orbit is significantly enlarged
compared with the uninjured side (
below
,
left
). Volumetric segmentation of the two
orbits (
right
) shows that the overall volume of the orbit has increased 28.6 percent.
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