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Principles for Management of Orbital Fractures in the Pediatric Population: A Cohort Study of 150 Patients PEDIATRIC/CRANIOFACIAL Reprinted by permission of Plast Reconstr Surg. 2016; 137(4):1234-1240.

Devin Coon, M.D., M.S.E. Martin Kosztowski, M.D. Nicholas R. Mahoney, M.D. Gerhard S. Mundinger, M.D. Michael P. Grant, M.D., Ph.D. Richard J. Redett, M.D. Baltimore, Md.

Background: Pediatric orbital fractures represent a challenging and sometimes controversial clinical problem. Patients may present with clear indications for surgery, but most require balancing benefits against intraoperative and late complications. The authors assessed these fractures at a state-designated oph- thalmology referral center to develop criteria for surgery. Methods: Institutional review board approval was obtained to retrospectively analyze pediatric trauma registry patients with orbital fracture diagnoses at the Wilmer Eye Institute over 10 years. Patients were excluded if they did not un- dergo a full ophthalmologic examination, never followed up after their injury, or had significant facial fractures outside of the orbit. Results: One hundred fifty patients met selection criteria; 116 patients (77 percent) completed all follow-up (average, 309 days). Two patients had 20/40 vision or worse at the end of follow-up. One hundred ten patients (71 percent) underwent surgery; 96 underwent acute repair (<3 weeks) and 11 underwent delayed repair (median, 49 days). Three patients required reopera- tion, two for plate infection and one for hyperglobus, with an overall complica- tion rate of 4.7 percent. Conclusions: The authors analyzed the largest series of operative pediatric orbital fractures to propose criteria for surgical intervention. There are four potential indications: (1) rectus muscle entrapment; (2) early enophthalmos; (3) central-gaze diplopia or extraocular movement restriction after the resolu- tion of swelling; and (4) loss of orbital support likely to produce secondary changes in globe position and/or binocular stereo vision. In our series, appli- cation of these principles offered excellent long-term aesthetic and ophthal- mic outcomes with an acceptably low complication profile. ( Plast. Reconstr. Surg. 137: 1234, 2016.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

I solated pediatric orbital fractures in the absence of other injuries warranting surgery represent a challenging and controversial area of manage- ment. 1–3 Some patients present with clear and abso- lute indications for reduction and internal fixation From the Department of Plastic Surgery and the Division of Oculoplastic Surgery, Wilmer Eye Institute, Johns Hopkins Medical Institutions. Received for publication July 10, 2015; accepted November 18, 2015. Presented at the 94th Annual Meeting of the American As- sociation of Plastic Surgeons, in Phoenix, Arizona, April 11 through 14, 2015, and recipient of the 2015 Johns Hop- kins/University of Maryland Plastic Surgery Dr. Chi-Tsung Su Award for Best Research. Copyright © 2016 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000002006

(e.g., restrictive strabismus with obvious muscle entrapment on imaging). 4 However, the majority of children will have a less clear clinical picture, with the risks of surgery balanced against the possibility of a secondary deformity that can be highly chal- lenging to correct (i.e., globe malposition). 5,6 Plastic surgeons may understandably have a higher thresh- old for recommending surgery to prevent potential enophthalmos in the context of surgical disruption of an orbit with residual growth potential of not only bone but also soft tissue and extraocular mus- cle function. 7 We aimed to quantitatively assess our experience with isolated pediatric orbital fractures

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

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