2017 Sec 1 Green Book

Plastic and Reconstructive Surgery • April 2016

Fig. 1. Management algorithm for surgical decision-making in pediatric orbital fractures.

In 104 cases (97 percent), an implant was placed (i.e., porous polyethylene, porous polyeth- ylene with titanium, or preformed anatomical tita- nium mesh). Of the three remaining cases, one involved a superomedial defect, one involved a very small floor defect with entrapped muscle that was felt to not require an implant, and one patient developed intraoperative mydriasis during poste- rior dissection and thus only a reduction after lim- ited dissection was performed. The three patients with nasoorbitoethmoid fractures also had reduc- tion of the medial canthal tendon–bearing bone fragment(s) with a titanium miniplate. Nonoperative Cohort The remaining 43 patients were managed nonoperatively because they did not have indica- tions for surgery. Younger age was strongly cor- related with a lower operative intervention rate ( p < 0.001; OR, 1.15 per year; 95 percent CI, 1.06 to 1.25). Follow-up completion rates were compara- ble between surgical and conservatively managed patients (81 percent versus 76 percent; p  = 0.5). Demographically, there were no significant differ- ences compared with the operative group except for age (Table 2). There were no cases of globe malposition in conservatively managed patients.

Outcomes Two patients had 20/40 vision or worse on the side of the fracture at the conclusion of follow- up. One patient had suffered a significant retinal injury and the other had suffered traumatic optic neuropathy caused by an orbital foreign body. In both cases, the final visual acuity was better than the preoperative visual acuity. A total of three patients (2.8 percent) had complications requiring reoperation. Two cases involved plate infection that resolved after implant removal and antibiotics. One patient underwent plate removal in a successful attempt to correct hyperglobus and diplopia. Three patients experi- enced postoperative globe malposition, with one patient demonstrating mild residual enophthal- mos and two patients (including the patient who underwent hardware removal) demonstrating mild hyperglobus. None of these patients demon- strated a functional impairment as a result of the globe malposition. There were no cases of eyelid malposition or unacceptable scarring. The overall complication rate was 4.7 percent. DISCUSSION Orbital fractures are among the most com- mon facial fractures in the pediatric population. 8,9

Table 2. Between-Cohort Differences

Overall

Surgical ( n = 107)

Nonoperative ( n = 43)

Age, yr

12.6 ± 4.2

13.3 ± 3.4

10.7 ± 5.4

12 yr or younger, %

31 73 52 41

25 75 46 47

44 70 69 24

Male sex, %

Race, %

 Caucasian

 African American

 Other

7

7

7

Follow-up, mo Diplopia, %*

10.2 51.5 58.7 16.8 1.4

10.1 62.5 74.3 20.6 2.0

10.2 22.2 20.9 7.5 0.0

Gaze restriction, %*

Initial VA worse than 20/40, % Final VA worse than 20/40, %

VA, visual acuity. *At the time of presentation.

26