2017 Sec 1 Green Book

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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