Pediatric orbital floor fracture: Direct extraocular muscle involvement

doi:10.1016/S0161-6420(00)00334-1

Ophthalmology

Volume 107, Issue 10, October 2000, Pages 1875-1879

https://doi.org/10.1016/S0161-6420(00)00334-1 Get rights and content

Abstract

Objective

To study the clinical presentation, operative findings, and postoperative results of a surgical series of isolated orbital floor fractures in children.

Design

Noncomparative, retrospective, consecutive case series.

Participants

Thirty-four patients (34 orbits) less than 18 years of age with isolated orbital floor fractures. Indications for surgery were severe limitation of extraocular ductions, 22 of 34; enophthalmos, 8 of 34: or both, 4 of 34.

Intervention

Surgical repair.

Main outcome measures

Cause of fracture, symptoms, clinical signs, radiographic data, operative findings, postoperative results, and complications.

Results

Children older than 12 years of age were more likely to sustain an orbital floor fracture as a result of interpersonal violence than were children less than 12 years of age (P = 0.020). Sixty-two percent of patients (21 of 34) exhibited pain with eye movements and/or nausea and vomiting. Most had a trapdoor type fracture (21 of 34). The inferior rectus muscle was entrapped in the orbital floor fracture in 69% (18 of 26) of patients with a severe limitation of ocular ductions. Preoperative nausea and vomiting were immediately relieved after surgery. The median time for improvement of preoperative duction deficits and diplopia was 4 days for patients receiving surgery within 7 days and 10.5 days for those undergoing surgery after 14 days (P = 0.030). Resolution of duction deficits or diplopia was not dependent on time of surgery if performed within 1 month of injury. Loss of vision, worsening of motility, or implant complications did not occur.

Conclusions

Pediatric patients with isolated orbital floor fractures who had pain, nausea, vomiting, and severe limitation of extraocular motility often have direct entrapment of the inferior rectus muscle into the fracture site. Surgical repair rapidly relieved preoperative pain, nausea, and vomiting. For patients with severe limitation of ductions, early surgical repair within 7 days of injury resulted in more rapid improvement of ductions and diplopia than surgery performed later.

Section snippets

Materials and methods

Exemption from University of Cincinnati Institutional Review Board approval was obtained. The medical records from the practice of two of the authors were reviewed for the years 1985 to 1996. All patients included in the study were less than 18 years of age, had suffered an isolated orbital floor fracture confirmed by computed tomography (CT), and had undergone surgical repair. Surgery was performed after a period of observation, when CT imaging documented an orbital floor fracture, a severe

Results

Thirty-four patients (31 males and 3 females) with unilateral isolated orbital floor fractures were studied. The mean age was 12.4 years, and the range was 5.5 to 17 years, with a median age of 13 years. The mechanism of injury is listed in Table 1. Forty-eight percent of children older than 12 years of age had been exposed to interpersonal violence (10 of 21) compared with no children less than 12 years of age (0 of 13) (P = 0.020). The signs and symptoms at presentation are shown in Table 2.

Discussion

To our knowledge, this is the largest reported consecutive series of pediatric patients with isolated orbital floor fractures receiving surgical repair. Most patients had a severe limitation of ocular ductions caused by direct entrapment of the inferior rectus muscle into the fracture site, confirmed by CT. Many patients, especially those with muscle entrapment, had pain with eye movements, nausea, and/or vomiting. Surgery within 1 month of injury resulted in improvements of preoperative

Acknowledgements

The authors thank Mark G. Hans, DDS, MSD, Associate Professor and Chairman, Department of Orthodontics, Case Western Reserve University, Cleveland, Ohio, for his review and suggestions regarding the anatomy and physiology of the developing orbit.

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Pediatric orbital blowout fractures can include pathologies that seem mild but require urgent release; serious sequelae can occur with standby surgery or conservative treatment. We sought to validate an algorithm for the treatment of pediatric orbital blowout fractures.
This retrospective cohort study included 61 pediatric patients, aged 18 years or younger, treated for pure orbital blowout fractures according to the algorithm from April 1, 2000, to August 31, 2020, at the Japanese Red Cross Asahikawa Hospital.
There were 52 males (85%). Median age was 14 years (range, 5–18 years). There were 9 patients categorized as needing urgent release, 16 as needing repair, and 36 as needing conservative treatment. Mean follow-up ocular movement was 98.0 (95% Confidence Interval [95% CI], 96.8–99.2). Postoperative diplopia was not observed in 96% (79.6%–99.9%) of patients, better than in previous studies. A higher proportion of patients aged 0–12 years needed urgent repair than those aged 13–18 years (Odds Ratio [OR] = 14.2; 95% CI 1.6–683.4; p = 0.0046). There were no differences in Hess area ratio by age group.
Clinical results with the algorithm were satisfactory. The algorithm is suitable for treatment of pediatric orbital blowout fractures.
4.
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Citation Excerpt :
First, the importance of ordering a CT scan of the orbits and face instead of only a head CT in patients with a high suspicion of orbital floor injury. Since white-eyed blowout fractures with entrapment share symptoms with increased ICP, there is a need for a CT scan of the orbit to be ordered to completely rule out white-eyed blowout fractures before continuing with testing and treatment of increased ICP or other similar head injuries [1-3]. CT scans of the orbit are important in identifying fractures; however, they are limited in the detection of soft tissue entrapment and therefore pose the possibility of human error during the reading of the scan by a radiologist due to the “trapdoor” nature and return of the bone fragment to its original position [8].
Patients with white-eyed blowout fracture with muscle entrapment in the pediatric population may be misdiagnosed as increased intracranial pressure (ICP) due to the similarity in presenting symptoms. A delay in the correct diagnosis can lead to permanent sequelae including diplopia, permanent loss of vision, and death.
In this case report we discuss the treatment of a male pediatric patient who presented in the ED with nausea, confusion, and restricted eye gaze. He was misdiagnosed with increased intracranial pressure and was admitted to the PICU. Subsequent consultation by ophthalmology allowed for the correct diagnosis of a trapdoor fracture. The patient was taken to the OR for emergent orbitotomy with reduction of the fracture and release of the entrapped muscle.
Symptoms of white-eyed orbital blowout fractures with muscle entrapment easily mimic symptoms of head trauma with increased ICP. Misdiagnosis of trapdoor orbital fractures with entrapment can be avoided by ordering and critically reviewing an orbital CT and requesting an ophthalmologic consultation in the ED to evaluate extraocular movement. This report should help to increase awareness of symptoms of white-eyed orbital blowout fractures with muscle entrapment, prevent confusion with elevated ICP, and assist accurate and timely diagnosis in the ED to arrange appropriate management and surgical intervention to ensure best outcomes.

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^☆: Supported by an unrestricted grant from Research to Prevent Blindness, Inc., New York, New York.

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Pediatric orbital floor fracture: Direct extraocular muscle involvement☆

Abstract

Objective

Design

Participants

Intervention

Main outcome measures

Results

Conclusions

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

Br J Plast Surg

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Ophthalmology

Int J Oral Maxillofac Surg

Ophthalmology

Surv Ophthalmol

Blowout fracture of the floor of the orbit

Trans Am Acad Ophthalmol Otolaryngol

“Blowout” fractures of the orbitan investigation into their anatomical basis

J Laryngol Otol

Progressive infraorbital nerve hypesthesia as a primary indication for blow-out fracture repair

Ophthal Plast Reconstr Surg

Long-term follow-up of orbital blow-out fractures with and without surgery

Mod Probl Ophthalmol

A fracture trap, the trapdoor fracture of the orbital floor

Ann Chir Plast

Current concepts on the management of orbital blow-out fractures

Ann Plast Surg