2017 Sec 1 Green Book

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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