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Floor fractures are the most common pediatric orbital fracture, surgeon says
Study finds strong association between nausea/vomiting and trapdoor fractures.
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---Sixteen-year-old boy sustained left orbital trauma, showing marked restriction of supraduction left eye.
ORLANDO, Fla. — A 5-year review of 34 pediatric patients (ages 1 to 18) with internal orbital fractures at the Albany Medical Center reveals that about one-third of these injuries are caused by assault, including horseplay. In addition, nearly two-thirds of patients were identified with pure internal orbital fractures (that is, those without involvement of the orbital rim), while about one-third had impure internal fractures (that is, those that extended through the orbital rim).
“The orbital floor was by far the most common fracture location, representing over 70% of the walls involved,” said senior author Dale R. Meyer, MD, an associate professor of ophthalmology at Albany Medical College in Albany, N.Y. “Recent publications from several disciplines evaluating the pediatric age group have suggested an increased potential for ‘trapdoor’ type fractures with extraocular muscle entrapment that may require expeditious repair to restore motility and reduce the possibility of soft tissue ischemia and necrosis. The frequency and characteristics of this phenomenon, however, are not well established,” said Dr. Meyer, who presented study results here at the American Academy of Ophthalmology.
Trapdoor fractures occurred in eight of 34 patients (24%). “All trapdoor fractures occurred in the subgroup of patients with pure internal orbital fractures,” Dr. Meyer said. In addition, seven of the eight trapdoor fractures involved the orbital floor, with only one being a medial wall fracture.
Vertical motility impairment
---CT scan showing left trapdoor-type fracture of the orbital floor.
Vertical motility impairment, either supraduction or infraduction limitation, was by far the most common limitation. Other than for one exception, “it was associated with fracture of the orbital floor, as you might expect,” Dr. Meyer said. Of the 27 patients with floor fractures, 13 had supraduction limitation, with 11 of these cases also having infraduction limitation.
“Initial ocular motility restriction was present in 44% of the patients,” Dr. Meyer said. However, enophthalmos greater than 2 mm only appeared in one of these patients. Furthermore, nausea and vomiting were presenting symptoms in 21% of patients overall. “All seven patients had pure internal orbital fractures, five being trapdoor type,” Dr. Meyer said.
The association between trapdoor fractures and ocular motility restriction was quite strong. “Indeed, all eight patients with trapdoor fractures demonstrated reduced ocular motility,” Dr. Meyer said. “In the subset of patients with floor fractures where trapdoor fractures tended to occur, there was much greater supraduction limitation in those with trapdoor fractures than in those without trapdoor fractures.”
Nausea/vomiting and trapdoor fractures
---Surgical exploration confirms orbital fracture with soft-tissue entrapment.
The study also found a strong link between nausea/vomiting and trapdoor fractures. “Of the seven patients with nausea/vomiting, five had trapdoor fractures,” Dr. Meyer said. Nausea/vomiting was thus “63% sensitive for the presence of trapdoor fractures and 92% specific for the entire group of 34 patients with internal orbital fractures.” Overall, the positive predictive value of nausea/vomiting for identifying trapdoor fractures in the group was 71%.
“We believe that nausea and vomiting may be a vagal-mediated response to pain or other sensory feedback associated with extraocular muscle entrapment,” Dr. Meyer said. “The mechanism is probably closely related to the oculocardiac reflex, which has recently been reported.”
In total, 11 patients underwent surgical expiration and repair for ocular motility restriction. “Eight of these were trapdoor fractures,” Dr. Meyer said. Nine surgeries were performed for repair of floor fractures, one for medial wall fracture and one for combined floor and lateral wall fracture. And while all patients showed improvement in ocular motility at their 3-month follow-up, “we found that the degree of ocular motility recovery was more complete in the group of patients who had surgical intervention in less than 13 days compared with those that underwent intervention later,” Dr. Meyer said.
Emergent interventions may be necessary
---Improved ocular motility following surgical repair.
At the meeting, Mark R. Levine, MD, past president of the American Society of Ophthalmic Plastic and Reconstructive Surgery and clinical professor of ophthalmology at Case Western Reserve University School of Medicine, critiqued the study. “I consider this to be a significant paper,” he said. The timing for surgical intervention “is somewhat controversial, ranging anywhere from a couple of days to a few weeks.” Although the authors considered 2 weeks to be a conservative, middle-of-the-road standard, “there are interventional periods that require slightly more immediate emergent intervention, such as a globe herniated into the maxillary sinus, or a small orbital fracture with a significant incarcerated extraocular muscle,” Dr. Levine said.
The authors also made a strong argument for early surgical intervention in the pediatric patient. However, only two patients were operated on within 48 hours. “These two patients had much more rapid recovery than those operated on 10 days to 13 days later,” Dr. Levine said. “A stronger case could have been made if more cases were operated on earlier, but at the Albany Medical Center, patients were seen 7 days following trauma and surgical intervention on average took place a full 13 days following trauma.”
On the other hand, Dr. Levine noted that the current study supports the findings of other papers that “emphasize much earlier surgical intervention to improve surgical outcome by preventing muscle ischemia.” In addition, “Computerized tomography may be difficult to identify small trapdoor fractures; therefore, it is incumbent upon surgeons not only to see the patient, but to review the films, as well.” Marked motility restriction, along with nausea and vomiting, “should alert the physician to the possibility of a trapdoor fracture and expedite the need for prompt surgical intervention,” he said.
For Your Information:
- Dale R. Meyer, MD, can be reached at Lions Eye Institute, 35 Hackett Blvd., Albany, NY 12208; (518) 262-2540; fax: (518) 262-2516; e-mail: meyerd@mail.amc.edu. Dr. Meyer has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Mark R. Levine, MD, can be reached at Ophthalmic Consultants and Surgeons, 26900 Cedar Road, Ste. 311, Beachwood, OH 44122; (216) 464-5028; fax: (216) 464-9398. Dr. Levine has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.