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Repair of isolated orbital floor fractures in children reduces preop pain, nausea
Patients who underwent early surgery had complete resolution of or improvements in preoperative duction deficits, diplopia or enophthalmos.
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MINNEAPOLIS, Minn. — Pediatric patients with isolated orbital floor fractures who experience pain, nausea, vomiting and severe extraocular motility limitations often have direct entrapment of the inferior rectus muscle into the fracture site. According to a recent study, surgical repair quickly relieves preoperative pain, nausea and vomiting.
“For pediatric patients with isolated orbital floor fractures, we recommend early surgery in those patients with severe duction deficits and inferior rectus muscle entrapment, particularly in those patients who have nausea, vomiting, pain with extraocular muscle movement or signs of the oculocardiac reflex. Patients receiving surgical repair within 1 month of injury were found to have complete resolution or improvements in preoperative duction deficits, diplopia or enophthalmos,” said James E. Egbert, MD, who conducted the study.
To evaluate the clinical presentation, operative findings and postoperative results of children with isolated orbital floor fractures, Dr. Egbert and his colleagues studied 34 patients with unilateral isolated orbital floor fractures. Included in the study were 31 boys and three girls who ranged in age from 5.5 to 17 years. Mean age was 12.4 years.
Caused by sports injuries
Most of the isolated orbital floor fractures were a result of injuries sustained while participating in sports. Almost half (48%) of the children older than 12 years had been exposed to interpersonal violence, while no children younger than 12 had been exposed to it. Of the 34 total patients, 62% exhibited nausea, vomiting or pain with eye movements. Additionally, 76% had a severe limitation of ocular movement.
“Eleven patients had enophthalmos develop before surgery, with six greater than or equal to 2 mm. For the five patients with less than 2 mm of enophthalmos, three had severe limitation of ductions, and two had large fractures with a risk of disfiguring enophthalmos if left untreated. Patients with enophthalmos or at risk for enophthalmos were less likely to have severe duction deficits than patients without enophthalmos,” Dr. Egbert said.
In 53% of patients, entrapment of the inferior rectus muscle into the fracture or maxilla was imaged by computed tomography. Nine patients had large fractures, 21 had trap-door fractures, three had hinged fractures and one had a comminuted fracture. “Patients with a trap-door type of fracture were more likely to have severe limitation of ocular ductions than patients with other types of fractures,” Dr. Egbert explained.
Time to surgery
Twelve patients underwent surgery within 7 days of injury, and 13 underwent surgery between 8 and 14 days after the injury. Five had surgery 15 to 21 days after the injury, and three had surgery between 22 and 28 days after injury. One patient did not have surgery until 3 months after the injury. “Sixty-two percent of all patients and 69% of patients with severe limitation of ocular ductions were found to have displacement of the inferior rectus muscle into the maxillary sinus through the orbital floor fracture. The remaining eight patients with severe limitation of ocular ductions had displacement of orbital fat and periorbital tissue into the maxilla,” he said.
The length of postoperative observation ranged from 1 day to 1 year. Extraocular duction improved in all but one patient after surgery. For patients who underwent surgery within 7 days of injury, the median time to improvement of preoperative duction deficit and diplopia was 4 days. For those who underwent surgery more than 14 days after the injury, the median time to improvement was 10.5 days. “For patients receiving surgery within 1 month of injury, the timing of surgery made no difference in time to complete resolution or occurrence of complete resolution of duction deficits or diplopia. Age, preoperative motility and type of fracture were not related to the rate of recovery of full ocular ductions or the presence or absence of diplopia in any field of gaze after surgery,” he explained.
Of the patients with enophthalmos or at risk for enophthalmos, three had residual enophthalmos at the last postoperative visit. “One patient with 3 mm of enophthalmos preoperatively had 1 mm postoperatively, and two patients with 2 mm of enophthalmos preoperatively had 2 and 1 mm of residual enophthalmos,” he said.
Two patients had postoperative complications. One had a cellulitis that resolved with parenteral antibiotics, and one had a subperiosteal hemorrhage that developed 1 day after fracture repair. No patient had loss of vision, worsening of motility, orbital abscess or extrusion of the orbital implant.
For Your Information:References:
- James E. Egbert, MD, can be reached at the department of ophthalmology, University of Minnesota Medical School, Box 493, 420 Delaware St., SE, Minneapolis, MN 55455-0501; (612) 625-4400; fax: (612) 626-3119.
- Egbert JE, May K, Kersten RC, Kulwin DR. Pediatric orbital floor fracture: Direct extraocular muscle involvement. Ophthalmology. 2000;107:1875-1879.