Orbital Roof Fractures: An Evidence-Based Approach

What Computed Tomography Findings Are Predictive of Posttraumatic Enophthalmos in Orbital Fractures?

BACKGROUND

Enophthalmos is a surgical indication for orbital fracture repair. However, guidelines to predict enophthalmos in orbital fractures are ambiguous. The authors systematically reviewed the existing literature on using computed tomographic findings to establish objective metrics to predict enophthalmos in asymptomatic patients during initial trauma work-up.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. PubMed and Embase were used to identify studies of interest. The Quality in Prognosis Studies tool was used for risk of bias assessment. Random-effects model meta-analyses of orbital volume change and fracture area values were completed. Regression analyses were performed to determine thresholds that predicted 2 mm of enophthalmos.

RESULTS

Of the initial 2236 abstracts, 36 met inclusion criteria. Thirty retrospective studies evaluated a total of 2851 patients, and 6 prospective studies evaluated 211 patients. All 36 studies had predominantly low risk of bias. Predictors of enophthalmos assessed were orbital volume change (21 articles), fracture surface area (13 articles), inferior rectus muscle displacements (7 articles), and fracture location (4 articles). Studies reporting on orbital volume change offered values ranging from 0.69 to 4.26 cm 3 . Fracture area predictor values ranged from 1.50 to 3.38 cm 2 . Meta-analyses confirmed the validity of both predictors. Pooled regression analyses demonstrated that 3.33 cm 3 of orbital volume increase or fracture area of 3.12 cm 2 were predictors of 2 mm of enophthalmos.

CONCLUSIONS

Both orbital volume change and fracture area measured on computed tomographic scan are good predictors of late posttraumatic enophthalmos. Pooled data indicate that 3.12 cm 2 of fracture area or 3.33 cm 3 of orbital volume increase is predictive of enophthalmos.

A Rare Case of Traumatic Orbital Pseudomeningocele

A traumatic orbital pseudomeningocele is a rare complication of orbital trauma associated with orbital roof fractures and is underreported in the literature. Clinical signs may include proptosis, ophthalmoplegia, and diplopia, and when severe, there can be additional periorbital swelling from the anterior subcutaneous extension of the pseudomeningocele. We present a rare case of an orbital roof fracture resulting in an orbital pseudomeningocele with periorbital extension. CT is the preferred imaging modality for detecting orbital and other maxillofacial fractures, and it is sensitive to structural complications of this nature. In most cases, surgical repair is necessary. Our case emphasizes the significance of diagnostic imaging and collaborative care for optimal patient outcomes.

Innovative Solutions in Orbital Fracture Management: The Role of Computer-aided Design and Computer-aided Manufacturing Technology

Being the intricate architecture of the maxillofacial region, rehabilitation of maxillofacial abnormalities is relatively hard for most maxillofacial surgeons. Orbital roof fractures are among the most uncommon craniofacial abnormalities. The fact that these fractures "grow" makes treatment challenging. An encephalocele can form as a result of a hemorrhage or swelling caused by a dural rupture. These "growing" fractures are prevalent in children. The etiology of these fractures is uncertain; however, a dural laceration usually occurs along the fracture line. After a latency period, clinical signs and symptoms of an expanding fracture of the orbital roof are observed. During this latent time, the fracture expands in size during the growth stage, causing the brain to herniate and cause ocular symptoms such as eyelid swelling or exophthalmos. Computed tomography scans are commonly used to diagnose this type of fracture, and computer-aided design and computer-aided manufacturing (CAD/CAM) can be used to render the three-dimensional model for treatment planning. Growing orbital roof fractures must be investigated as a differential diagnosis in patients with chronic ocular complaints. The case study that follows sheds light on the relevance of the use of CAD/CAM technology for such patients in treatment planning.

An unusual presentation of orbital encephalocele following a self-inflicted gunshot wound injury: A case report and literature review

While orbital encephaloceles secondary to orbital roof fractures, in the setting of gunshot wound injuries, are rare, it is important to discuss diagnosis, treatment, and outcomes. This comprehensive manuscript aims to accomplish these objectives.

Clinical characteristics and associated features of pure orbital roof fractures: A ten-year retrospective review

PURPOSE

To present the demographics and clinical characteristics of pure (rim-sparing) orbital roof fractures.

METHODS

This retrospective observational study used 10 years of data from a single institution. Patient age, sex, laterality, field of binocular single vision, associated injuries, and radiologic features were analyzed. Orbital roof fractures were categorized into four groups: comminuted/open, hinged, trapdoor, and linear. These were further subdivided into blow-in (-down) and blow-out (-up) fractures. Injury etiology was classified into fall, traffic accidents, sports injuries, assault, work-related, and others.

RESULTS

Data documented a low incidence rate of 2.5% (27 patients) in 1074 patients. Most patients were male (81%). The most common cause of injury was fall (48%), followed by traffic accidents (22%). Comminuted/open fractures constituted the bulk of fracture types (54%), followed by hinged, and linear fractures. Blow-in and blow-out fractures had an incidence rate of 50% each. Concomitant fractures of the medial and inferior orbital walls were predominant. Low surgical intervention was noted owing to acceptable field of binocular single vision outcomes, and the field of binocular single vision included the primary position of gaze in 88% of patients.

CONCLUSION

Pure orbital roof fractures occurred in 2.5% of patients with pure orbital fractures. Patients were predominantly male with trauma caused by high energy forces, which regularly caused comminution of the roof and fractures of the medial and inferior orbital walls. Most patients were managed conservatively.

Traumatic Orbital Roof Fracture With Superior Rectus Entrapment in a Pediatric Patient

Pediatric patients often present with orbital fractures after facial trauma, most commonly fractures of the orbital floor. Evaluation of orbital fractures for entrapment of the extraocular muscles is crucial, as urgent surgical exploration and possible repair are needed in these cases. We report a 2-year-old male who presented after a fall with multiple left orbital wall fractures, including a roof fracture. On examination, the patient's OS appeared fixed in an upward gaze. Positive forced ductions revealed clinical concern for entrapment of the superior rectus. The patient was taken to the operating room for exploration, and the entrapped superior rectus muscle was freed from the fracture. The patient subsequently recovered fully with complete extraocular movements. This represents the first reported case of superior rectus entrapment in an orbital roof fracture.

Successful Management of Post-Traumatic Residual Orbital Roof Defects with Cosmetic Disfigurement and Functional Deficits Using Innovative Titanium Plate Orbitoplasty

Introduction

Late presentations of post-traumatic residual orbital roof deformities ensuing from old, unaddressed orbital injuries, can be extremely challenging to manage and quite complicated to correct, owing to proximity of the brain and frontal sinus, malunion or bony fusion of the displaced, delicate orbital fracture fragments, necrosis of entrapped extraocular muscles and progressive intraorbital soft tissue fibrosis and adhesions. There exists a paucity in literature on delayed repair of displaced and comminuted orbital roof fractures and late reconstruction of the three-dimensional architecture of the orbital frame and internal orbit.

Aim & Objectives

To present an unusual case of severe post-traumatic residual orbital roof deformity, resulting in longstanding aesthetic disfigurement and persisting functional deficits, and its successful management.

Material & Methods

The patient had sustained orbital injuries sixteen months ago, on being punched in the face at a boxing tournament. The increased orbital volume produced by an impure blowout fracture of the left orbital roof, with comminution of the upper and lower orbital rims, had resulted in considerable cosmetic deformity, discomfort as well as functional debility, all of which were successfully and efficaciously managed by an innovative use of a Titanium Orbital Plate for orbital roof reconstruction.

Discussion

Overlooked, undetected or ignored derangements in intraorbital volume and contour, can lead to severe cosmetic disfigurement in the form of enophthalmos, hypoglobus, entropion, telecanthus, palpebral fissure width narrowing and ptosis; in addition to crippling functional deficits, such as diplopia, blurred vision, levator dysfunction, restricted ocular motility and reduced visual range and acuity.

Results & Conclusions

An innovative Titanium mesh orbitoplasty enabled achievement of both, the aesthetic and functional goals of reconstruction of the distorted bony orbit, with successful correction of severe functional and aesthetic deficits.

Predictors of Surgical Versus Medical Management of Eyes in the Setting of Orbital Fracture at an Academic Level I Trauma Center

We present clinical and imaging predictors of ocular injuries that required medical management versus surgical intervention in cases of orbital fractures. From 2014 to 2020, a retrospective review of patients with orbital fractures who received ophthalmologic consultation and computed scan (CT) analysis at a level I trauma center was performed. Inclusion criteria were patients with confirmed orbital fracture on CT and ophthalmology consultation. Patient demographics, associated injuries, comorbidities, management, and outcomes were collected. Two hundred and one patients and 224 eyes (11.4% bilateral orbital fractures) were included. Overall, 21.9% of orbital fractures presented with a significant concomitant ocular injury. Associated facial fractures were present in 68.8% of eyes. Management included surgical treatment in 33.5% of eyes and ophthalmology-directed medical treatment in 17.4%. On multivariate analysis, clinical predictors of surgical intervention were retinal hemorrhage (OR=4.7 (1.0-21.0), P =0.0437), motor vehicle accident injury (OR=2.7 (1.4-5.1), P =0.0030) and diplopia (OR=2.8 (1.5-5.3), P =0.0011). Imaging predictors of surgical intervention were herniation of orbital contents (OR=2.1 (1.1-4.0), P =0.0281) and multiple wall fractures (OR=1.9 (1.01-3.6), P =0.0450). Predictors of medical management were corneal abrasion (OR=7.7 (1.9-31.4), P =0.0041), periorbital laceration (OR=5.7 (2.1-15.6), P =0.0006), and traumatic iritis (OR=4.7 (1.1-20.3), P =0.0444). We demonstrated a 22% incidence of concomitant ocular trauma in orbital fracture patients at our level I trauma center. Predictors of the surgical intervention included multiple wall fractures, herniation of orbital contents, retinal hemorrhage, diplopia, and motor vehicle accident injury. These findings emphasize the importance of a multidisciplinary team in managing ocular and facial trauma.

Pediatric orbital fractures

PURPOSE OF REVIEW

The aim of this study was to summarize current evidence on the clinical presentation, evaluation, and management of pediatric orbital fractures. Recent trends in management strategies as well as emerging surgical techniques for pediatric orbital fracture repair are presented.

RECENT FINDINGS

Although somewhat limited, growing bodies of evidence support a conservative approach with close follow up in pediatric orbital fractures. For those patients necessitating surgical repair, resorbable implants are increasingly preferred given their lack of donor site morbidity and a minimal impact on the developing craniofacial skeleton. There are emerging data reporting the use of three-dimensional (3D) printing-assisted approaches and intraoperative navigation; however, more research is needed to assess their applicability in the pediatric population.

SUMMARY

There are few studies with large patient cohorts and long-term follow up given the rare incidence of pediatric orbital fractures, which restricts the generalizability of research on the topic. The studies available increasingly suggest that fractures without clinical evidence of entrapment can be managed conservatively with close follow up. A variety of reconstructive implants are available for those fractures necessitating repair. Donor site morbidity, availability, and need for additional procedures should all be factored into the reconstructive decision-making process.

Supramuscular upper blepharoplasty approach to orbital roof and/or lower anterior table frontal sinus fractures: A meta-narrative review

BACKGROUND

An approach to orbital roof fractures (ORFs) and/or lower anterior table frontal sinus fractures (LATFSFs) is a challenging task. The conventional coronal approach (CCA) appears to suit multiple/complex fractures of the upper face, while periorbital transcutaneous incisions (PTIs), e.g. gull wing, open sky, butterfly, and Lynch incisions, often impair aesthetic outcomes. The aims of this paper were to provide an overview of the supramuscular upper blepharoplasty approach (SUBA) to ORFs/LATFSFs.

METHODS

Using a meta-narrative review study design, the investigators enrolled published data extracted from PubMed/Medline, Embase, Cochrane Library, and Google Scholar concerning SUBA to ORFs/LATFSFs. Only publications with the highest and most recent level of evidence (LoE) in English, French or German available until 6 May 2022 were included. The LoE were evaluated using the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM)'s classification.

RESULTS

In total, 70 articles were included; however, most contained low LoE. Under general and local anaesthesia, SUBA to ORFs/LATFSFs can be performed safely and appeared to be superior to its submuscular counterpart in terms of fewer risks of adjacent tissue injuries, and speedy operative time (maximal 5 min. in experienced hands).

CONCLUSIONS

In contrast to CCA and PTIs, the SUBA is a minimally invasive approach to the ORF/LATFSF with favourable aesthetic outcomes, direct visualisation of the fracture, quick operative time, rare complications, and easy learning.

The Management of Orbital Roof Fractures and Defects: A Review

PURPOSE

To explore the anatomy, etiopathogenesis, diagnosis and classification, current evidence on intervention and the surgical management of orbital roof fractures and defects (ORFD) for oculoplastic surgeons presented with such cases.

METHODS

A review of the current literature through the MEDLINE database using the following search terms: "orbital roof fracture (+treatment/management)," "orbital roof defect (+treatment/management)," "orbital roof erosion (+treatment/management)," "orbital roof repair," "orbital roof," "orbital fracture," "pediatric orbital roof (defect/fracture/erosion)," "orbital anatomy," and "orbital roof anatomy" was conducted. As relatively little has been published on this topic, inclusion criteria were broad and peer-reviewed articles judged to be of clinical importance, relevant to the aims of this review, were included. Non-English abstracts were also included if relevant. Year of publication was not a strict exclusion criterion, and older articles were judged for their suitability based on clinical importance and relevance to current practice. Additional references were obtained from citations in key articles and recommendations from the coauthors based on their areas of expertise.

RESULTS

The etiopathogenesis of ORFD varies. Classification systems have been formulated to guide management decisions and can range from conservative management to complex neurosurgery. Eyelid approaches have also been described. This review provides a summary of the evidence for each and a management framework oculoplastic surgeons can use when presented with ORFD.

CONCLUSION

Oculoplastic surgeons can be involved, either alone or as part of a multidisciplinary team, in the management of ORFD, and for some, conduct orbital approach reconstructive surgery.

Pediatric Facial Fractures

Facial trauma is common in the pediatric population with most cases involving the soft tissue or dentoalveolar structures. Although facial fractures are relatively rare in children compared with adults, they are often associated with severe injury and can cause significant morbidity and disability. Fractures of the pediatric craniomaxillofacial skeleton must be managed with consideration for psychosocial, anatomical, growth and functional differences compared with the adult population. Although conservative management is more common in children, displaced fractures that will not self-correct with compensatory growth require accurate and stable reduction to prevent fixed abnormalities in form and function.

Approach to Orbital Fractures After Athletic Injuries

The bony orbit is commonly involved in athletic injuries. Evaluation should include a comprehensive history and ocular examination. Computed tomography imaging is the gold standard for diagnostic testing. Urgent surgical intervention for orbital floor fractures should occur after "white eye" trapdoor fractures or if oculocardiac response occurs. Most orbital fractures do not require urgent intervention and repair can be completed within 2 weeks of injury. There are many approaches to repair orbital fractures, and consideration of techniques depends on the unique fracture pattern. Intraoperative computed tomography has become frequently used and can lead to increased identification of plate malpositioning intraoperatively.