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Pediatric Orbital Floor Fractures: Clinical and Radiological Predictors of Tissue Entrapment and the Effect of Operative Timing on Ocular Outcomes
Joseph M. Firriolo, MD, Nicole C. Ontiveros, BA, Carolyn M. Pike, MPH, John G. Meara, MD, DMD, MBA, Arin K. Greene, MD, MMSc, Oren Ganor, MD, Amir H. Taghinia, MD, MPH, Brian I. Labow, MD.
Boston Children's Hospital, Harvard Medical School, Boston, MA

PURPOSE: Although rare, orbital floor fractures in the pediatric population are cause for concern. Specifically, children’s bones exhibit considerable elasticity, increasing their risk of tissue entrapment. These injuries have the potential to produce acute constitutional symptoms and poor long-term ocular outcomes. This study aims to determine the clinical and radiological predictors of tissue entrapment and to establish how operative timing influences ocular outcomes.
METHODS: We retrospectively reviewed the medical records of pediatric patients who acutely presented with orbital floor fractures at our institution from October 2007 to October 2015. 152 patients, aged less than 18 years, were consulted, managed, and followed-up by pediatric plastic surgery and ophthalmology services. Patients were considered to have experienced poorer ocular outcomes at follow-up if they had persistent enopththalmos, extraocular movement restriction, or diplopia. Independent t-tests and Fisher’s exact tests were used to analyze the association between variables at both presentation and outcome. RESULTS: 152 patients with 159 orbital floor fractures (seven bilateral) were included in the study. 122 (80.3%) patients were male, and the mean age was 12.2 ± 4.2 years. Twelve patients (7.9%) sustained orbital floor fractures with tissue entrapment. At presentation, extraocular movement restriction, diplopia, nausea, and vomiting were all associated with tissue entrapment (P<0.001). Facial computed tomography scans detected all cases of tissue entrapment, with a sensitivity of 100% and specificity of 97.9%.

Signs and symptoms used to screen for tissue entrapment

Amongst patients with trapdoor fractures, the presence of nausea and/or vomiting was predictive of tissue entrapment: positive predictive value 80%, and negative predictive value 100%.For all patients, regardless of fracture configuration, vomiting alone had a negative predictive value of 94.1% for tissue entrapment. For patients with tissue entrapment, poorer ocular outcomes were significantly associated with the length of operation (P=0.007), but not with the time interval to operation (P=0.146).
CONCLUSION: Whilst EOM restriction and diplopia have a well-established relationship with tissue entrapment, they are often difficult to accurately assess in children in the emergency room setting. Pain and edema frequently complicate the interpretation of these signs, and a lack of cooperation during physical examination may also obscure deficits. Nausea and vomiting are valuable predictors of tissues entrapment, particularly when EOM restriction and diplopia are equivocal. In our study, radiological findings were predictive of entrapment, but a lack of consistent language in this area limits the external validity of these results. Our study also draws attention to the relationship between operation length and poorer ocular outcomes. Operation length may be a surrogate marker of case severity/complexity, surgical technique and/or surgeon experience; where possible, optimizing these factors may improve ocular outcomes.


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