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Surgical outcomes of orbital trapdoor fracture in children and adolescents
Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 444e447
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Surgical outcomes of orbital trapdoor fracture in children and adolescents Jae Wook Yang b, Jong Eun Woo a, Jae Hwan An a, * a b
Department of Ophthalmology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Republic of Korea Department of Ophthalmology, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 18 May 2014 Accepted 19 January 2015 Available online 27 January 2015
Purpose: Orbital trapdoor fractures are uncommon but more frequent in children and adolescents. Orbital trapdoor fractures have been discussed in many previous reports, early treatment has been advocated but there is controversy over treatment policy and surgical outcomes. Our retrospective study analyzed the surgical outcomes of orbital trapdoor fracture in children and adolescents to investigate the appropriate timing of treatment and the relationship between severity of extraocular muscle movement (EOM) limitation before the operation and the period of recovery after operation. Methods: A total of 44 children and adolescents with orbital wall fractures were operated on from 2009 to 2013. This study included 25 patients who underwent surgery for orbital trapdoor fractures; age range 9e18 years (mean age 14.0). We investigated the interval from trauma to surgery, the period of full EOM recovery after operation and the correlation between these factors, retrospectively. Results: The mean follow-up duration was 90.2 days. At follow-up, nine out of ten patients who underwent surgery within 24 h (Group 1) had full EOM recovery, with a mean recovery time of 25.1 days; five out of six patients who underwent surgery within 24e72 h (Group 2) had full EOM recovery with a mean recovery time of 60.2 days; and seven out of nine patients who underwent surgery after 72 h (Group 3) had full EOM recovery with a mean recovery time of 67.6 days. There was no statistical difference in the operation success rates between the groups. Also, the four patients that not completely recovered EOM had a mild EOM limitation below grade 1. Conclusion: In our study, we found that patients with orbital trapdoor fractures can recover full EOM regardless of the interval from trauma to surgery. Therefore, we suggest that appropriate surgical technique is important in the treatment of patients with orbital trapdoor fractures, in addition to the urgent surgery recommended for these fractures in a pediatric population. Furthermore, we expect a good prognosis following the treatment of orbital trapdoor fractures if appropriate surgical techniques are used, even if a relatively long time has passed after the trauma. © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Adolescents Children Orbital trapdoor fracture Surgical outcomes
1. Introduction Orbital floor blowout fractures of the trapdoor type are more frequent in children and adolescents than in adults because children and adolescents have greater elasticity of the facial bones than adults (Jordan et al., 1998; Basangi and Meyer, 2000; Egbert et al., 2000). These fractures allow herniation and entrapment of the orbital contents, resulting in limitation of * Corresponding author. Department of Ophthalmology, Ulsan University Hospital, Ulsan University College of Medicine, 290-3 Jeonha-dong, Dong-gu, Ulsan, 682-714, Republic of Korea. Tel.: þ82 52 250 7170; fax: þ82 52 250 8200. E-mail address: [email protected] (J.H. An).
extraocular muscle movement (EOM), diplopia, pain in eyeball movement, nausea and vomiting (Soll and Poley, 1965; Stotland and Do, 2011). Orbital trapdoor fractures in younger patients have been studied and discussed widely in published reports. However, the treatment policy and outcome remain controversial, although many have advocated early treatment (Matteini et al., 2004; Holck and Ng, 2006; Criden and Ellis, 2007; Gerbino et al., 2010). Our retrospective study analyzed the surgical outcomes of pediatric and adolescent patients who had undergone surgery for orbital trapdoor fractures of the orbital floor to determine the outcome in relation to the interval to surgery.
http://dx.doi.org/10.1016/j.jcms.2015.01.010 1010-5182/© 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
J.W. Yang et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 444e447
2. Material and methods From January 2009 to September 2013, 44 children and adolescents with orbital wall fractures underwent surgery at the Ophthalmology Department of the Inje University Busan Paik Hospital, Korea. Of these, a total of 25 patients had orbital trapdoor fractures. The age range was 9e18 years old. The diagnosis of trapdoor fracture was made from preoperative computed tomography (CT) images, and clinical symptoms of severe pain on eyeball movement, diplopia, nausea and vomiting, and minimal soft tissue swelling and ecchymosis. The mean follow-up duration was 90.2 days. Pediatric patients with incomplete clinical and radiological evidence were excluded from this study. Of the 25 patients enrolled in this study, 23 were boys and 2 were girls. Cause of fractures, interval to surgery, preoperative limitation of EOM, follow-up duration, postoperative EOM limitation and diplopia were recorded for retrospective analysis. Preoperative EOMs were determined on a scale of 0 to 4, with 0 representing no limitation and 4 representing no movement into that field of gaze. Additionally, we measured the distance between both corneal limbus margins in each direction of gaze. If the distance between both corneal limbus margins is 1 mm, we graded 1. In the same method, if the distance is 2 mm, 3 mm and 4 mm or more, we graded 2, 3 and 4. Surgery was determined mainly on the basis of clinical evidence of muscle entrapment and CT confirmation of trapdoor fracture (Fig. 1). The surgical intervention was a transconjunctival (fornix) approach to the orbital floor in each case. After visualizing the posterior margin of the fracture site, the entrapped orbital contents were restored gently into the orbit. If the entrapped muscle and tissue was not fully
445
corrected because of tight entrapment between the fractured bones, we broke the fractured bones to allow restoration of the orbital contents. The fractured orbital floor was patched using MEDPOR (Stryker, Kalamazoo, MI, USA) to prevent postoperative herniation and entrapment. Forced duction tests were performed at the end of surgery to confirm the complete release of entrapped tissue as part of each procedure. We analyzed the data using Microsoft Excel 2010 and SPSS 21.0 (IBM, Portsmouth, UK). 3. Results Since 2009, we performed surgery on a total 44 children and adolescents, 25 of these were diagnosed with orbital trapdoor fractures. The 25 patients with trapdoor fractures included 22 with inferior orbital wall fractures and three with medial orbital wall fractures. The average age of the 25 patients at the time of the fracture was 14.0 years and the most common causes of orbital wall fractures were games (8 patients) and violence (8 patients) (Table 1). We classified the patients into three groups according to the time interval between trauma and surgery. Group 1 contained 10 patients who underwent surgery within 24 h (urgent treatment). Group 2 contained six patients who underwent surgery between 24 and 72 h. Group 3 contained nine patients who underwent surgery after 72 h. The average interval to surgery was 92.9 h (Table 2). The average time to surgery for patients in Group 1 was 20.6 h; for Group 2 it was 48.7 h; and in Group 3 it was 202.7 h. In addition, the average EOM limitation for Group 1 was 3.3; for Group 2 it was 3.5 and for Group 3 it was 2.6. The average preoperative
Fig. 1. A male 15-year-old patient had an inferior orbital trapdoor fracture due to bumping into another friend's head. 1 day after trauma, (A) supraduction; and (B) infraduction limitation of left eye was noted with grade 3; (C) CT image pre-operation. Inferior orbital trapdoor fracture was noted with frank muscle entrapment (red arrow); (D) CT image post-operation. Entrapped inferior rectus muscle was recovered.
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J.W. Yang et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 444e447
Table 1 Summary of patient information. Patient No.
Age (yrs)
Sex
Group 1 (Interval to surgery 1 15 Male 2 14 Male 3 15 Male 4 16 Male 5 14 Male 6 14 Male 7 13 Male 8 12 Male 9 14 Male 10 12 Male Group 2 (Interval to surgery 11 18 Male 12 9 Female 13 13 Male 14 11 Male 15 9 Female 16 18 Male Group 3 (Interval to surgery 17 15 Male 18 15 Male 19 16 Male 20 11 Male 21 12 Male 22 14 Male 23 15 Male 24 17 Male 25 18 Male
Cause
Vagal symptoms (nausea/vomiting)
within 24 h) Violence N/V Violence N/V Violence N/V Slipdown N/V Violence N/V Game e Unknown N/V Game e Violence N/V Game N/V from 24 to 72 h) Slipdown N/V Slipdown e Game e Game N/V Game e Game N/V after 72 h) Sport e Post-op (BOFx) e Violence e Slipdown e Sport N/V Violence e Violence N/V Game e Sport e
True muscleentrap-ment on CT images (M)
Interval to surgery (hours)
Pre-operative EOM limitation (grade)
Follow-up duration (days)
Interval to full EOM recovery (days)
Post-operative EOM limitation (grade)
M M M M e e M M e e
5 24 24 24 24 24 24 24 24 9
4 3.5 3 3 2 2 4 4 4 3
30 90 30 30 150 7 30 30 90 7
7 1 30 1 30 30 90 7
Full 0.5 Full Full Full Full Full Full Full Full
e M M e e M
28 72 48 48 48 48
3 4 4 4 4 2
7 90 90 270 30 30
90 90 90 1 30
0.5 Full Full Full Full Full
M e e e M M e e e
120 720 192 144 120 168 96 168 96
4 2 2 3 4 2.5 2 1.5 2
120 450 90 30 330 30 90 90 14
EOM limitation was 3.1 in all patients. The average follow-up duration was 90.2 days; Group 1 average 49.4 days; Group 2 average 86.2 days; and 138.2 days in Group 3. Three patients had orbital medial wall fractures (one patient in each group). After surgery, full recovery of EOM was achieved in nine patients out of ten in Group 1 (90%); five patients out of six in Group 2 (83.3%); and seven patients out of nine in Group 3 (77.8%). There was no statistical difference in operation success rates between the groups (KruskaleWallis test, p ¼ 0.368). Four patients had mild EOM limitation with grade 0.5; one patient in Group 1, one in Group 2, and two patients in Group 3. The average follow-up duration was 50.25 days; two patients for 90 days, one patient for 7 days and the other patient for 14 days. We analyzed correlation between interval to surgery and interval to full recovery of EOM limitation. The interval to full EOM recovery in Group 1 was 25.1 days; in Group 2 it was 60.2 days; and in Group 3 it was 67.6 days. The result showed that extension of the time interval to surgery tended to lengthen the interval to full EOM recovery. However, the KruskaleWallis test showed that the difference between groups was not statistically significant (p ¼ 0.350). We also analyzed the correlation between the severity of EOM limitation at the moment of initial examination and the period of
30
30 180 30 180 30 90 1
Full Full 0.5 Full Full Full Full Full 0.5
time to full EOM recovery. In Table 3, we classified four groups according to the initial grade of EOM limitation. The only patient with grade 1 had recovered full EOM in 1 day. Patients with grade 2 recovered in 60.2 days; grade 3 in 11.3 days and grade 4 in 66.1 days. The average period of full EOM recovery was 50.9 days. There was no statistically significant correlation between severity of EOM limitation before operation and the period of time to full EOM recovery after operation (nonparametric correlation coefficient of Kendall and Spearman, p ¼ 0.1 in Kendall, p ¼ 0.114 in Spearman). We operated on three patients with medial orbital wall trapdoor fractures. All of them had EOM limitation grade 2. Two of these patients recovered with full EOM: the Group 1 patient after 1 day, and the Group 2 patient after 30 days. The third patient (Group 3) had mild EOM limitation with grade 0.5 at 2 weeks follow-up. It is difficult to distinguish between true muscle entrapment and pure soft tissue (e.g. periorbital fat) entrapment on CT images in patients of trapdoor fracture. In this study, six patients out of ten in Group 1 (60%), three patients out of six in Group 2 (50%), and three patients out of nine in Group 3 (33.3%) showed definite muscle entrapment on CT images. There was no difference in prognosis after surgery between cases with definite muscle entrapment and
Table 2 Summary of each patient group.
Group 1 Group 2 Group 3 Total
Patients (n)
Age (yrs)
Interval to surgery (hours)
Pre-operative EOM limitation
F/U duration (days)
Interval to full EOM recovery (days)
Post-operative full EOM limitation
Post-operative diplopia
10 6 9 25
13.9 13.0 14.8 14.0
20.6 48.7 202.7 92.9
3.3 3.5 2.6 3.1
49.4 86.2 138.2 90.2
25.1 60.2 67.6 50.9
9/10 5/6 7/9 21/25
1/10 1/6 2/9 4/25
J.W. Yang et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 444e447 Table 3 Correlation between the severity of EOM limitation and period of full EOM recovery. Grade of EOM limitation
Period of full EOM recovery (days)
Remarks
1 2 3 4 Total
1 60.2 11.3 66.1 50.9
1 patient in grade 1.5 1 patient in grade 2.5 1 patient in grade 3.5
cases with pure soft tissue entrapment on CT images. In four patients who did not recover completely and had EOM limitation at last follow-up, only one case showed definite muscle entrapment on CT images, three cases did not. 4. Discussion A total of 25 patients with orbital trapdoor fractures who had undergone surgical correction were studied. Children and adolescents have a different pattern of orbital wall fracture to that seen in adults. The increased elasticity and flexibility of the facial bones in children results in fractures with soft tissue and muscle entrapment (Jordan et al., 1998; Grant et al., 2002; Kwon et al., 2005; Cobb et al., 2013). Earlier surgical treatment shows better outcomes in terms of restoration of ocular mobility (Egbert et al., 2000; Manson et al., 2002; Joshi et al., 2011; Neinstein et al., 2012) but, there is no consensus that treatment delay can increase clinical risk. Some investigators have considered early treatment to include treatment up to 3e5 days or more after the trauma (Burnstein, 2002; Wang et al., 2010; Wei and Durairaj, 2011). In our study, considering the interval between the trauma and surgery, the success rate was 90% (9/10) for urgent surgery within 24 h, 83.3% (5/6) for early surgery between 24 and 72 h, and 77.8% (7/9) for late surgery more than 72 h after trauma. These results showed that there was no statistically significant difference between the interval to surgery and operation success rate for orbital trapdoor fracture surgery. The results suggest that patients with orbital trapdoor fractures can recover with full EOM regardless of the time interval from trauma to surgery. Therefore, we suggest that appropriate surgical technique is also important in the treatment of patients with orbital trapdoor fractures in addition to the urgent surgery recommended in a pediatric population. It is important to completely free entrapped and herniated muscle and tissue when operating on orbital trapdoor fractures. If the entrapped muscle and tissue is not fully released, EOM limitation and diplopia can continue. So, we suggest that when operators approach the fractured site, they ensure that the posterior margin of the fracture is checked to confirm the complete release of entrapped muscle and tissue. Furthermore, one patient with an inferior orbital wall trapdoor fracture who had initial surgery in the department of plastic surgery required a second operation 1 month later. He was 15 years old and had grade 2 in infraduction. At the second operation, we discovered some tissue that had remained entrapped at the fracture site; this was corrected completely and the tissue fully released. He needed 6 months to fully recover EOM and was followed up for 15 months. Therefore, we suggest that patients with orbital trapdoor fractures can expect a good prognosis, with full EOM recovery following appropriate surgical intervention even though they have a long interval from trauma to surgery. Also, we investigated the correlation between the initial severity of EOM limitation and the interval to full EOM recovery. There is no
447
statistically significant difference between the initial severity of EOM limitation and the time interval to full EOM recovery. Four patients still had mild EOM limitation at grade 0.5; they initially had EOM limitations of grade 2, 2, 3 and 3.5. The follow-up duration ranged from 7 to 90 days and we think that they will need long term follow-up. In addition, we had experience of three cases of medial orbital wall trapdoor fractures. Two patients recovered full EOM and no other complications; one patient had mild EOM limitation with grade 0.5 in adduction but he was only followed up for 2 weeks. 5. Conclusion We suggest that appropriate surgical technique is also important in the treatment of patients with orbital trapdoor fractures in addition to the urgent surgery which is recommended for orbital trapdoor fractures in a pediatric population. Furthermore, we expect a good prognosis following the treatment of orbital trapdoor fractures if appropriate surgical techniques are used, even if a relatively long time has passed after the trauma or there is severe EOM limitation at the time of trauma. Conflict of interest This work was supported by the 2013 Inje University Research Grant. Acknowledgment This work was supported by the 2013 Inje University Research Grant. References Basangi ZC, Meyer DR: Internal orbital fractures in the pediatric age group, characterization and management. Ophthalmology 107: 829e836, 2000 Burnstine MA: Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. Ophthalmology 109: 1207e1210, 2002 Cobb ARM, Jeelani NO, Ayliffe PR: Orbital fractures in children. BJOMS 51: 41e46, 2013 Criden MR, Ellis FJ: Linear nondisplaced orbital fractures with muscle entrapment. J AAPOS 11: 142e147, 2007 Egbert JE, May K, Kersten RC, Kulwin DR: Pediatric orbital floor fracture: direct extraocular muscle involvement. Ophthalmology 107: 1875e1879, 2000 Gerbino G, Roccia F, Bianchi FA, Zavattero E: Surgical management of orbital trapdoor fracture in a pediatric population. J Oral Maxillofac Surg 68: 1310e1316, 2010 Grant JH, Patrinely JR, Weiss AH, Kierney PC, Gruss JS: Trapdoor fracture of the orbit in a pediatric population. Plast Reconstr Surg 109: 482e489, 2002 Holck DEE, Ng JD: Evaluation and treatment of orbital fractures: a multidisciplinary approach. Philadelphia, PA: Elsevier-Saunders, 2006 [Chapter 15] Jordan DR, Allen LH, White J, Harvey J, Pashby R, Esmaeli B: Intervention within days for some orbital floor fractures: the white-eyed blowout. Ophthal Plast Reconstr Surg 14: 379e390, 1998 Joshi S, Kassira W, Thaller SR: Overview of pediatric orbital fractures. J Craniofac Surg 22: 1330e1332, 2011 Kwon JH, Moon JH, Kwon MS, Cho JH: The differences of blow-out fracture of the inferior orbital wall between children and adults. Arch Otolaryngol Head Neck Surg 131: 723e727, 2005 Manson PN, Iliff N, Robertson B: Trapdoor fracture of orbit in a pediatric population. Plast Reconstr Surg 109: 490e495, 2002 Matteini C, Renzi G, Becelli R, Belli E, Iannetti G: Surgical timing in orbital fracture treatment: experience with 108 consecutive cases. J Craniofac Surg 15: 145e150, 2004 Neinstein RM, Phillps JH, Forrest CR: Pediatric orbital floor trapdoor fractures: outcomes and CT-based morphologic assessment of the inferior rectus muscle. J Plast Reconstr Aesthet Surg 65: 869e874, 2012 Soll DB, Poley BJ: Trapdoor variety of blowout fracture of the orbital floor. AM J Ophthalmol 60: 269e272, 1965 Stotland MA, Do NK: Pediatric orbital fractures. J Craniofac Surg 22: 1230e1235, 2011 Wang NC, Ma L, Wu SY, Yang FR, Tsai YJ: Orbital blow-out fractures in children: characterization and surgical outcome. Chang Gung Med J 33: 313e320, 2010 Wei LA, Durairaj VD: Pediatric orbital floor fractures. J AAPOS 15: 173e180, 2011
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Surgical outcomes of orbital trapdoor fracture in children and adolescents Jae Wook Yang b, Jong Eun Woo a, Jae Hwan An a, * a b
Department of Ophthalmology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Republic of Korea Department of Ophthalmology, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 18 May 2014 Accepted 19 January 2015 Available online 27 January 2015
Purpose: Orbital trapdoor fractures are uncommon but more frequent in children and adolescents. Orbital trapdoor fractures have been discussed in many previous reports, early treatment has been advocated but there is controversy over treatment policy and surgical outcomes. Our retrospective study analyzed the surgical outcomes of orbital trapdoor fracture in children and adolescents to investigate the appropriate timing of treatment and the relationship between severity of extraocular muscle movement (EOM) limitation before the operation and the period of recovery after operation. Methods: A total of 44 children and adolescents with orbital wall fractures were operated on from 2009 to 2013. This study included 25 patients who underwent surgery for orbital trapdoor fractures; age range 9e18 years (mean age 14.0). We investigated the interval from trauma to surgery, the period of full EOM recovery after operation and the correlation between these factors, retrospectively. Results: The mean follow-up duration was 90.2 days. At follow-up, nine out of ten patients who underwent surgery within 24 h (Group 1) had full EOM recovery, with a mean recovery time of 25.1 days; five out of six patients who underwent surgery within 24e72 h (Group 2) had full EOM recovery with a mean recovery time of 60.2 days; and seven out of nine patients who underwent surgery after 72 h (Group 3) had full EOM recovery with a mean recovery time of 67.6 days. There was no statistical difference in the operation success rates between the groups. Also, the four patients that not completely recovered EOM had a mild EOM limitation below grade 1. Conclusion: In our study, we found that patients with orbital trapdoor fractures can recover full EOM regardless of the interval from trauma to surgery. Therefore, we suggest that appropriate surgical technique is important in the treatment of patients with orbital trapdoor fractures, in addition to the urgent surgery recommended for these fractures in a pediatric population. Furthermore, we expect a good prognosis following the treatment of orbital trapdoor fractures if appropriate surgical techniques are used, even if a relatively long time has passed after the trauma. © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Adolescents Children Orbital trapdoor fracture Surgical outcomes
1. Introduction Orbital floor blowout fractures of the trapdoor type are more frequent in children and adolescents than in adults because children and adolescents have greater elasticity of the facial bones than adults (Jordan et al., 1998; Basangi and Meyer, 2000; Egbert et al., 2000). These fractures allow herniation and entrapment of the orbital contents, resulting in limitation of * Corresponding author. Department of Ophthalmology, Ulsan University Hospital, Ulsan University College of Medicine, 290-3 Jeonha-dong, Dong-gu, Ulsan, 682-714, Republic of Korea. Tel.: þ82 52 250 7170; fax: þ82 52 250 8200. E-mail address: [email protected] (J.H. An).
extraocular muscle movement (EOM), diplopia, pain in eyeball movement, nausea and vomiting (Soll and Poley, 1965; Stotland and Do, 2011). Orbital trapdoor fractures in younger patients have been studied and discussed widely in published reports. However, the treatment policy and outcome remain controversial, although many have advocated early treatment (Matteini et al., 2004; Holck and Ng, 2006; Criden and Ellis, 2007; Gerbino et al., 2010). Our retrospective study analyzed the surgical outcomes of pediatric and adolescent patients who had undergone surgery for orbital trapdoor fractures of the orbital floor to determine the outcome in relation to the interval to surgery.
http://dx.doi.org/10.1016/j.jcms.2015.01.010 1010-5182/© 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
J.W. Yang et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 444e447
2. Material and methods From January 2009 to September 2013, 44 children and adolescents with orbital wall fractures underwent surgery at the Ophthalmology Department of the Inje University Busan Paik Hospital, Korea. Of these, a total of 25 patients had orbital trapdoor fractures. The age range was 9e18 years old. The diagnosis of trapdoor fracture was made from preoperative computed tomography (CT) images, and clinical symptoms of severe pain on eyeball movement, diplopia, nausea and vomiting, and minimal soft tissue swelling and ecchymosis. The mean follow-up duration was 90.2 days. Pediatric patients with incomplete clinical and radiological evidence were excluded from this study. Of the 25 patients enrolled in this study, 23 were boys and 2 were girls. Cause of fractures, interval to surgery, preoperative limitation of EOM, follow-up duration, postoperative EOM limitation and diplopia were recorded for retrospective analysis. Preoperative EOMs were determined on a scale of 0 to 4, with 0 representing no limitation and 4 representing no movement into that field of gaze. Additionally, we measured the distance between both corneal limbus margins in each direction of gaze. If the distance between both corneal limbus margins is 1 mm, we graded 1. In the same method, if the distance is 2 mm, 3 mm and 4 mm or more, we graded 2, 3 and 4. Surgery was determined mainly on the basis of clinical evidence of muscle entrapment and CT confirmation of trapdoor fracture (Fig. 1). The surgical intervention was a transconjunctival (fornix) approach to the orbital floor in each case. After visualizing the posterior margin of the fracture site, the entrapped orbital contents were restored gently into the orbit. If the entrapped muscle and tissue was not fully
445
corrected because of tight entrapment between the fractured bones, we broke the fractured bones to allow restoration of the orbital contents. The fractured orbital floor was patched using MEDPOR (Stryker, Kalamazoo, MI, USA) to prevent postoperative herniation and entrapment. Forced duction tests were performed at the end of surgery to confirm the complete release of entrapped tissue as part of each procedure. We analyzed the data using Microsoft Excel 2010 and SPSS 21.0 (IBM, Portsmouth, UK). 3. Results Since 2009, we performed surgery on a total 44 children and adolescents, 25 of these were diagnosed with orbital trapdoor fractures. The 25 patients with trapdoor fractures included 22 with inferior orbital wall fractures and three with medial orbital wall fractures. The average age of the 25 patients at the time of the fracture was 14.0 years and the most common causes of orbital wall fractures were games (8 patients) and violence (8 patients) (Table 1). We classified the patients into three groups according to the time interval between trauma and surgery. Group 1 contained 10 patients who underwent surgery within 24 h (urgent treatment). Group 2 contained six patients who underwent surgery between 24 and 72 h. Group 3 contained nine patients who underwent surgery after 72 h. The average interval to surgery was 92.9 h (Table 2). The average time to surgery for patients in Group 1 was 20.6 h; for Group 2 it was 48.7 h; and in Group 3 it was 202.7 h. In addition, the average EOM limitation for Group 1 was 3.3; for Group 2 it was 3.5 and for Group 3 it was 2.6. The average preoperative
Fig. 1. A male 15-year-old patient had an inferior orbital trapdoor fracture due to bumping into another friend's head. 1 day after trauma, (A) supraduction; and (B) infraduction limitation of left eye was noted with grade 3; (C) CT image pre-operation. Inferior orbital trapdoor fracture was noted with frank muscle entrapment (red arrow); (D) CT image post-operation. Entrapped inferior rectus muscle was recovered.
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J.W. Yang et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 444e447
Table 1 Summary of patient information. Patient No.
Age (yrs)
Sex
Group 1 (Interval to surgery 1 15 Male 2 14 Male 3 15 Male 4 16 Male 5 14 Male 6 14 Male 7 13 Male 8 12 Male 9 14 Male 10 12 Male Group 2 (Interval to surgery 11 18 Male 12 9 Female 13 13 Male 14 11 Male 15 9 Female 16 18 Male Group 3 (Interval to surgery 17 15 Male 18 15 Male 19 16 Male 20 11 Male 21 12 Male 22 14 Male 23 15 Male 24 17 Male 25 18 Male
Cause
Vagal symptoms (nausea/vomiting)
within 24 h) Violence N/V Violence N/V Violence N/V Slipdown N/V Violence N/V Game e Unknown N/V Game e Violence N/V Game N/V from 24 to 72 h) Slipdown N/V Slipdown e Game e Game N/V Game e Game N/V after 72 h) Sport e Post-op (BOFx) e Violence e Slipdown e Sport N/V Violence e Violence N/V Game e Sport e
True muscleentrap-ment on CT images (M)
Interval to surgery (hours)
Pre-operative EOM limitation (grade)
Follow-up duration (days)
Interval to full EOM recovery (days)
Post-operative EOM limitation (grade)
M M M M e e M M e e
5 24 24 24 24 24 24 24 24 9
4 3.5 3 3 2 2 4 4 4 3
30 90 30 30 150 7 30 30 90 7
7 1 30 1 30 30 90 7
Full 0.5 Full Full Full Full Full Full Full Full
e M M e e M
28 72 48 48 48 48
3 4 4 4 4 2
7 90 90 270 30 30
90 90 90 1 30
0.5 Full Full Full Full Full
M e e e M M e e e
120 720 192 144 120 168 96 168 96
4 2 2 3 4 2.5 2 1.5 2
120 450 90 30 330 30 90 90 14
EOM limitation was 3.1 in all patients. The average follow-up duration was 90.2 days; Group 1 average 49.4 days; Group 2 average 86.2 days; and 138.2 days in Group 3. Three patients had orbital medial wall fractures (one patient in each group). After surgery, full recovery of EOM was achieved in nine patients out of ten in Group 1 (90%); five patients out of six in Group 2 (83.3%); and seven patients out of nine in Group 3 (77.8%). There was no statistical difference in operation success rates between the groups (KruskaleWallis test, p ¼ 0.368). Four patients had mild EOM limitation with grade 0.5; one patient in Group 1, one in Group 2, and two patients in Group 3. The average follow-up duration was 50.25 days; two patients for 90 days, one patient for 7 days and the other patient for 14 days. We analyzed correlation between interval to surgery and interval to full recovery of EOM limitation. The interval to full EOM recovery in Group 1 was 25.1 days; in Group 2 it was 60.2 days; and in Group 3 it was 67.6 days. The result showed that extension of the time interval to surgery tended to lengthen the interval to full EOM recovery. However, the KruskaleWallis test showed that the difference between groups was not statistically significant (p ¼ 0.350). We also analyzed the correlation between the severity of EOM limitation at the moment of initial examination and the period of
30
30 180 30 180 30 90 1
Full Full 0.5 Full Full Full Full Full 0.5
time to full EOM recovery. In Table 3, we classified four groups according to the initial grade of EOM limitation. The only patient with grade 1 had recovered full EOM in 1 day. Patients with grade 2 recovered in 60.2 days; grade 3 in 11.3 days and grade 4 in 66.1 days. The average period of full EOM recovery was 50.9 days. There was no statistically significant correlation between severity of EOM limitation before operation and the period of time to full EOM recovery after operation (nonparametric correlation coefficient of Kendall and Spearman, p ¼ 0.1 in Kendall, p ¼ 0.114 in Spearman). We operated on three patients with medial orbital wall trapdoor fractures. All of them had EOM limitation grade 2. Two of these patients recovered with full EOM: the Group 1 patient after 1 day, and the Group 2 patient after 30 days. The third patient (Group 3) had mild EOM limitation with grade 0.5 at 2 weeks follow-up. It is difficult to distinguish between true muscle entrapment and pure soft tissue (e.g. periorbital fat) entrapment on CT images in patients of trapdoor fracture. In this study, six patients out of ten in Group 1 (60%), three patients out of six in Group 2 (50%), and three patients out of nine in Group 3 (33.3%) showed definite muscle entrapment on CT images. There was no difference in prognosis after surgery between cases with definite muscle entrapment and
Table 2 Summary of each patient group.
Group 1 Group 2 Group 3 Total
Patients (n)
Age (yrs)
Interval to surgery (hours)
Pre-operative EOM limitation
F/U duration (days)
Interval to full EOM recovery (days)
Post-operative full EOM limitation
Post-operative diplopia
10 6 9 25
13.9 13.0 14.8 14.0
20.6 48.7 202.7 92.9
3.3 3.5 2.6 3.1
49.4 86.2 138.2 90.2
25.1 60.2 67.6 50.9
9/10 5/6 7/9 21/25
1/10 1/6 2/9 4/25
J.W. Yang et al. / Journal of Cranio-Maxillo-Facial Surgery 43 (2015) 444e447 Table 3 Correlation between the severity of EOM limitation and period of full EOM recovery. Grade of EOM limitation
Period of full EOM recovery (days)
Remarks
1 2 3 4 Total
1 60.2 11.3 66.1 50.9
1 patient in grade 1.5 1 patient in grade 2.5 1 patient in grade 3.5
cases with pure soft tissue entrapment on CT images. In four patients who did not recover completely and had EOM limitation at last follow-up, only one case showed definite muscle entrapment on CT images, three cases did not. 4. Discussion A total of 25 patients with orbital trapdoor fractures who had undergone surgical correction were studied. Children and adolescents have a different pattern of orbital wall fracture to that seen in adults. The increased elasticity and flexibility of the facial bones in children results in fractures with soft tissue and muscle entrapment (Jordan et al., 1998; Grant et al., 2002; Kwon et al., 2005; Cobb et al., 2013). Earlier surgical treatment shows better outcomes in terms of restoration of ocular mobility (Egbert et al., 2000; Manson et al., 2002; Joshi et al., 2011; Neinstein et al., 2012) but, there is no consensus that treatment delay can increase clinical risk. Some investigators have considered early treatment to include treatment up to 3e5 days or more after the trauma (Burnstein, 2002; Wang et al., 2010; Wei and Durairaj, 2011). In our study, considering the interval between the trauma and surgery, the success rate was 90% (9/10) for urgent surgery within 24 h, 83.3% (5/6) for early surgery between 24 and 72 h, and 77.8% (7/9) for late surgery more than 72 h after trauma. These results showed that there was no statistically significant difference between the interval to surgery and operation success rate for orbital trapdoor fracture surgery. The results suggest that patients with orbital trapdoor fractures can recover with full EOM regardless of the time interval from trauma to surgery. Therefore, we suggest that appropriate surgical technique is also important in the treatment of patients with orbital trapdoor fractures in addition to the urgent surgery recommended in a pediatric population. It is important to completely free entrapped and herniated muscle and tissue when operating on orbital trapdoor fractures. If the entrapped muscle and tissue is not fully released, EOM limitation and diplopia can continue. So, we suggest that when operators approach the fractured site, they ensure that the posterior margin of the fracture is checked to confirm the complete release of entrapped muscle and tissue. Furthermore, one patient with an inferior orbital wall trapdoor fracture who had initial surgery in the department of plastic surgery required a second operation 1 month later. He was 15 years old and had grade 2 in infraduction. At the second operation, we discovered some tissue that had remained entrapped at the fracture site; this was corrected completely and the tissue fully released. He needed 6 months to fully recover EOM and was followed up for 15 months. Therefore, we suggest that patients with orbital trapdoor fractures can expect a good prognosis, with full EOM recovery following appropriate surgical intervention even though they have a long interval from trauma to surgery. Also, we investigated the correlation between the initial severity of EOM limitation and the interval to full EOM recovery. There is no
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statistically significant difference between the initial severity of EOM limitation and the time interval to full EOM recovery. Four patients still had mild EOM limitation at grade 0.5; they initially had EOM limitations of grade 2, 2, 3 and 3.5. The follow-up duration ranged from 7 to 90 days and we think that they will need long term follow-up. In addition, we had experience of three cases of medial orbital wall trapdoor fractures. Two patients recovered full EOM and no other complications; one patient had mild EOM limitation with grade 0.5 in adduction but he was only followed up for 2 weeks. 5. Conclusion We suggest that appropriate surgical technique is also important in the treatment of patients with orbital trapdoor fractures in addition to the urgent surgery which is recommended for orbital trapdoor fractures in a pediatric population. Furthermore, we expect a good prognosis following the treatment of orbital trapdoor fractures if appropriate surgical techniques are used, even if a relatively long time has passed after the trauma or there is severe EOM limitation at the time of trauma. Conflict of interest This work was supported by the 2013 Inje University Research Grant. Acknowledgment This work was supported by the 2013 Inje University Research Grant. References Basangi ZC, Meyer DR: Internal orbital fractures in the pediatric age group, characterization and management. Ophthalmology 107: 829e836, 2000 Burnstine MA: Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. Ophthalmology 109: 1207e1210, 2002 Cobb ARM, Jeelani NO, Ayliffe PR: Orbital fractures in children. BJOMS 51: 41e46, 2013 Criden MR, Ellis FJ: Linear nondisplaced orbital fractures with muscle entrapment. J AAPOS 11: 142e147, 2007 Egbert JE, May K, Kersten RC, Kulwin DR: Pediatric orbital floor fracture: direct extraocular muscle involvement. Ophthalmology 107: 1875e1879, 2000 Gerbino G, Roccia F, Bianchi FA, Zavattero E: Surgical management of orbital trapdoor fracture in a pediatric population. J Oral Maxillofac Surg 68: 1310e1316, 2010 Grant JH, Patrinely JR, Weiss AH, Kierney PC, Gruss JS: Trapdoor fracture of the orbit in a pediatric population. Plast Reconstr Surg 109: 482e489, 2002 Holck DEE, Ng JD: Evaluation and treatment of orbital fractures: a multidisciplinary approach. Philadelphia, PA: Elsevier-Saunders, 2006 [Chapter 15] Jordan DR, Allen LH, White J, Harvey J, Pashby R, Esmaeli B: Intervention within days for some orbital floor fractures: the white-eyed blowout. Ophthal Plast Reconstr Surg 14: 379e390, 1998 Joshi S, Kassira W, Thaller SR: Overview of pediatric orbital fractures. J Craniofac Surg 22: 1330e1332, 2011 Kwon JH, Moon JH, Kwon MS, Cho JH: The differences of blow-out fracture of the inferior orbital wall between children and adults. Arch Otolaryngol Head Neck Surg 131: 723e727, 2005 Manson PN, Iliff N, Robertson B: Trapdoor fracture of orbit in a pediatric population. Plast Reconstr Surg 109: 490e495, 2002 Matteini C, Renzi G, Becelli R, Belli E, Iannetti G: Surgical timing in orbital fracture treatment: experience with 108 consecutive cases. J Craniofac Surg 15: 145e150, 2004 Neinstein RM, Phillps JH, Forrest CR: Pediatric orbital floor trapdoor fractures: outcomes and CT-based morphologic assessment of the inferior rectus muscle. J Plast Reconstr Aesthet Surg 65: 869e874, 2012 Soll DB, Poley BJ: Trapdoor variety of blowout fracture of the orbital floor. AM J Ophthalmol 60: 269e272, 1965 Stotland MA, Do NK: Pediatric orbital fractures. J Craniofac Surg 22: 1230e1235, 2011 Wang NC, Ma L, Wu SY, Yang FR, Tsai YJ: Orbital blow-out fractures in children: characterization and surgical outcome. Chang Gung Med J 33: 313e320, 2010 Wei LA, Durairaj VD: Pediatric orbital floor fractures. J AAPOS 15: 173e180, 2011