Orbital Roof Fractures: An Evidence-Based Approach

Abstract

Importance: There is controversy surrounding the management of orbital roof fractures. Guidelines with regard to when to operate and type of reconstruction are lacking. Categorizing these data will help clinicians make informed decisions about the management of orbital roof fractures and avoid preventable complications.Objective: To perform a systematic review evaluating underlying causes, associated complications, and management of orbital roof fractures including reconstructive options in the general population of children and adults. Evidence Review: A systematic review using the PubMed, EmBase, Cochrane, and MEDLINE databases identified relevant studies for inclusion. Studies were included from 1987 to 2017. Demographics, symptoms, management, reconstruction, and outcomes were reported following preferred reporting items for systematic reviews and meta-analyses guidelines. Inclusion criteria included articles discussing management of traumatic orbital roof fractures across all ages. Included studies were assessed for level of evidence. Findings: Forty-seven studies encompassing 526 patients met inclusion criteria. There were 28 case reports, 15 retrospective case series and 4 retrospective cohort studies. The most common etiologies were motor vehicle accidents (39.5%), falls (30.3%), and assault (11.8%). Periorbital ecchymosis, exophthalmos, and dystopia were the most common initial symptoms. In total, 60.0% of patients underwent surgical repair and 40% of patients were managed conservatively. The most common surgical approach was bicoronal (94.8%), followed by a superolateral orbital rim approach and transpalpebral (5.1%). A variety of grafting materials were utilized, including titanium miniplates (46.2%), bone graft (37.7%), porous polyethylene (2.8%), and silastic implants (2.8%). Overall patients undergoing surgery were adults with clinical symptoms including exophthalmos, diplopia, and gaze restriction as well as patients with dura exposure. Most patients undergoing surgery were those with concomitant fractures. The most common fractures among the surgical patients were frontal bone (32.2%), ethmoid (25.2%), and zygomaticomaxillary complex/zygoma (12.2%). Conclusions and Relevance: Management of orbital roof fractures varies based on individual clinical features including the presence of exophthalmos, gaze restriction, and concomitant injuries such as dural tears. Surgically, bicoronal approaches were performed most commonly along with reconstruction utilizing titanium miniplates. Conservative management was more common among the pediatric population. This systematic review demonstrates both conservative and surgical measures can lead to positive outcomes in appropriately selected patients.

Pediatric orbital fractures

“…Orbital roof fractures typically do not require operative intervention as these rarely have significant displacement. Lucas et al [28] published a systematic review on management of orbital roof fractures. Although the study included both adult and pediatric populations, they found that pediatric populations were more frequently treated with conservative management [28].…”

“…Lucas et al [28] published a systematic review on management of orbital roof fractures. Although the study included both adult and pediatric populations, they found that pediatric populations were more frequently treated with conservative management [28]. This was further supported in a review published by Sandhu et al [29 ▪ ] with reported operative intervention rates ranging from 6 to 18%.…”

Pediatric Facial Fractures

“…In a systematic review by Lucas et al, most orbital roof fractures were noncomminuted and thus managed expectantly, with close follow-up examinations and reimaging for new or worsening symptoms. 25 It is important to note that if left untreated, displaced supraorbital fractures can result in a fixed deformity with significant diplopia that cannot be fully corrected. Therefore, follow-up often includes more long-term evaluation compared with other patterns to avoid missing a progressive deformity.…”

“…The transconjunctival approach is often used for orbital fractures to minimize risk of external scar, ectropion, and eyelid retraction; however, a transcutaneous incision may be required in complex cases needing greater visualization. 25 Iliac, rib, or skull donor sites can be used for autogenous orbital reconstruct in immature calvarium when the absence of a calvarial diploe space prevents harvesting split calvarial grafts, a pericranial shave graft can be harvested with a sharp osteotome (►Fig. 5).…”

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

“…Complications of surgical interventionmost frequently, longstanding diplopia, persistent enophthalmos, ectropion and, most concerning, vision loss-underscore the importance of establishing consistent findings that warrant surgical intervention. 6 Despite many studies examining the management of various isolated and combination orbital wall fractures, [10][11][12] an algorithm for treatment using ophthalmologic exam and CT findings has yet to be established for eyes in the setting of orbital fractures broadly. This study examines orbital fractures at a level I trauma center for clinical and imaging findings to guide patient stratification into conservative follow-up, medical treatment, and/or surgical management approaches.…”