Defining Pediatric Orbital Roof Fractures: Patterns, Sequelae, and Indications for Operation

Background: There are few published data addressing pediatric orbital roof fractures, particularly regarding long-term outcomes and indications for operative intervention. To provide evidence-based guidelines for the management of these injuries, the authors examined a large cohort of patients with this injury pattern. Methods: Institutional review board approval was obtained to review pediatric patients presenting to Johns Hopkins Hospital from 1991 to 2011. All patients with a diagnosis indicating orbital or skull base fractures were reviewed to determine orbital roof involvement. Patients with roof fractures were assessed for demographics, management, and outcomes. Results: A total of 1484 pediatric patients carried the diagnoses of orbital fracture or anterior skull base fracture. After review, 159 patients (11 percent) were found to have true orbital roof fractures, with 36 percent being comminuted. One hundred five patients returned after discharge (average follow-up, 19 months). One patient developed vertical dystopia 10 months after being lost to follow-up with a large, comminuted fracture. Ten patients underwent surgery to repair the orbital roof. Inferior displacement correlated with need for surgical repair (p < 0.001). Conclusions: In the largest study to date analyzing pediatric orbital roof fractures, the authors found that most can be managed conservatively with good long-term outcomes. Vertical dystopia occurred in less than 1 percent of patients and was associated with large, comminuted fractures. Inferiorly displaced and fractures with a surface area over 2 cm(2) represent higher risk fractures that should be followed closely for possible intervention based on the development of sequelae such as vertical dystopia or encephalocele.