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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 Taghinia, MD, MPH, Brian I. Labow, MD.
Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.

PURPOSE: To determine the clinical and radiological predictors of tissue entrapment in pediatric orbital floor fractures and to explore the effect of operative timing on ocular outcomes.
METHODS: We retrospectively reviewed the medical records of pediatric patients (aged <18 years) who acutely presented with orbital floor fractures from October 2007 to October 2015.
RESULTS: 152 patients with 159 orbital floor fractures were included. 122 (80.3%) patients were male, and the mean age was 12.2 years. Twelve patients (7.9%) sustained orbital floor fractures with tissue entrapment. At presentation extraocular movement (EOM) restriction, diplopia, nausea, and vomiting were all associated with tissue entrapment (P<0.001).
Signs and symptoms used to screen for tissue entrapment
Sign/SymptomSensitivity (%)Specificity (%)Positive Predictive Value (%)Negative Predictive Value (%)
Extraocular movement (EOM) restriction100.081.231.6100.0
Diplopia83.383.330.398.3
Nausea and/or vomiting83.372.920.898.1
Nausea75.080.725.097.4
Vomiting83.375.722.794.1
Headache50.088.627.395.4
Bradycardia16.799.366.793.3
Radiological evidence of tissue entrapment100.097.980.0100.0
Trapdoor fracture (as described by reporting radiologist)33.394.333.394.3

Amongst patients with trapdoor fractures, the presence of nausea and/or vomiting was predictive of tissue entrapment: positive predictive value 80%, negative predictive value 100%. For patients with tissue entrapment, poorer ocular outcomes (persistent EOM restriction and diplopia) were significantly associated with the length of operation (P=0.007), but not with the time interval to operation (P=0.146).
CONCLUSION: 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 draws attention to the relationship between operation length and poorer ocular outcomes, suggesting that case severity/complexity and surgeon technique/experience may influence ocular outcomes.


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