Emergency Management Of Orbital Fractures In Children - Signs, Types, Diagnosis, Treatment

What Are Orbital Fractures in Children?

An orbit is a bony structure around the eyes. It has many bony cavities, each housing the globe and its structures. The orbit is formed by seven bones: the zygomatic, ethmoid, sphenoid, frontal, maxillary, lacrimal, and palatine.

Orbital fractures are fractures of the eyes. These are the results of breaking one or more bones around the eyes, which can happen due to any injury caused by a blunt object and can be devastating for vision and aesthetics. These fractures are most likely to occur in young, teenage individuals or children who play baseball and softball.

What Are the Signs of an Orbital Fracture?

The symptoms of an orbital fracture depend on its severity and type. Some of the symptoms of this fracture are-

• Swelling: Due to inflammation, swelling occurs on the forehead, cheeks, or skin under the eyes.
• Changes in the eyeballs of the eyes: These changes include blood in the white part of the eye or the eyeballs becoming sunken.
• Pain: On opening the mouth, pain is felt in the eyes and sometimes in the cheeks.
• Double vision: An orbital fracture causes vision changes. It becomes double, decreased, or blurry sometimes.
• Bruising of the eye: Pooling blood under the skin can cause bruising around the eyes. This bruising can be black or blue.
• Restricted eye movement: A person may not be able to move his eyes or face easily.
• Numbness: Numbness on the affected side of the face is present. Cheeks become flattened.

What Are The Types Of Fractures?

These are the types of fractures:

• Orbital rim fractures: These are caused mainly by car accidents. These fractures affect the thick bone at the outer edge of the eye socket. Since the bone is too thick, it requires a large force to break, which may injure the face and the optic nerve.
• Blow-out fracture: Breaking the thin inner wall of the eye socket or the eye socket floor. The cracking of the thin bone that makes up this wall can also pinch muscles and other structures around the eyes. This is usually the result of getting hit by a baseball or by a fist.
• Orbital floor fracture: The bones of the eyes are pushed back due to the blow to the rim of the eye socket, which causes the downward buckle of the bones of the orbital floor. Children with an orbital floor fracture and a medial wall fracture possess a higher risk of entrapment (an emergency surgery due to ischemia of the involved muscle can cause permanent damage), as pediatric bones are susceptible to greenstick fracture. The most common nerve damaged in this injury is the infraorbital nerve. As a result, a child is not able to look upward properly. In addition, muscles and nerves around the eyes are also affected. Usually, in elderly patients, these fractures are caused by falling and getting hit by any hard object, such as furniture.
• Orbital roof fracture: These fractures are most commonly seen in children as the frontal sinus has not yet developed air-filled cavities. The entire force of the superior orbital rim is transferred to the anterior cranial base.
• NOE (nasal orbital ethmoid) fractures: They account for one-third of all pediatric fractures. In this fracture type, direct force is applied to the nasal bone, causing damage to the nasal, lacrimal, and ethmoid bones. If left untreated, it can cause severe deformities in the face. These are most commonly seen in older children and adults.
• Midface fractures: They are common in children and account for 5% of all pediatric fractures. They occur when a considerable force is present, as in a car accident; they include LeFort 1, 2, and 3 fractures. Orbit is involved mainly in LeFort 2 and 3.
• Zygoma fractures: These are rarely seen in children.

How Is Zygomatic Fracture Diagnosed?

Zygomatic fractures are diagnosed using the following methods:

• An ophthalmologist will note down the proper history of the accident by the type of object, i.e., blunt or sharp.

• In case of a road accident, by which vehicle it occurred and of what intensity it was.

• He will do the physical examination thoroughly by checking the eye and the area around it. Pictures of the eye and eye socket are taken.

• The ophthalmologist checks the vision and proper movement of the child’s eyes. They may also take eye measurements to check its position in the socket.

• X-ray: This shows the images of internal tissues and organs.

• CT (computed tomography) scan: This shows a detailed view of any body part, which shows the child’s bones, muscles, fat, and organs. It can detect the abnormality more precisely.

What Is The Treatment Of Orbital Fractures In Children?

The treatment of an orbital fracture is determined by the fracture's severity, the child's age, and overall health. The treatment protocols that are to be followed are discussed below:

• In case of minor injuries, some fractures do not necessarily require immediate treatment. The ophthalmologist may suggest waiting until the swelling and bruising around the eye decrease before the treatment. Double vision usually corrects on its own after some time.

• In case of a severe fracture, a patient should undergo ophthalmic, neurogenic, and trauma examinations. Along with the orbits, they can also affect other parts of the face. Treatment is quite challenging, as they can hinder vision. Acute treatment involves the management of ocular injuries. Educating the patient to avoid blowing the nose is important, as air from the sinonasal tract could enter the orbit, which results in orbital compartment syndrome and can cause blindness.

• Surgical intervention is required in severe fractures. As per the radiographic and CT scan, further treatment must be followed. Reconstructive surgeries are also suggested in some cases. Implants are also placed if required. Many advanced treatment modalities can be seen these days. Endoscopic surgeries are performed if needed.

Conclusion:

This article discusses orbital fractures, which are the fractures of the orbit. Orbital fractures commonly occur in the midface, which could create various eye complications that need to be managed very carefully. The number of orbital fractures seen in boys is higher than in girls. The management of orbital fractures in children needs more care as the anatomy of their faces differs from that of adults. The treatment aims to restore the orbit's position and eye movements safely and effectively. Surgical interventions are needed in cases of complex fractures. Sometimes post-surgical complications also occur, such as blurred vision, which needs to be taken care of.