Orbital Roof fractures
Article summary goes here.
Fractures of the roof of the orbit are typically associated with trauma to the forehead/frontal bone are are often extensions of superior orbital rim fractures. Isolated non-displaced orbital roof fractures most commonly seen in children and rarely require surgical intervention.
Orbital Roof Fracture (ICD - # 802.?)
Isolated orbital roof fractures in adults are uncommon. Most roof fractures are associated with other orbital fractures and result from significant head trauma. The frontal sinus is often involved. Large comminuted displaced orbital roof fractures are often associated with severe head and face trauma and these fractures are therefore often managed via a multi-disciplinary approach with members of the neurosurgery and otolaryngology services. In children, fractures of the orbital roof may be seen in isolation and may arise from much more trivial events.
Patients who sustain any trauma to the head are at risk for orbital roof fractures. In adults, the traumatic event is typically associated with greater energy transfer (e.g. unhelmeted motorcycle accident) than in children.
In adults, the roof of the orbit is often paper thin in the area of the frontal sinus. The floor of the frontal sinus is the roof of the orbit and trauma to the frontal bar of the superior orbital rim can cause a buckling of this bone. Orbital emphysema is common when the frontal sinus is involved. In addition, extension of fractures of the cranial vault may involve the roof of the orbit with subsequent cerebral spinal fluid leakage. Children are more likely to have isolated linear fractures of the orbital roof similar to the greenstick fractures seen in the orbital floor.
The same hydraulic and buckling theories that are associated with the orbital floor and medial walls apply to the orbital roof. See Orbital Floor Fractures.
Prevention is accomplished only by avoiding or mitigating trauma to the head and face. Protective gear such as full face helmets for high impact sports and other activities may lessen the incidence of orbital roof fractures.
Most commonly, patients will report a recent history of trauma to the head and/or face. In children, the parents my note only minor trauma such as butting heads with a sibling on the trampoline.
A formal and complete ophthalmic exam to rule out globe trauma is essential in the examination of all facial trauma patients. It is particularly important to document to visual acuity and optic nerve function (e.g. pupillary exam) as early in the exam as possible. In cases of evolving pathology such as an orbital hematoma, serial exams may be necessary. If significant globe trauma is identified (i.e. ruptured globe or retinal detachment), orbital surgery is usually postponed due to the increased risk this places on the damaged globe.
In addition to the formal ophthalmic exam, a complete orbital exam is required. In addition to the pupillary exam, other optic nerve function tests such as red desaturation and color plate testing may aid the examiner. Palpation of the orbital rims may show rim step-offs and other defects. Crepitus with air from the frontal sinus may be seen. Exophthalmometry measurements may reveal proptosis or enophthalmos.
Signs of orbital roof fractures are similar to those seen with other orbital fractures but may be minimal. Periorbital hematoma and edema are common as are subconjuntival hemorrhage and chemosis. The patient may have ocular misalignment. Proptosis or enophthalmos may be seen and other head and facial trauma signs such as lacerations are common as well.
In cases of relatively minor trauma, the patient may have no complaints. Other symptoms are similar to those seen with other orbital fractures including poor vision, double vision, pain with eye movement and pain with nose blowing.
With the typical signs and symptoms outlined above, the clinician will have a high suspicion for orbital fractures. The ultimate diagnosis is made by computed tomography (CT) of the face.
The gold standard for diagnosis of an orbital roof fracture is thin-cut coronal CT scanning of the face/orbits. Contrast is not needed. Although sagittal sections are also helpful in some cases, the axial images are less so. The CT scan will reveal the exact size and location of the fracture as well as associated fractures of the orbit, face and head. Other entities such as foreign bodies, hematoma, globe rupture and optic nerve trauma may also be found.
It is common for trauma patients to have periorbital ecchymoses and edema without fractures. In addition, poor/blurry vision, blurry vision, double vision and ocular pain are seen in facial trauma without orbital fracture. The differential diagnosis of any orbital fracture should include orbital floor fractures, medial wall fractures and lateral wall fractures.
After a thorough ophthalmic exam and after other trauma has been ruled out, the patient and physician discuss the possible need for surgical intervention.
In cases of minor isolated orbital roof fractures where no surgical intervention is needed, the patient may require no treatment. The use of oral antibiotics is controversial in that some practitioners prescribe them for orbital fractures and some do not. Likewise, some surgeons give oral steroids to help decrease orbital edema and congestion but some do not. In all cases the patient is advised to avoid nose blowing.
Medical follow up
Uncomplicated orbital fractures that do not require surgical intervention are often seen 1-2 weeks after the initial injury and the as needed thereafter.
Surgical intervention in the case of isolated orbital roof fractures is uncommon. If signs of muscle entrapment (e.g. levator dysfunction) are seen, surgery may be required. Access to the roof may be gained through a superior lid crease approach. In cases of large comminuted and displaced fractures of the roof, surgical intervention often requires a team approach with members of the neurosurgical team and/or members of the otolaryngology department. The approach for these types of fractures is via a coronal flap with craniotomy.
Repair of roof fractures can be complicated. Gravitational forces make it difficult to keep an implant in place from the orbital side of the fracture. Most implants must be placed form the frontal sinus/cranial side of the fracture making access difficult.
Surgical follow up
In the immediate post operative period, the patient is reminded to avoid nose blowing and strenuous exercise. The patient is seen at one week and at some time thereafter depending on how the recovery goes. Patients are reminded that because of edema, hematoma, damage to the muscles and nerves of the orbit, and boney fusion, the ultimate post operative healing outcome may not occur for months. Patience is a virtue.
Complication of the surgery are directly related to the severity of the orbital fracture. Common complications are postoperative edema, chemosis, ecchymoses, blurry vision, discomfort and tenderness. Double vision may persist even after release of entrapment secondary to extraocular muscle and nerve damage. Dislodgement of an implant may occur and optic nerve damage is possible. In cases of frontal sinus involvement, the patient may need to be followed for possible frontal sinus mucocoele. If intracranial communication with the orbit and/or sinus is present, meningitis or encephalitis my occur.
Prognosis is directly related to the severity of the roof fracture. In cases of isolated non-displaced roof fractures, the prognosis is excellent. If the roof fracture is large, comminuted and severely displaced, the prognosis is less promising.
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