Orbital Roof Fractures

Abstract

Orbital roof fractures contribute only to a very limited extent to the number of facial fractures. Apart from a skeletal-orbital fracture, concomitant neurologic and/or ophthalmological injury can be present. Surgical intervention is indicated when specific findings are present. One should be aware of the potential development of late complications. Three illustrative patient cases will be discussed.

FormalPara Learning Objectives

• Adequate diagnosis of the extent of an orbital roof fracture.

• Intracranial involvement: indication for surgical intervention.

Introduction

Orbital roof fractures are infrequent and are commonly associated with high impact facial trauma. An estimated 1–14.7% of orbital fractures are fractures of the orbital roof [1,2,3,4]. These fractures are relatively rare in comparison to fractures of the infero-lateral wall of the orbit and there are limited indications for surgical intervention. In this short overview, we will discuss the indications of surgical reconstruction of orbital roof fractures.

The first line of treatment in orbital roof fractures is often conservative [5]. Management varies based on individual clinical and radiological findings [5,6,7].

Indication for surgery depends on the symptoms at presentation; skeletal and (brain)soft tissue injury findings on the CT scan, the degree of displacement of bone fragments, the degree of intracranial involvement and the involvement of the superior orbital rim. The majority of these surgical procedures will be a collaboration between surgeons of different background in neurosurgery, maxillofacial surgery, plastic surgery and ophthalmology.

Background

Isolated orbital roof fractures are uncommon since the roof is well protected by the sturdy supraorbital rim, the zygoma, and more posteriorly the sphenoid bone. Most superior orbital wall fractures are caused by high-energy impact trauma to the head and are more frequent in the paediatric population; in the younger paediatric population, fractures of the orbital roof are the most common type of fracture in this region, due to the neurocranium – face ratio and the associated characteristics of the orbit at the younger age [8, 9] (Chap. 12). As the frontal sinus pneumatizes during age, the transmission of force from the superior orbital rim to the anterior cranial base diminishes: concordantly, orbital roof fractures become less frequent during adulthood. In adults, an orbital roof fracture is often associated with more extensive cranial-facial and brain injury than in children. In children, these orbital fractures are typically isolated (linear skull fracture) and treated conservatively accept when there is a risk of a growing skull fracture, which can result as a “late” complication of a dural laceration. In such paediatric head trauma cases, after several months, herniation of (cerebral) brain tissue through the skull-dura defect may occur. Typically, a delayed onset develops of neurological deficits [1, 5]. The majority (>75%) of adult orbital roof fractures are associated with traumatic brain injury and infringe on the cranial integrity potentially leading to CSF fistula, pneumocephalus and secondary meningitis [2, 5, 6].

Presentation

Despite the infrequent presentation of orbital roof fractures, if not well recognized ophthalmological, neurological, functional and aesthetic complications and associated morbidity may potentially result. The characteristic symptoms of orbital roof fractures are orbito-frontal skin lacerations, peri-orbital hematoma, oedema and orbital emphysema. Furthermore, displacement of the globe in any direction may occur (exophthalmos, enophthalmos, hyperglobus or hypoglobus). In addition, limitation of eye movement or gaze restriction, diplopia or visual impairment, i.e. loss of vision from a raised intraorbital pressure and altered sensation in the supraorbital and supratrochlear skin region, facial asymmetry are described (see patient III). The most common intracranial injury is the presence of a CSF leak. Intracranial haemorrhage may be present as well as prolapse of brain tissue. A (late) developing pulsatile exophthalmos in case of an orbital meningoencephalocele may occur.

Several classifications of orbital roof fractures have been described: the blow-in fracture, with inferior displacement of the orbital roof, the blow-up fracture, with superior displacement of the orbital roof-rim into the anterior cranial fossa, supraorbital rim fracture and frontal sinus fracture with involvement of the adjacent orbital roof [5,6,7].

Management

When an orbital roof fracture is suspected, assessment of the (associated) injuries by a multi-disciplinary team must be done rapidly to avoid secondary damage to the brain tissue, orbit and globe [1,2,3]. Treatment is individually tailored. Generally, a nonsurgical approach is warranted in the absence of intracranial, sinus or orbital symptoms. The choice of surgical versus conservative treatment starts with an accurate assessment of the injury. An adequate work-up must include neurological and ophthalmological assessment. When neurological injury is suspected or proven, prompt consultation by a neurosurgical team is indicated. The standard Glasgow Coma Scale workup is essential. The radiological imaging of choice is a thin (1 mm) high-resolution CT scan with 3D-reconstructions [7]. (Chap. 4) In orbital roof fractures, MR imaging is of lesser importance and contra-indicated when magnetic foreign bodies are suspected [2,3,4]. Immediate surgical intervention (decompression) is needed in a minority of patients with a retrobulbar hematoma or threatening orbital compartment syndrome and consists of urgent lateral canthotomy or cantholysis. In the short-term post traumatic period, patients should be advised not to blow their nose as this may result in emphysema or pneumocephalus.

Skeletal Injury: Isolated Orbital Roof Fracture

Isolated fractures of the orbital roof (Figs. 11.1 and 11.2) are rare and can usually be treated conservatively in the absence of diplopia, rectus muscle impingement or persistent cerebrospinal fluid (CSF) leak. In the case of CSF fistula with oculorrhea or rhinorrhea, a period of watchful waiting for at least 48 hours is advisable because the majority of cases resolves spontaneously [2, 10]. The efficacy of lumbar drainage and prophylactic antibiotics in these cases with CSF leaks is still subject of debate [2, 4].

Fig. 11.1

CT scan: sagittal slide showing isolated displaced orbital roof fracture, wide spread emphysema present

Fig. 11.2

CT scan: coronal slide showing isolated orbital roof fracture

Skeletal Injury: Concomitant Skull Fractures

When there is an associated fracture of the adjacent supra-orbital rim or frontal sinus wall, surgical intervention is often indicated, more so when displacement of bony fragments is present (see patient III). When the posterior table of the frontal sinus wall is involved in the fracture, cranialisation should be considered. Other, frequent bone injuries consist of a fracture of the zygoma and ethmoid.

Concomitant Ophthalmologic and Neurologic Injuries

In patients presenting with major ophthalmologic signs and/or clear ocular injury, urgent surgery is warranted to prevent further deterioration especially in cases with a substantial displacement of bone fragment intra-orbitally or intracranially [11]. The timing of surgery also depends on the need for urgent treatment of concomitant (brain)injury. Surgery of solitary orbital roof fractures with displacement of the orbital rim usually takes place in the sub-acute stage after the initial swelling has subsided.

Oculorrhea and/or Rhinorrhea

As stated above, in the case of CSF fistula with oculorrhea or rhinorrhea, a period of watchful waiting is advisable for at least 48 h because the majority resolve spontaneously [10]. In case of persistent leakage, surgery is indicated. Surgical nuances are variable and case-specific, but all consist of a subcranial approach to the orbital roof through a bitemporal (coronal) or superior-orbital incision. After resection of bone fragments and reconstruction of dura, orbital roof reconstruction with titanium screws with plates and/or mesh systems yield an effective result but is not a necessity when the orbital rim is intact [6].

Care is taken to avoid perioperative entrapment of the superior rectus and superior oblique muscle. Postoperative CSF leakage is rare but should be watched for; therefore, MRI and fluid analysis may be indicated.

To summarize, the indications for surgical reconstruction of superior orbital wall fractures are as follows:

• 1. Concomitant intracranial injury or penetrating orbital roof fragments intracranially.

• 2. Visual impairment or globe displacement.

• 3. Persistent CSF leakage warranting reconstruction of the frontal sinus.

• 4. Dislocation or fragmentation of the superior orbital rim.

• 5. Growing fracture in the paediatric population.

Illustrative Cases

Patient I

A first illustrative case is a healthy young man working on a construction site who was hit by a large metal rod and presented to our ER with an orbito-frontal skin laceration but without neurological or visual deficits (Fig. 11.3). A CT-scan including 3D reconstruction revealed a comminuted fracture of the left orbital rim, frontal sinus and superior orbital roof (Figs. 11.4 and 11.5). We opted for surgery because of the comminution and extent of the orbital roof fracture in combination with the orbital rim and frontal sinus. Intervention was carried out in the acute phase because of a large skin laceration necessitating primary closure and cosmetic reasons. He was treated in a joint venture of the neuro- and maxillofacial surgeons with primary open fracture reduction, plate fixation and dural repair through the existing laceration (Figs. 11.6 and 11.7). No prophylactic antibiotics were administered. He made an uneventful recovery and was discharged after 5 days.

Fig. 11.3

Clinical image frontal laceration

Fig. 11.4

CT scan revealing an orbito-frontal fracture with displacement on the left side with involvement of the orbital roof and frontal sinus: axial and coronal view (patient Fig. 11.3)

Fig. 11.5

CT scan-3D reconstruction revealing an orbito-frontal fracture with involvement of the orbital roof and frontal sinus including (patient Fig. 1.3)

Fig. 11.6

Preoperative view comminuted superior orbital rim, anterior table frontal sinus and associated orbital roof fracture (patient Fig. 11.3)

Fig. 11.7

Postoperative open reduction and internal fixation of comminuted superior orbital rim and frontal sinus anterior table fracture (patient Fig. 11.3)

Patient II

A second case is an elderly cyclist who fell off his e-bike and presented with headache, vomiting and peri-orbital swelling but without ophthalmologic symptoms. On radiologic examination, a right orbito-frontal fracture with involvement of the orbit and frontal sinus was evident as well as a pneumocephalus indicating traumatic fisteling of the frontal sinus and the intracranial space (Figs. 11.8 and 11.9). The patient was operated by the neuro- and maxillofacial surgeons on the second day after trauma when the initial swelling had partially subsided. Repositioning of the bone fragments as well as reconstruction and cranialisation of the frontal sinus was preformed through a coronal approach. The surgery was effective in treating the cosmetic defect but afterwards, he developed nasal CSF leakage which was treated with 3 days of external lumbal CSF drainage and prophylactic antibiotics. On discharge, he was diagnosed with epilepsy and mild cognitive dysfunctions which were not present on initial presentation. This case illustrates that clinical outcome after orbital roof fractures is mostly dependent on the extent of the traumatic injury to the brain.

Fig. 11.8

CT scan revealing an orbito-frontal fracture, displacement present, with involvement of the orbital roof and frontal sinus

Fig. 11.9

CT scan revealing an orbito-frontal fracture with involvement of the orbital roof and frontal sinus including a pneumocephalus

Patient III

In a third case, a 34-year-old male patient presented to the ER after being involved in a bike accident and fell with the tempo-frontal side of his head onto the pavement. The patient complaint about severe headache, no vomiting. There was no double vision. Facial examination revealed some flattening of the involved forehead, more evident on the right side. Also, evident enophthalmos OD was measured, which was, according to the patient not present prior to the accident. No diplopia was reported, BSV was present and all ductions were normal. A CT scan showed an extensive comminuted fracture of the supraorbital rim as well as a blow-out fracture of the orbital roof (Fig. 11.10). Because of the extent of the comminution of the rim fracture, the displaced orbital roof fracture and the resultant enophthalmos, open reduction and internal fixation was carried out using a coronal approach which allowed for wide exposure of the fracture site (Fig. 11.11). Miniplate fixation was applied (Fig. 11.12a, b). Postoperatively, facial symmetry was accomplished with proper globe position, no double vision or neurological symptoms occurred.

Fig. 11.10

CT scan, coronal, sagittal and axial view including 3-D reconstruction showing an extensive supraorbital rim fracture in combination with a cranially displaced orbital roof fracture (patient Fig. 11.10)

Fig. 11.11

Bicoronal incision providing wide access to the fracture of the supraorbital rim and associated orbital roof OD (patient Fig. 11.10)

Fig. 11.12

(a) Open reduction and internal fixation with miniplates of comminuted supraorbital fracture (patient Fig. 11.10). (b) Open reduction and internal fixation with miniplates of comminuted supraorbital fracture (patient Fig. 11.10)

Conclusion

The evaluation and treatment of complex orbital fractures is best done in a medical centre with experience in craniofacial trauma and by a multidisciplinary team. The indication of surgical treatment of orbital roof fractures is limited to fractures with substantial dislocation of bone fragments that result in penetration of the orbit and/or cranial fault, visual disturbance or cosmetic defects. The surgical goals are reduction of penetrating bone fragments, dural repair and (cosmetic) reconstruction of orbit and frontal sinus. Although scientific evidence to guide treatment choices is limited to case series and expert opinions, both surgical and conservative treatment are effective in selected patients. The clinical outcome of these patients depends mostly on collateral damage due to traumatic brain injury and visual disturbances.