This study aimed to evaluate the injury patterns in pediatric patients with an orbital wall fracture (OWF) and to identify the differences in injury patterns between preschool and school-aged patients with OWF who presented to the emergency department.
We performed a retrospective observational study in the emergency department of a tertiary hospital between January 2004 and March 2014. A total of 177 pediatric patients (<18 years) with OWF who underwent facial bone computed tomography scans with specific discharge codes were included. Patients were categorized into preschool (≤7 years) and school-aged (>7 years) pediatric groups.
The inferior wall was the most common fracture site in both the preschool and school-aged pediatric groups (50.0% vs. 64.4%, P=0.15). The male-to-female ratio and the mechanism of injury showed significant differences between the two age groups. Violence was the most common mechanism of injury in the school-aged pediatric group (49.3%), whereas falls from a height caused OWF in approximately half of the patients in the preschool pediatric group (42.9%). Concomitant injuries and facial fractures had a tendency to occur more frequently in the school-aged pediatric group.
Significant differences according to the sex and mechanisms of injury were identified in preschool and school-aged pediatric patients with OWF.
In emergency departments, orbital wall fracture in pediatric patients is commonly misdiagnosed and unrecognized in many cases. Misdiagnosis and delayed diagnosis in pediatric patients with orbital wall fracture can lead to long-term complications such as diplopia and the impairment of ocular motility.
The inferior wall was the most common fracture site in both the preschool and school-aged pediatric groups. Concomitant injuries and other facial bone fractures had a tendency to occur more frequently in the school-aged pediatric group.
Injured patients usually visit the emergency department (ED) because of its timely management of cases and 24-hour accessibility. In patients with blunt facial trauma, emergency physicians perform a thorough ophthalmic examination to evaluate for the possibility of orbital wall fractures (OWFs).
OWF is rare in pediatric trauma patients, and achieving the correct diagnosis can be challenging. In EDs, OWF in pediatric patients is commonly misdiagnosed and unrecognized in as many as 30% of cases [
Misdiagnosis and delayed diagnosis in pediatric patients with OWF can contribute to long-term complications such as permanent diplopia and the restriction of ocular motility [
We conducted a retrospective case-control study at the ED of our hospital between January 1, 2004 and March 31, 2014. All consecutive patients with OWF who presented at the ED were retrospectively identified using discharge codes according to the International Classification of Diseases 10th revision (ICD-10) from the de-identified clinical data warehouse of our institute [
In this study, we included 177 pediatric patients (aged <18 years) who underwent facial bone computed tomography (CT) scans and who were discharged with specific ICD-10 codes. Patients were excluded if they were referred from another hospital after the diagnosis of OWF due to their incomplete medical records or no formal interpretive reports of CT scans. All orbital fractures were confirmed using facial bone CT scans, which included fractures of one or more walls of the orbit (frontal bone, sphenoid bone, zygoma, maxillary bone, and ethmoid bone), the orbital rim, or both [
Data regarding age, sex, injury mechanism, site of orbital wall fracture, and concomitant facial bone fractures were collected from formal interpretive reports of CT scans prepared by radiology specialists. The common signs and symptoms of OWF were also noted, including diplopia, ecchymosis, emphysema, enophthalmus, and periorbital swelling. In our hospital, an emergency physician initially collected patient history and performed physical examinations, including ophthalmic examinations. We categorized the mechanisms of injury into five groups: falls from heights, ground-level falls, motor vehicle accidents, violence, and other causes (penetrating and other blunt trauma). After patients were diagnosed with an orbital fracture on CT examination, an ophthalmologist performed a full ophthalmic examination. An emergency physician and ophthalmologist prepared their respective medical records.
Data were expressed as median with interquartile range for continuous variables and as numbers and percentages for categorical variables. The Mann-Whitney U-test was used to compare continuous variables, and the Pearson’s chi-square test or Fisher’s exact test was applied for categorical variables. For all analyses, a two-sided P-value of <0.05 was considered to indicate a statistically significant difference. Statistical analyses were performed using IBM SPSS ver. 20 (IBM Corp., Armonk, NY, USA).
Between January 1, 2004 and March 31, 2014, 177 pediatric patients (aged <18 years) were included in our study. They were categorized into preschool pediatric (n=25) and school-aged pediatric groups (n=152) based on age (below or above 7 years) (
There were differences in the mechanisms of injury between the two groups. Violence was the most common mechanism of injury in the school-aged pediatric group (49.3%) and it tended to occur more commonly in middle and high school-aged pediatric groups. In contrast, violence was the least common mechanism of injury in the preschool pediatric group (4.0%, P<0.001). Approximately half of the OWFs in the preschool pediatric group (48.0%) resulted from falls from a height, whereas falls from a height caused OWFs in only two of 149 patients (1.3%) in the school-aged pediatric group (P<0.001). The site of OWF according to the mechanism of injury is presented in
Periorbital swelling was the most common sign in all OWF types (inferior OWF, 90.0%; medial OWF, 88.8%; superior OWF, 95.7%; lateral OWF, 100.0%), followed by ecchymosis (inferior OWF, 55.5%; medial OWF, 48.3%; superior OWF, 56.5%; lateral OWF, 75.0%), and emphysema (inferior OWF, 20.9%; medial OWF, 22.5%; superior OWF, 17.4%; lateral OWF, 33.3%). Diplopia (inferior OWF, 14.5%; medial OWF, 6.7%; superior OWF, 0%; lateral OWF, 8.3%) and enophthalmus (inferior OWF, 5.5%; medial OWF, 4.5%; superior OWF, 4.3%; lateral OWF, 8.3%) were uncommon signs in all OWF types.
Based on the facial bone CT reports, the distribution of OWF showed a different pattern in the preschool versus school-aged pediatric groups (
Concomitant injuries and facial fractures seemed to occur more frequently in the school-aged pediatric group; however, no statistically significant difference was noted. Hemosinus was the most common concomitant injury in preschool and school-aged pediatric patients (44.1%), followed by fat herniation (28.2%), extraocular muscle herniation (7.3%), and extraocular muscle entrapment (5.6%). Concomitant facial fractures were less frequently observed in preschool pediatric patients than in school-aged pediatric patients (24.0% vs. 33.6%, P=0.34). This tendency was noted for all facial bone fractures except frontal bone fracture (12.0% vs. 9.9%, P=0.72). None of the patients in the preschool pediatric group had multiple facial bone fractures (0% vs. 15.1%, P=0.05).
In this study, we evaluated the injury patterns and concomitant injuries in pediatric patients with OWF and identified differences according to age at the time of injury (preschool and school-aged pediatric groups). The sex ratio, mechanism of injury, and the incidence of OWF site were different in the preschool vs. school-aged pediatric groups. The inferior wall was the most common fracture site in pediatric patients, and concomitant as well as multiple facial bone fractures were less likely to occur in preschool pediatric patients. These findings imply that anatomic changes as well as activity changes consistent with childhood development contributed to the differences in injury pattern and the magnitude of concomitant injuries.
Pediatric trauma patients have different anatomic features and demonstrate different physiologic responses to injury. The management of these patients involves more complex decision-making because they are still in the process of development. In our study, the male-to-female ratio varied significantly between the preschool and school-aged pediatric groups (52.0% vs. 93.4% male, P<0.001). The predominance of male patients with facial trauma has been observed in other studies and may be attributed to the differences in physical activities between boys and girls [
The age-related differences in mechanisms of injury might have contributed to the differences between OWF injury patterns and concomitant injuries in preschool versus school-aged patients. Interestingly, there was no statistically significant difference in the frequency of concomitant facial bone fractures between the preschool and school-aged pediatric groups (24.0% vs. 33.6%, P=0.34), but the frequency of multiple facial bone fractures was higher in the school-aged pediatric group (15.1% vs. 0%, P=0.05).
Despite the lack of significance, concomitant injuries, including fractures of the sinus, maxilla, nasal bone, and zygoma, did tend to occur more frequently in the school-aged pediatric group than in the preschool pediatric group. These differences might be attributed to anatomic changes. Many previous studies have suggested that after the age of 7 years, faces and sinuses become more vulnerable to blunt facial trauma [
This study had some limitations that should be acknowledged. First, this was a retrospective study and thus was subject to potential errors inherent to this type of study, such as selection bias. Second, the possibility of referral bias should be considered in our study, since it was based at a university-affiliated, tertiary referral center with both a pediatric ophthalmology referral center and a pediatric ED. Third, although all patients had routine ophthalmologic examinations, these were sometimes incomplete when the patients were severely injured. Additionally, in comparison with older children, the youngest patients were not cooperative during history-taking and ophthalmologic examination. History-taking was often performed with parents serving as a proxy instead, thereby introducing a potential error, especially in cases of child abuse. Fourth, the high school-aged group should ideally include patients aged 16 to 18 years; however, we included only the patients less than 18 years old. Fifth, we evaluated all injuries using CT scans, which can underestimate muscle and soft tissue injuries in the pediatric population [
In conclusion, we identified significant differences between preschool and school-aged pediatric patients with OWF in regard to sex ratio and mechanism of injury. The inferior wall was the most common site of fracture in both groups. School-aged pediatric patients tended to have concomitant injuries and more multiple facial bone fractures than preschool patients.
No potential conflict of interest relevant to this article was reported.
The site of orbital wall fracture according to mechanism of injury. Mechanism of injury including violence, traffic accident, ground level falls, and falls from heights were listed in order of frequency.
Demographic and clinical characteristics of pediatric patients with orbital wall fracture in preschool and school-aged groups
Variable | Total (n = 177) | Preschool pediatric group (n = 25) | School-aged pediatric group (n = 152) | P-value | Elementary school- aged pediatric group (n = 44) | Middle school-aged pediatric group (n = 47) | High school-aged pediatric group (n = 61) |
---|---|---|---|---|---|---|---|
Age (yr) | 13.0 (10.5–16.0) | 2.0 (1.0–6.0) | 14.0 (12.0–17.0) | < 0.001 | 11.0 (9.0–12.0) | 13.0 (13.0–14.0) | 17.0 (16.0–17.0) |
Sex, male | 155 (87.6) | 13 (52.0) | 142 (93.4) | < 0.001 | 38 (86.4) | 45 (95.7) | 59 (96.7) |
Mechanism of injury | |||||||
Violence | 76 (42.9) | 1 (4.0) | 75 (49.3) | < 0.001 | 15 (34.1) | 28 (59.6) | 32 (52.5) |
Traffic accident | 30 (16.9) | 5 (20.0) | 25 (16.4) | 0.77 | 4 (9.1) | 3 (6.4) | 18 (29.5) |
Ground level falls | 21 (11.9) | 3 (12.0) | 18 (11.8) | 0.99 | 9 (20.5) | 5 (10.6) | 4 (6.6) |
Falls from heights | 14 (7.9) | 12 (48.0) | 2 (1.3) | < 0.001 | 0 (0) | 1 (2.1) | 1 (1.6) |
Other causes |
36 (20.3) | 4 (16.0) | 32 (21.1) | 0.56 | 16 (36.4) | 10 (21.3) | 6 (9.8) |
Signs and symptoms | |||||||
Periorbital swelling | 157 (88.7) | 25 (100.0) | 132 (86.8) | 0.08 | 35 (79.5) | 40 (85.1) | 57 (93.4) |
Ecchymosis | 94 (53.1) | 18 (72.0) | 76 (50.0) | 0.04 | 20 (45.5) | 25 (53.2) | 31 (50.8) |
Emphysema | 32 (18.1) | 3 (12.0) | 29 (19.1) | 0.58 | 9 (20.5) | 5 (10.6) | 15 (24.6) |
Diplopia | 19 (10.7) | 1 (4.0) | 18 (11.8) | 0.48 | 6 (13.6) | 8 (17.0) | 4 (6.6) |
Enophthalmos | 7 (4.0) | 1 (4.0) | 6 (3.9) | 0.99 | 4 (9.1) | 1 (2.1) | 1 (1.6) |
Values are presented as median (interquartile range) or number (%).
Of 36 patients, orbital wall fracture was caused by sports-related trauma (n=13), an object collision (n=11), a collision against other person (n=10), and unknown mechanism (n=2).
Radiologic findings for pediatric patients with orbital wall fracture in the preschool and school-aged groups
Variable | Total (n = 177) | Preschool pediatric group (n = 25) | School-aged pediatric group (n = 152) | P-value |
---|---|---|---|---|
Types of orbital wall fractures | ||||
Inferior wall | 110 (62.1) | 11 (44.0) | 99 (65.1) | 0.04 |
Medial wall | 89 (50.3) | 7 (28.0) | 82 (53.9) | 0.02 |
Superior wall | 23 (13.0) | 9 (36.0) | 14 (9.2) | 0.001 |
Lateral wall | 12 (6.8) | 2 (8.0) | 10 (6.6) | 0.68 |
Multiple orbital wall fractures | 49 (27.7) | 4 (16.0) | 45 (29.6) | 0.16 |
Concomitant injuries | ||||
Fat herniation | 50 (28.2) | 3 (12.0) | 47 (30.9) | 0.05 |
EOM hernia | 13 (7.3) | 2 (8.0) | 11 (7.2) | 0.99 |
EOM entrapment | 10 (5.6) | 2 (8.0) | 8 (5.3) | 0.64 |
Orbital hematoma | 2 (1.1) | 0 (0) | 2 (1.3) | 0.99 |
Hemosinus | 78 (44.1) | 6 (24.0) | 72 (47.4) | 0.03 |
Concomitant facial bone fracture | 57 (32.2) | 6 (24.0) | 51 (33.6) | 0.34 |
Maxilla fracture | 29 (16.4) | 2 (8.0) | 27 (17.8) | 0.38 |
Nasal bone fracture | 28 (15.8) | 0 (0) | 28 (18.4) | 0.02 |
Frontal bone fracture | 18 (10.2) | 3 (12.0) | 15 (9.9) | 0.72 |
Zygoma fracture | 13 (7.3) | 1 (4.0) | 12 (7.9) | 0.70 |
Mandible fracture | 2 (1.1) | 0 (0) | 2 (1.3) | 0.99 |
Multiple facial bone fractures | 23 (13.0) | 0 (0) | 23 (15.1) | 0.05 |
Values are presented as number (%).
EOM, extraocular muscle.