Just a Frontal Bone Fracture?

Damien LingUnaccredited Ophthalmology Registrar

The Royal Hobart Hospital

Acknowledgements: A/Prof Nitin Verma, Dr Nancy Saunders-Clay

CASE OVERVIEW

17 year old male

Otherwise fit and well

Social Hx Year 12

Works at Bunnings

Keen skateboarder

PRESENTATION

Skateboarding at high speed down Bridge of Remembrance

Fell face-first onto middle metal handrail, exiting the bridge

Brief (<10sec?) LOC

Ambulance to ED at RHH

BRIDGE OF REMEMBRANCE

Opened March 2019

200m long, 4m wide

$11 million

Shared pedestrian and cycling bridge

Links Cenotaph and Soldiers Memorial Avenue on the Queens Domain

PRESENTATION

Called by Maxillofacial registrar re: ?Possible penetrating eye injury by eccentric piece of frontal bone

Pain in right eye

No visual loss, no blurred vision, no diplopia

PRESENTATION

Shown CT orbits on my arrival to ED Resus

Has the eye been ruptured?

EXAMINATION

GCS 14 (E3 = eyes opening to voice)

Observations stable Transient bradycardia (HR 43 from 76)

?oculocardiac reflex

Right periorbital swelling and ecchymosis Patient unable to open lids without assistance

5cm laceration, 1cm below right eyebrow, extending 1cm lateral to eyebrow No visible arterial bleeding

Superficial left lateral temporal skin abrasion

VISUAL SYSTEM EXAMINATION

Visual acuity: right 6/12, left 6/6 (3m chart)

IOP (Tonopen): R 22mmHg L 17mmHg

No RAPD

Right SCH

Anterior segment NAD (portable slit lamp)

Fundus – difficult examination Posterior pole NAD No vitreous or retinal haemorrhages Unable to visualise superior retina

CT BRAIN / FACIAL BONES

PROGRESS

Right supraorbital ORIF (performed by Oral & Maxillofacial Unit) that evening Access via existing laceration

Titanium mesh plates and 11 x 4mm screws

Forced ductions: full

PROGRESS

Day 1: CT

PROGRESS

Day 1 Subjectively blurred VAR

No diplopia

VA R 6/5 L 6/5

IOP R 19 L 21

Full range of EOM

Moderate right periorbital swelling, SCH

Remainder of examination unremarkable

PROGRESS

3 week review No diplopia

VA R 6/6 L 6/5

IOP R 19 L 21

Full EOM

Normal Hess

Ocular examination normal

2 month review Vision NAD

Still no diplopia

No forehead numbness / paraesthesiae

Mild brow swelling

SUPERIOR ORBITAL RIM / ORBITAL ROOF FRACTURES

1-9% of facial fractures involve orbital roof1

Most common mechanism: high-energy, blunt trauma to orbit or forehead

Often associated with “blow-out”/”blow-up” or “blow-in” fractures of orbital roof

Usually associated with concomitant injuries (e.g. other craniofacial fractures)

1. Haug RH et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;93(3):238–246.2. Cossman JP et al. Plast Reconstr Surg. 2014 Mar;133(3):335e-343e

Orbital roof “blow-out” fracture2 Orbital roof “blow-in” fracture2

ORBITAL ROOF FRACTURES –CLASSIFICATION SYSTEM

Orbital Roof Fracture Associated Injuries

I. Undisplaced Suspected or Proven:F – other facial fracturesN – neurological / intracranial injuryO – ocular / intraorbital injuryS – frontal sinus injury

II. Rim

III. Roofa. Blow-outb. Blow-in

IV. Roof and Rima. Blow-outb. Blow-in

Connon FV et al. Craniomaxillofac Trauma Reconstr. 2015 Sep; 8(3): 198–204.

Risk of Ocular Injury: “BAD ACT”

Blow-out FractureAcuity changeDiplopiaAmnesiaComminuted fractureTrauma to the eye

ORBITAL ROOF FRACTURES

1. Connon FV et al. Craniomaxillofac Trauma Reconstr. 2015 Sep; 8(3): 198–2042. Cossman JP et al. Plast Reconstr Surg. 2014 Mar;133(3):335e-343e3. Fulcher TP, Sullivan TJ. Ophthalmic Plast Reconstr Surg. 2003 Sep;19(5):359-63

Majority can be managed conservatively (90%)1,2

Indications for fixation: Risk to surrounding structures – intracranial, intraorbital

Functional deficit/symptomatic

Severe aesthetic deformity

Ophthalmic complications3

Traumatic optic neuropathy, ptosis, penetrating eye injury, intraorbital foreign body, oculomotor nerve palsy

Multidisciplinary team: Maxillofacial, neurosurgery, ophthalmology, plastics

REFERENCES

Haug RH, Van Sickels JE, Jenkins WS. Demographics and treatment options for orbital roof fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;93(3):238–246.

Cossman JP, Morrison CS, Taylor HO, Salter AB, Klinge PM, Sullivan SR. Traumatic orbital roof fractures: interdisciplinary evaluation and management. Plast Reconstr Surg. 2014 Mar;133(3):335e-343e

Connon FV, Austin SJB, Nastri AL. Orbital Roof Fractures: A Clinically Based Classification and Treatment Algorithm. Craniomaxillofac Trauma Reconstr. 2015 Sep; 8(3): 198–204.

al-Qurainy IA, Titterington DM, Dutton GN, Stassen LF, Moos KF, el-Attar A. Midfacial fractures and the eye: the development of a system for detecting patients at risk of eye injury. Br J Oral Maxillofac Surg. 1991 Dec;29(6):363-7.

Fulcher TP, Sullivan TJ. Orbital roof fractures: management of ophthalmic complications. Ophthalmic Plast Reconstr Surg. 2003 Sep;19(5):359-63.