Menoufia Medical Journal

ORIGINAL ARTICLE
Year
: 2014  |  Volume : 27  |  Issue : 2  |  Page : 379--385

Fronto-orbital bone fracture: management and outcome


Fouad M Ghareeb1, Ahmed M Elbarah1, Yaser M Elsheikh1, Ahmed Th. Nassar1, Osama M Ebied2, Hana Z Nohc3,  
1 Plastic Department, Menoufia University, Faculty of Medicine, Shebin El-Kom, Egypt
2 Radiology Department, Menoufia University, Faculty of Medicine, Shebin El-Kom, Egypt
3 Anatomy Department, Menoufia University, Faculty of Medicine, Shebin El-Kom, Egypt

Correspondence Address:
Ahmed Th. Nassar
MSc, Berket Al Sabaa, Menofia
Egypt

Abstract

Objective The aim of this study was to review the effect of early and late surgical intervention and armamentarium used on the functional and esthetic outcome of fronto-orbital fracture repair. Background Orbital roof fractures represent an important group of orbital fractures because of their close relation to the frontal lobe of the brain and also because of their relation to the eye. Management of orbital roof fractures requires good assessment, early reconstruction, if possible, and team management. Functional and esthetic outcomes should be assessed. Patients and methods Twelve patients with orbital roof and frontal bone fractures were included in this study. Surgical treatment included open bone reduction alone, open reduction with fixation, and/or orbital reconstruction. Postoperative assessment of functional ocular deformities (limited eye movement and diplobia) and esthetic deformities (enophthalmos, dystopia, and proptosis) was carried out. Radiologic assessment for bone reduction and orbital volume was carried out. Results All patients were males. They ranged in age from 16 to 61 years. Road traffic accidents were the cause of trauma in about 67% of patients. Early intervention was performed in 50% of patients, with 100% correction of functional deformities, 90% correction of esthetic deformities and accurate bone reduction in 95% of cases, and good patient satisfaction in 85% of cases. This was much better than late intervention. Titanium mesh was used in 50% of the cases, with accurate orbital volume reduction in 90% of the cases, which was only 50% with bone graft use. Conclusion Early management of orbital roof and frontal bone fractures yields the best results. The use of titanium mesh leads to good functional and esthetic outcomes, with no donor-site morbidity, and saves time.



How to cite this article:
Ghareeb FM, Elbarah AM, Elsheikh YM, Th. Nassar A, Ebied OM, Nohc HZ. Fronto-orbital bone fracture: management and outcome.Menoufia Med J 2014;27:379-385


How to cite this URL:
Ghareeb FM, Elbarah AM, Elsheikh YM, Th. Nassar A, Ebied OM, Nohc HZ. Fronto-orbital bone fracture: management and outcome. Menoufia Med J [serial online] 2014 [cited 2019 Dec 6 ];27:379-385
Available from: http://www.mmj.eg.net/text.asp?2014/27/2/379/141712


Full Text

 Introduction



The orbital roof is composed almost entirely of the frontal bone, with a tiny contribution from the lesser wing of sphenoid tapering posteriorly into the anterior clinoid process. The orbital roof is very strong and rarely fractures. There is variable pneumatization of the roof by the frontal sinus [1].

Epidemiologic studies indicate that traffic accidents account for most of the orbital fractures in the urban population [2].

The fracture frontal region was classified in relation to the frontal sinus and orbital roof into five levels of injury. Type 1, anterior frontal sinus table involving the orbital rim; type 2, anterior frontal sinus table comminuted with orbital roof involvement; type 3, anterior and posterior frontal sinus table comminuted with roof involvement; type 4, anterior and posterior frontal sinus walls with frontobasilar injury involving cribriform with or without dural tears; and type 5, as in type 3 or 4 but with bone loss [3].

The majority of the examination should focus on the status of the globe and neurologic state in case of fronto-orbital fractures. Although every patient with an orbital fracture should be evaluated preoperatively by an ophthalmologist and a neurosurgeon, there are crucial aspects to the history and examination that should be studied by the plastic surgeon [4].

Complex fractures can still result in cosmetic and functional deformity. The current challenge is to consistently restore patients back to their preinjury form and function, but this is not always possible. Greater understanding and developments have significantly improved outcomes, although controversy still exists in some areas [5].

 Patients and methods



Twelve patients with fronto-orbital fractures were treated in the Plastic Surgery Department, Faculty of Medicine Hospital, Menoufia University, Egypt, between December 2010 and December 2012.

Clinical assessment

Assessment of history

Complete assessment of history was performed for all patients. Analysis of complaints carried out in detail, with a focus on the time, type, site, and mode of trauma. Assessment of systemic manifestations associated with trauma, especially neurologic and ophthalmologic manifestations, was performed.

Examination

A detailed general examination was performed. Assessment of vital signs was essential. Review of different body systems was carried out to exclude other trauma or other disease that would affect the time, type, or priority of treatment.

A detailed assessment by a neurosurgeon was essential in all cases. A complete ophthalmologic assessment by an ophthalmologist was carried out, with a detailed written report that included assessment of visual acuity, color perception, pupillary reflex, and fundus examination. A surgical decision was made in consultation with all team members.

Local examination was carried out of all facial skeleton and soft tissues. Oral cavity examination and assessment of occlusion were performed.

Radiologic assessment

A three-dimensional (3D) computed tomography (CT) scan of the facial skeleton and other necessary investigations were performed for the patients.

Treatments

(1) First aid management was performed for emergency cases including stabilization of unstable fractures of the mandible, control of bleeding, and stabilization of the general condition. Unstable cases were admitted to the ICU under team supervision including ICU, general surgeons, neurosurgeons, and plastic surgeons.

(2) Surgical treatment was performed for indicated cases. Surgical treatment was planned according to the type and site of fracture and the associated functional and/or esthetic ocular deformities.

(a) Preoperative: before the surgical intervention, patients were informed about the case, the aim of surgery, the expected complication, and postoperative details (edema, pain, ecchymosis, minor blood ooze, whether intermaxillary fixation would be performed, etc.). Then, consent was obtained from the patient and his relatives including a detailed description of the surgery, expected complications, and consent to the use of photographs in medical research.

(b) Operative steps:

(i) Tube: we used armored tubes. Patient intubation was performed, either nasally, orally, or submentally according to the site and degree of fracture and surgery plan. A fiberoptic flexible laryngoscope was used in six cases with difficult intubation.

(ii) Position: a supine position with a slightly extended neck and a slight semi sitting position was used.

(iii) Disinfection: bovodine iodine solution (betadine) was used for scrub and patient sterilization. We ensured that the eyes and ears of the patients were not soaked with the sterilization solution.

(iv) Eye closure: the eyes were closed before the start of surgery in each case with a rounded needle Vicryle 0.4 to protect the globe and the cornea from iatrogenic injury or irritation.

(v) Marking of the incisions was performed regularly either preoperatively with a permanent marker or intraoperatively before a saline-adrenaline injection with a sterilized marker or with methylene blue.

(vi) Saline-adrenaline 1 : 200 000 was injected into the site of the planned incision using an insulin syringe.

(vii) Approaches and incisions: the type of incision was decided according to the site and degree of fracture and its associated ocular deformity. For orbital roof fractures, we used coronal approach, trans-eyebrow incision, and existing trauma wound.

(viii) Exposure: subperiosteal dissection was used for fracture exposure. Intraorbital dissection was performed carefully releasing soft tissue entrapped through the fracture. Bipolar diathermy was used for any minute vessels that arose from the small orbital foramina such as ethmoidal vessels using bipolar diathermy.

(ix) Reduction: bone reduction was performed according to the site and degree of fracture. Reduction of some fronto-orbital fractures required double intracranial and extracranial approaches with comanagement by neurosurgeons.

(x) Dealing with fracture: after proper exposure and reduction dealing with fracture was done. Reduction without fixation was performed for small bone fragments that could be reduced and lifted safely without fixation. Reduction and fixation with miniplates and screws was performed for most of or cases. The length of screws was 5 mm at the fronto-orbital area. Low-profile titanium miniplates were used around the orbit. When there was an orbital wall defect that required reconstruction, titanium mesh was the main tool used in the current study. Iliac and calvarial bone grafts were used in a limited number of cases when mesh was not available or extravolume was need. Type of miniplates, screws, and mesh were Martin (Germany) or Stryker (Germany).

(xi) A frontal sinus fracture was present in three patients. One showed anterior wall involvement and in the other two patients, both the anterior and the posterior table had a dural tear and there was frontal recess involvement in one of them. The anterior table fracture was managed by reduction and fixation. Posterior table fracture with frontal recess involvement was managed by sinus obliteration. The posterior table alone was managed by sinus cranialization.

(xii) Complementary or substitute procedures: a dermal graft was used in one case with a contour defect.

(xiii) Drain: we used suction drain for coronal wounds. Both rubber drain and tube drains were used for the bone graft site when needed. Drain removal was performed 24-48 h postoperatively.

(c) Postoperative management:

The immediate postoperative period requires close follow-up and medical treatment.

(i) A semisetting position can help in decreasing edema and preventing aspiration.

(ii) Cold foments were performed for the first 24-48 h postoperatively. We used latex or sterile gloves with cold water and no ice was used.

(iii) Analgesia: intramuscular nonsteroidal analgesics were used during the first 24-48 h. Some patients required opioid analgesics, but it was not the main regimen.

(iv) Intravenous fluids were used according to each patient and the onset of oral feeding and type of fracture.

(v) Antibiotics: intravenous third-generation cephalosporins were the main postoperative antibiotic used for 24-48 h and then replaced by oral antibiotics, which were in the form of quinlons for the rest of the first week postoperatively.

(vi) Antiedema drugs: intramuscular a-chemotrypsin was used for the first 2-3 days postoperatively.

(vii) Monitoring: this important in the postoperative period, especially the first 24 h. Eye pressure and criteria such as ocular pain, proptosis, and visual disturbance indicators for retro bulbar hematoma or intraorbital bleeding that can cause increased intraorbital pressure and blindness were assessed. Any suspicion should be managed with reoperation. Fortunately, we did not encounter this problem in our patients. Monitoring of vital signs is also important.

Follow-up

Postoperative follow-up and assessment was carried out by a 3D CT scan for most cases postoperatively. Radiographs for the cases where 3D CT scan was done. A postoperative ophthalmologic assessment was performed to test eye movement and visual acuity. Neurologic assessment was performed for cases where there was neurologic insult preoperatively or required intraoperative comanagement.

 Results



In the current study, all the patients were males. They ranged in age from 16 to 61 years. Fractures were because of a car accident (six patients), a motor cycle accident (two patients), violence and struggle (three patients), and one falling from height.

Four patients were managed immediately because of critical indications (dural tear, intracranial hemorrhage, or compound depressed fracture) as decided by neurosurgeons. Two patients were managed during the first 2 weeks after trauma and considered for an early intervention. The other six patients were managed after the first 2 weeks of trauma with variable periods and considered for a late intervention. This was because of contraindications for an early intervention or late presentation of the patients after 2 weeks [Table 1].{Table 1}

Functional problems included limited ocular movement in six patients; one of them had superior orbital fissure syndrome. One patient had optic nerve compression and visual disturbance [Table 2].{Table 2}

There was frontal sinus involvement in three patients, one with anterior wall involvement, and in the other two patients, both the anterior and the posterior table had a dural tear and were managed immediately. One of them was managed by dural repair, restoration of the displaced bones, and sinus mucosal striping with backing using a galeal graft, which is called sinus obliteration, where the frontal recess shows flow obstruction. The other case was managed by frontal sinus cranialization.

Esthetic deformities included enophthalmos in four patients, enophthalmos and hypoglobus in two, hypoglobus in one, proptosis in three, and eyebrow asymmetry with frontal depression in two.

Comparison between early and late surgical interventions was performed including edema, patient features, soft tissue and bone condition, operative time, osseous reduction, soft tissue response, radiologic assessment, and patient satisfaction [Table 3]. In early intervention there were edema and disturbed patient features than late interventions. In contrast, hand bone condition and soft tissue response were better in early intervention with shorter operative time and better outcome than late intervention.{Table 3}

We used the trans-eyebrow incision in four patients, coronal incision in one, and through the wound in others because of trauma.

We used titanium mesh alone in five patients, titanium mesh with calvarial bone in one, iliac bone graft in one, simple bone reduction alone or with fixation in five, and dermal graft in one for simple esthetic correction [Table 4].{Table 4}

A comparison between titanium mesh and bone grafts is shown in [Table 5], with multiple advantages of using titanium mesh.{Table 5}

Postoperative assessment of functional defects indicated full recovery of ocular mobility in five patients with limited ocular mobility. Patients with superior orbital fissure syndrome showed limited improvement in the early follow-up period. Patients with optic compression and deterioration in visual acuity showed an improvement in visual acuity from light perception to 1/60.

The esthetic outcome was as follows: patients with eyebrow depression and asymmetry showed an excellent esthetic outcome. Three patients with enophthalmos alone showed good improvement, but one patient had a remnant defect. Patients who received an early intervention showed improvements in both hypoglobus and enophthalmos. The other patient with hypoglobus and enophthalmos who was managed late showed a mild improvement. Patients with hypoglobus alone showed a moderate improvement. Patients with proptosis showed marked improvement.

One of our patients developed a complication in the form of CSF rhinorrhea and pneumocephaly; he was managed conservatively and showed improvement. Follow-up was performed for 6 months postoperatively, with no recurrence of CSF rhinorrhea after conservative treatment [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5] and [Figure 6].{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}

 Discussion



Orbital roof fracture is a critical condition that is usually associated with neurosurgical insult. Of 12 patients with orbital roof fractures, six were managed early and the other six were managed late. In the early intervention, neurosurgical indication for surgery was mostly associated with a dural tear or hemorrhage in addition to ocular problems such as limited movement, hypoglobus, and enophthalmos. In these cases, bone reduction or the use of reconstructive materials was easy because of limited fibrosis and preserved anatomical criteria of the tissues. Among other patients who received a delayed intervention, five presented late because of variable causes in periods ranging from 1 month to a years. There complaint was esthetic (disfigurement because of fronto-orbital irregularity). One patient received a delayed intervention because of his poor general condition. After improvement in his condition and weaning from mechanical ventilation, correction of associated enophthalmos, hypoglobus, and diplobia was attempted, but minimal improvement was achieved.

Thus, the results of an early intervention in orbital roof fractures led to better operative conditions and better postoperative outcome than delayed intervention.

This was similar to other studies that advocated early surgical intervention of orbital roof fractures to prevent meningitis and brain abscess formation. Piotrowski et al. [6] reported that about 80% of patients achieved good overall functional and cosmetic results with an early surgical intervention and about 20% of patients showed an unsatisfactory result, mainly because of orbital problems such as motility restrictions or enophthalmos, which were also in agreement with the results of Fulcher and Sullivan's [7] study.

In this study, early intervention led to decreased operative time, better results, especially esthetic results, and decreased incidence of complications. However, delayed intervention led to prolonged operative time and difficult restoration of the fractured segment because of fibrosis, and markedly affected the esthetic outcome. This was not in agreement with the results of some authors who recommended a conservative approach in the management of orbital roof fractures [7].

In the current study, the use of titanium mesh alone when there was a bone defect led to decreased operative time and provided rigid, durable fixation with easy contouring, no donor-site morbidity, and acceptable cost. It can be associated with autologous bone graft if it is needed to decrease the amount of needed bone. Also, titanium mesh provides a stable scaffold that fixes the bone graft and gains a good contour easily.

Reconstruction of the frontal region with augmentation procedures predictably improves contour deficiencies. The experience with iliac bone grafts indicated less resorption over time compared with calvarial bone grafts. Hydroxyapatite cement is a reasonable alternative, but should be used with caution in the frontal sinus region and should generally not be placed in contact with this sinus [8].

 Conclusion



Early management of orbital roof and frontal bone fractures yields the best result, whereas delayed management because of poor general condition or other causes leads to poor outcome. Titanium mesh yields good functional and esthetic outcomes, with no donor-site morbidity, and saves time. Especially in combined orbital roof and frontal bone titanium mesh give the ability to reconstruct both as one unite easily.

 Acknowledgements



Conflicts of interest

None declared.

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