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British Journal of Oral and Maxillofacial Surgery 51 (2013) 41–46

Orbital fractures in children

Alistair R.M. Cobb a,∗ , N. Owase Jeelani b , Peter R. Ayliffe c
a Craniofacial Centre, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, UK
b Paediatric Neurosurgery and Craniofacial Centre, Great Ormond Street Hospital for Children, London, UK
c Department of Oral and Maxillofacial Surgery, Great Ormond Street Hospital for Children, London, UK

Accepted 13 March 2012

Available online 10 April 2012

Abstract

In children, differences in the properties and proportions of bone in the craniofacial skeleton and the lack of development of the paranasal
sinuses result in orbital fractures that present differently from those in adults. Facial growth may be disturbed by such injuries and also
by surgical intervention, which should therefore be as conservative as possible. However, urgent operation is needed to prevent irreversible
changes when fractures of the orbital floor involve entrapped muscle. We present an approach to such injuries.
© 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Orbit; Paediatric; Trauma; Blow out fracture; Facial fracture

Introduction
Orbital fractures can present difficult reconstructive problems
because they are sited between the brain, paranasal sinuses,
globe, adnexal tissues, and craniofacial skeleton, and the hard
and soft tissues related to the globe and the preservation of
sight can complicate the functional and aesthetic demands
of corrective surgery. In children, surgery should be limited
to prevent iatrogenic disruption of natural development and
growth, but must correct deformity that would impair the
process of growth itself.
Growth and development
The foetal face at 11 weeks is characterised by orbits that are
set widely apart and sandwiched between a diminutive visce-
rocranium and a dominant frontally projecting neurocranium.
This relation is maintained until about 7 years of age. The
orbital axes rotate gradually from 180◦ in the embryo to 50◦
in adulthood.1 Height and width across the orbital entrance,
∗ Corresponding author.
E-mail address: alicobb@yahoo.com (A.R.M. Cobb).
orbital depth, and the cubic root of its volume all develop in
a linear relation with time. It continues past birth until about
7 years of age when it has developed to roughly 70% of its
final size.1,2 Frontal sinuses are not present in the neonate,
and they do not start to develop until about 2 years of age.
They may first be identified radiographically at 8 years and
do not reach adult size until 12 years or older.
The development of the orbit is closely linked to its prox-
imity to the nasal cavity and paranasal sinuses. Its height is
dependent on the development of the lateral nasal wall, which
itself is dependent on the growth and development of the eth-
moid and maxillary sinuses. The infant face therefore has
pronounced frontal bossing and the face sits “underneath”
the frontal bones and supraorbital ridges, which act as a
protective hood.
Orbital roof and frontal fractures are more common in
this younger age group, and blowout fractures of the floor
are rare in children under five.3 Logistic regression analysis
shows that the probability of fracture of the lower orbit does
not exceed that of the orbital roof until the age of 7.1 years.4
The very young are therefore more likely to have a fracture of
the roof (Fig. 1). With the lack of pneumatised frontal bones,
there is no crumple zone, and in direct frontal trauma (more
likely because of the size and projection of the frontal bone at

0266-4356/$ – see front matter © 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2012.03.006
42 A.R.M. Cobb et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 41–46
Fig. 1. The absence of frontal sinuses in the young child can result in
fractures which involve the supraorbital rim and orbital roof.
this age) fractures are more likely to involve the supraorbital
rim and even extend basally across the anterior cranial floor or
orbital roof. With the development of the frontal sinuses we
see a shift from supraorbital frontobasilar to isolated frontal
fractures. The pattern of change is similar in the development
of the maxillary and ethmoid sinuses, and blowout fractures
of the orbital floor and medial wall.
Features of bone in children
The flat facial bones are richly vascular and have a higher
ratio of cancellous to cortical bone. The periosteum is thicker,
stronger, and more active than in adults, but is also more eas-
ily stripped from the underlying bone.5,6 In children it is a
primary source for the formation of new bone and for repair,
but if it is disrupted and a haematoma forms, unwanted sub-
periosteal bone may develop, and dissection must be limited
to prevent this, particularly near the medial canthus and nasal
dorsum.
Bone in children has a persistence of a portion of foetal
woven bone and a less organised structure than in adults. The
collagen fibres are irregularly orientated and more organic
components are not mineralised. The bone is less calcified
and is permanently being remodelled as the child grows. It is
less rigid, more flexible, more pliable, less brittle, and more
elastic,5 and is more likely to deform plastically. It is more
likely to have a greenstick fracture (bowing of bone with
incomplete cortical disruption on the other side) or a torus
injury (buckling and deformation with no discontinuity of
bone). Therefore it may not be possible to reduce a fracture
accurately.
Epidemiology of orbital fractures in children
The incidence of orbital and facial injuries increases with
age.7–9 Most studies report that mandibular fractures are the
most common facial fractures in children at 20–50% of the
total.10–13 However, in a series of 772 facial fractures in chil-
dren, Grunwaldt et al. reported that orbital fractures were the
most common in all age groups (56–45%), and decreased
with age.9 Unlike previous studies, this may have less selec-
tion bias as all presentations to a level I children’s trauma
centre were included, not just those referred to specialist
care.The most common causes of both orbital and facial
injuries in children are motor vehicle accidents and activi-
ties of daily living in the young, with an increasing trend
from sports and violence with age. Boys are more likely to
be affected than girls.7–9
Assessment
Clinical assessment can be difficult in children with orbital
injuries. An attempt should be made to examine the eye move-
ments, position of the globe, eyelids, and visual acuity. All
patients should have orthoptic assessments at least for visual
acuity, diplopia, and movement in all nine fields of gaze, and
Hess charting or equivalent, and fields of binocular vision.
Ophthalmic assessment of the corneal surface, lens, anterior
and posterior compartments, and fundus for evidence of con-
comitant ophthalmic injuries is essential. As part of a standard
examination of the craniofacial and maxillofacial skeleton,
one should pay particular attention to flattening of the nasal
complex, telecanthus, and vertical or horizontal malposition-
ing of the globe, particularly if naso-orbitoethmoid fractures
are suspected (Fig. 2).
Radiographic plain films can be unreliable. The level of
maxillary sinus fluid is merely an indictor of trauma to the
antral mucosa, not of the presence of fracture. The “tear drop”
sign, suggestive of blowout of the floor and herniation of
the orbital contents inferiorly can be caused by antral dis-
ease such as benign polyps.14 The investigation of choice is
therefore computed tomography (CT) that is reviewed and
reported by a radiologist.
Approaches to the orbit in children
We prefer to approach the orbital floor by a transconjunctival
approach.15 It may be combined with a lid swing crow’s foot
extension (lateral canthotomy and cantholysis) if necessary,
but is rarely required.
The transcaruncular extension16 may be used for access to
the medial wall, but the subtarsal approach gives better access
for reconstruction of the medial canthal ligament and is less
likely to damage the lacrimal system. It has a proven record
of satisfactory healing. Fractures of the roof and supraorbital
rim are approached through a bitemporal coronal flap unless
there is a particularly well-placed scar or laceration. However,
it is generally safer and more accurate to have wide exposure
of the surgical site and to work away from the globe.
 A.R.M. Cobb et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 41–46
Fig. 2. Typical features of a naso-orbitalethmoid fracture in a 9-year-old
child (printed with permission).
Access to the zygomaticofrontal suture by the eyebrow
incision has largely been replaced by the horizontal upper
lid blepharoplasty in our practice. However, the crow’s foot
extension of the transconjunctival approach is sometimes all
that is required, and can also provide excellent access to the
lateral orbital wall and sphenozygomatic suture. In all oper-
ations for orbital trauma the cornea can be protected with a
rubber laser eye shield with 1% chloramphenicol ointment
applied to the surface of the fitting.
Recent assertions for the role of endoscopy in orbital
surgery do not seem to us to be relevant currently in injured
children.
Classification
A clinically based classification can guide the approach to
surgical management. We may consider orbital fractures in
children as orbitozygomatic (lateral orbital wall), craniofacial
(involving the roof or frontobasilar region), part of complex
facial injuries (including naso-orbitoethmoid fractures), or
blowout fractures of the floor or medial orbital wall, or both.
While these may coexist, this approach can inform about
individual problems and help to focus the management plan.
We consider each of these in turn below.
43
Management of orbitozygomatic fractures
The presentation and clinical signs for these in children are
similar to those in adults. The extent of the bony displacement
is best examined with CT.
The Gillies temporal approach and lift, or intraoral
approaches may be used. We try to avoid plating, as there is
less muscular distraction of the bony fragments. There is typ-
ically less need for dissection, which minimises the potential
for disturbing growth. Direct inspection of the lateral orbital
wall may be indicated when enophthalmos secondary to an
increase in volume has not been corrected, and in such cases
buckling may have occurred. It may be possible to achieve
a satisfactory reduction of the malar body and arch, but the
lateral orbital rim may not be reduced sufficiently. If the two
aspects of bone cannot be bent back surgically, the lateral
orbital wall should be correctly reduced and checked back
to the sphenozygomatic suture, as this is usually the point of
fracture. Bone grafting to the malar eminence or the anterior
arch, or both, may be required immediately or as a delayed
secondary procedure.
Management of fractures of the orbital roof or
supraorbital rim
Fractures of the orbital roof and supraorbital rim are usually
managed conservatively,4,17 but have a significant chance
of neurocranial injury.4 However, some specific indica-
tions for intervention are: functional impairment of ocular
movement; a concomitant indication for neurosurgical inter-
vention; dural tear or leakage of cerebrospinal fluid (CSF);
more pronounced aesthetic compromise; or large, displaced
fractures.18 Early intervention may be prevented by more
urgent medical needs as neurological comorbidities are
highly likely with such injuries.
The surgical approach through a bitemporal coronal flap
raised in subgaleal and pericranial planes gives excellent
access to the orbital roof after frontal craniotomy. The pericra-
nium may be used as an inferiorly based vascularised flap to
seal leakage of CSF if required, or to provide soft tissue cover-
age to augment the nasal dorsal tissues in naso-orbitoethmoid
fragments (Fig. 2). A combined neurosurgical and craniofa-
cial reconstructive approach is necessary to repair the injured
brain, dura, and craniofacial skeleton. A bitemporal coronal
flap gives good exposure of the fracture site, and allows auto-
genous bone to be harvested. When good reduction and direct
stabilisation of the fractures is achieved, it is usually possible
to reconstruct the complete orbital roof.
Management of complex facial fractures with orbital
involvement including naso-orbitoethmoid (NOE)
fractures
In children, greenstick fractures and buckling can prevent
the complete reduction of a fracture. Rather than a lateral
to medial approach to craniomaxillofacial trauma it may
44 A.R.M. Cobb et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 41–46

Table 1
Classification of orbital fractures in children.
Orbitozygomatic
Craniofacial – involving the roof or frontobasilar region, fractures
of the orbital roof or supraorbital rim
Blowout fractures of the orbital floor or medial wall
Complex craniomaxillofacial (including naso-orbitoethmoid
fractures)

Table 2
Classification of naso-orbitoethmoid (NOE) fractures (Ayliffe19 ).
Level Description
I En bloc minimal displacement fracture of entire nasoethmoid
complex
II En bloc displaced fracture with minimal fragmentation
III Comminuted fracture but canthal tendons attached to bone
fragments that are large enough to fix with miniplates
IV Comminuted fracture with free canthal ligaments not enough to
capture with miniplate fixation Fig. 3. A spur of bone projects from the orbital margin to the frontal region.
V Gross comminution
Frontal suffix [e.g. Type II NOE-F2]:
[F0 – subcranial – usually unnecessary to specify]
F1 – involving nasofrontal spur (requires bitemporal coronal flap
access but no osteotomy to reduce frontal fracture)
F2 – extensive frontal extension (requires bitemporal coronal flap
access and osteotomy to reduce frontal fracture)

therefore be necessary to attend to the central middle third

of the face first and compromise laterally if necessary.
In adults, naso-orbitoethmoid fractures can be classified
according to the degree of comminution and the ease with
which the bony fragments, to which the medial canthal liga-
ments are attached, can be fixed with a plate.19 Such injuries
are rare in children under 5 years but are progressively more
common in adolescents. Management in the older child is
similar to that in adults, but in the very young there may be
a frontal extension. Type F0 injuries follow an adult pattern Fig. 4. The entire frontal region is involved with the orbital fracture and will
and may be approached in the usual manner (Tables 1 and 2). require osteotomising to convert to separate frontal and orbital fractures.
In type F1 injuries a buckled spur of frontal bone is attached
to the nasal fragment (Fig. 3), which may be bent back into with no subconjunctival haemorrhage – a “white eye blow out
place after reconstruction of the fractures and soft tissue lig- fracture”22 with upgaze diplopia (Fig. 5), and general malaise
amentous anatomy. However, if this is not possible, they may caused by the oculovagal reflex.23–25 There is marked restric-
need to be treated as type F2 injuries. In these, the more tion of motility in upward and downward gazes and there
complex and extensive craniofacial extension of the fracture may be little evidence of disruption to the orbital floor on
warrants frontonasal osteotomy to convert the fracture into CT – only a small crack or trapdoor defect with little bony
separate NOE and frontal fractures, which can be managed displacement.26 This is caused by greenstick fractures of the
individually (Fig. 4). Therefore F0 is subcranial and follows
the adult scheme, whereas F1 and F2 require a craniofacial
approach with a bitemporal coronal flap and possibly a dorsal
graft.

Management of orbital blowout fractures

Fractures of the orbital floor are rare in children under 8

years old, but until the age of 9 years they are more likely
to involve the anterior orbital floor than the posterior orbital
floor as in adults,20 and to be associated with diplopia. Clas- Fig. 5. Limitation of upgaze movement on the right because of entrapped
sic presentation of an orbital blowout fracture in a child21 is tissue in a fracture of the orbital floor.
 A.R.M. Cobb et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) 41–46
orbital floor in children, rather than the “blowout” of a portion
of the more brittle bone in adults. The greenstick “trapdoor”
of bone in the orbital floor or medial wall in children tends to
spring back after fracture and trap inferior orbital soft tissues,
typically the inferior rectus muscle. If not released quickly it
will tend towards permanent ischaemic necrosis and poten-
tially in a Volkmann ischaemic contracture,27 and can result
in permanent impairment.
The oculovagal (Aschner-Dagnini or oculocardiac)
reflex28,29 presents with a decrease in pulse rate associated
with traction on the extraocular muscles or compression of
the globe.30 Children are particularly sensitive. The reflex
is mediated in the reticular formation in the brain stem
by connections between sensory afferent fibres of the oph-
thalmic division of the trigeminal nerve and the visceral
motor nucleus of the vagus nerve. Vagal efferents depress the
sinoatrial node and myocardial contractility,31 which result
in bradycardia and hypotension accompanied by headache,
nausea, and vomiting. In extreme cases resuscitation with gly-
copyrrolate or atropine may be necessary. The effects of the
response may be misdiagnosed as a head injury and there-
fore delay operation.25 Attending clinicians should have a
high index of suspicion in such cases as prompt diagnosis is
essential for the best outcome.32
When there is evidence of entrapment we advise early
operation to prevent visual impairment through permanent
muscle damage.33–35 De Man et al. recommend operation
as soon as possible (24–48 h) for trapdoor-type fractures,36
but Jordan et al. recommend it in 2–3 days.22 We suggest a
pragmatic approach. In cases where operation is indicated,
early intervention means a shorter period of ischaemia and
sickness caused by the oculovagal reflex, and a lower risk of
irreversible change in the muscle.37 We therefore intervene
and free the entrapped tissues on the same day or the next
day if prevented by medical concerns or starvation protocols
for general anaesthesia.
Usually no graft to the orbital floor is required in children,
however, where it is required we prefer polydioxanone sheet
or cranial bone.
Conclusions
Orbital injuries in children present differently from those
in adults, assessment is difficult, and CT is unreliable in
blowout fractures. The bone tends to buckle without fracture,
or to greenstick fracture, which may result in entrapment
of tissue in fractures of the orbital floor or medial wall
and the need for urgent release of incarcerated muscle to
prevent permanent visual impairment. Buckling of bone may
prevent complete reduction of hard tissue injuries. Initially
one may therefore have to consider a medial approach to the
reduction of facial fractures in children, and perfect lateral
reduction of fractures may not be possible. Treatment should
be as conservative as possible to minimise the disruption
of facial growth and to prevent the formation of new
45
subperiosteal bone. Orbital trauma should be managed by a
multidisciplinary team that includes an orthoptist, and max-
illofacial, craniofacial, ophthalmic, and neurosurgeons, as
appropriate.
Acknowledgements
We would like to extend our thanks to Mr. Paul Johnson,
Royal Surrey County Hospital Guildford, for use of the image
of one of his patients and David Smithson ICH/GOS Graphic
Design Studio for the illustrations.
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