Evaluation and management of pediatric orbital fractures in a primary care setting

To review and evaluate the management of white-eyed blowout fractures (WEBOF) from Emergency Department (ED) triage through surgical repair.

Retrospective chart review of consecutive cases of pediatric orbital blowout fracture requiring surgical repair at a large ophthalmologic referral center. The characteristics of patients with WEBOF and those with conventional orbital blowout fractures were compared, including: mechanism of injury, clinical presentation, ED management and referral patterns, and time to definitive treatment.

Sixteen patients comprised the WEBOF study group, and 14 patients with conventional blowout fractures comprised the control group. All WEBOF had pain with eye movement, limited ductions and diplopia, and 75% had nausea and vomiting. These symptoms were present in significantly lower frequencies in control patients (64%, 64%, 7%, 14%, respectively). Compared to controls, WEBOF patients were younger; had injury more often resulting from sports and play; were less likely to undergo orbital imaging in the ED; were more likely to be diagnosed with concussion in the ED; were less likely to be seen urgently by an ophthalmologist; and were told to follow-up with an ophthalmologist 4-5 days later than control patients.

WEBOF is a clinical diagnosis consisting of vertical diplopia, gaze restriction and nausea and/or vomiting in the setting of peri-orbital trauma in the pediatric and young-adult age group. The paucity of external signs of trauma may lead to initial misdiagnosis and delay in treatment. All patients who meet WEBOF criteria should undergo dedicated orbital CT as part of the ED evaluation. If WEBOF is suspected, a prompt referral to an ophthalmologist should be made.