The white-eyed blowout fracture in the child: beware of distractions
1Department of Oral and Maxillofacial Surgery, Russells Hall Hospital, Dudley, West Midlands, UK d.hammond@tesco.net.
Insights
Pediatric orbital floor fractures require prompt surgical intervention to prevent poor outcomes. Misdiagnosis, even with minor symptoms like nausea, can delay critical treatment for these common childhood injuries.
Area of Science:
- Ophthalmology
- Pediatric Surgery
- Emergency Medicine
Background:
- Inferior 'trapdoor' orbital floor fractures are common in children, often involving muscle and soft tissue incarceration.
- Delayed treatment of pediatric orbital fractures can lead to significant morbidity.
Observation:
- A 14-year-old boy with an orbital injury was misdiagnosed with a head injury due to subtle signs and symptoms (nausea, vomiting).
- This misdiagnosis resulted in a critical delay in surgical intervention for the orbital fracture.
- The oculovagal reflex, associated with orbital injuries, can present without subconjunctival hemorrhage, complicating diagnosis.
Findings:
- Prompt surgical repair (within 48 hours) is recommended for 'white-eyed blowout' fractures in children to ensure a good prognosis.
- Emergency department and pediatric staff must consider orbital injuries in patients with head trauma, even without obvious ocular signs.
Implications:
- Highlights the importance of thorough examination to detect orbital blow-out and entrapment, even with atypical presentations.
- Emphasizes the need for heightened clinical suspicion for orbital fractures in pediatric patients presenting with head trauma and associated symptoms.
- Underscores the potential for severe consequences due to delayed diagnosis and treatment of pediatric orbital floor fractures.
Abstract:
Inferior 'trapdoor' orbital floor fractures with muscle and soft tissue incarceration are the most common type of orbital fracture in children. Delays to treatment can lead to a significant morbidity. It has been recommended that children who present with a 'white-eyed blowout' fracture should have surgery performed within 48h of diagnosis, otherwise prognosis is poor. A 14-year-old boy was initially misdiagnosed with a head injury due to the minor appearance of his orbital injury and his presenting complaint of nausea and vomiting. This resulted in a significant delay to surgery. The oculovagal reflex associated with orbital injuries is well documented (Wei and Durairaj in Pediatric orbital floor fractures. J AAPOS 2011;15: :173-80). It should be considered by emergency department and paediatric staff when dealing with patients who have sustained a blow to the orbital region, despite not having a subconjunctival haemorrhage. The importance of examination to detect other features of orbital blow-out and entrapment are stressed.
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