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Updated: Apr 25, 2026
Three-Dimensional Reconstruction of Orbital Fractures
Published on: May 16, 2025
Defining pediatric orbital roof fractures: patterns, sequelae, and indications for operation
Devin Coon1, Nance Yuan, Danielle Jones
1Baltimore, Md. From the Department of Plastic Surgery and the Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins Medical Institutions.
Insights
Most pediatric orbital roof fractures heal well with conservative management. Surgery is typically needed for large, comminuted fractures with inferior displacement to prevent complications like vertical dystopia.
Area of Science:
- Ophthalmology
- Pediatric Surgery
- Neurosurgery
Background:
- Limited data exist on pediatric orbital roof fractures and their long-term outcomes.
- Evidence-based guidelines for managing these injuries are needed.
Purpose of the Study:
- To examine a large cohort of pediatric patients with orbital roof fractures.
- To establish guidelines for the management of pediatric orbital roof fractures.
Main Methods:
- A retrospective review of pediatric patients (1991-2011) diagnosed with orbital or skull base fractures at Johns Hopkins Hospital.
- Identification of patients with orbital roof fractures and assessment of demographics, management, and outcomes.
- Analysis of 159 pediatric patients with orbital roof fractures, including 105 with follow-up data.
Main Results:
- 159 pediatric patients (11%) had orbital roof fractures; 36% were comminuted.
- Only one patient developed vertical dystopia after significant follow-up loss.
- Ten patients required surgical repair, with inferior displacement being a significant predictor (p < 0.001).
Conclusions:
- The majority of pediatric orbital roof fractures can be managed conservatively with favorable long-term outcomes.
- Vertical dystopia is rare (<1%) and linked to large, comminuted fractures.
- Inferiorly displaced fractures or those >2 cm² warrant close monitoring for potential sequelae requiring intervention.
Background:
There are few published data addressing pediatric orbital roof fractures, particularly regarding long-term outcomes and indications for operative intervention. To provide evidence-based guidelines for the management of these injuries, the authors examined a large cohort of patients with this injury pattern.
Methods:
Institutional review board approval was obtained to review pediatric patients presenting to Johns Hopkins Hospital from 1991 to 2011. All patients with a diagnosis indicating orbital or skull base fractures were reviewed to determine orbital roof involvement. Patients with roof fractures were assessed for demographics, management, and outcomes.
Results:
A total of 1484 pediatric patients carried the diagnoses of orbital fracture or anterior skull base fracture. After review, 159 patients (11 percent) were found to have true orbital roof fractures, with 36 percent being comminuted. One hundred five patients returned after discharge (average follow-up, 19 months). One patient developed vertical dystopia 10 months after being lost to follow-up with a large, comminuted fracture. Ten patients underwent surgery to repair the orbital roof. Inferior displacement correlated with need for surgical repair (p < 0.001).
Conclusions:
In the largest study to date analyzing pediatric orbital roof fractures, the authors found that most can be managed conservatively with good long-term outcomes. Vertical dystopia occurred in less than 1 percent of patients and was associated with large, comminuted fractures. Inferiorly displaced and fractures with a surface area over 2 cm represent higher risk fractures that should be followed closely for possible intervention based on the development of sequelae such as vertical dystopia or encephalocele.
Clinical Question/Level Of Evidence:
Therapeutic, IV.
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