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Background Although rare, orbital floor fractures in the pediatric population are cause for concern. Specifically, children’s bones exhibit considerable elasticity, increasing their risk of tissue entrapment. These injuries have the potential to produce acute constitutional symptoms and poor long-term ocular outcomes. This study aims to determine the clinical and radiological predictors of tissue entrapment and to establish how operative timing influences ocular outcomes.
Methods We retrospectively reviewed the medical records of pediatric patients who acutely presented with orbital floor fractures at Boston Children’s Hospital from October 2007 to October 2015. 152 patients, aged less than 18 years, were consulted, managed, and followed-up by pediatric plastic surgery and ophthalmology services. Patients were considered to have experienced poorer ocular outcomes at follow-up if they had persistent enopththalmos, extraocular movement (EOM) restriction, or diplopia. Independent t-tests and Fisher’s exact tests were used to analyze the association between variables at both presentation and outcome.
Results 152 patients with 159 orbital floor fractures (seven bilateral) were included in the study. 122 (80.3%) patients were male, and the mean age was 12.2 ± 4.2 years. Twelve patients (7.9%) sustained orbital floor fractures with tissue entrapment. At presentation, extraocular movement restriction, diplopia, nausea, and vomiting were all associated with tissue entrapment (P<0.001). Facial computed tomography scans detected all cases of tissue entrapment, with a sensitivity of 100% and specificity of 97.9%. Amongst patients with trapdoor fractures, the presence of nausea and/or vomiting was predictive of tissue entrapment: positive predictive value 80%, and negative predictive value 100%.
For all patients, regardless of fracture configuration, vomiting alone had a negative predictive value of 94.1% for tissue entrapment. For patients with tissue entrapment, poorer ocular outcomes were significantly associated with the length of operation (P=0.007), but not with the time interval to operation (P=0.146).

Signs/symptoms used to screen for tissue entrapment

Sign/symptom	Sensitivity (%)	Specificity (%)	Positive Predictive Value (%)	Negative Predictive Value)
Extraocular movement (EOM) restriction	100.0	81.2	31.6	100.0
Diplopia	83.3	83.3	30.3	98.3
Nausea and/or vomting	83.3	72.9	20.8	98.1
Nausea	75.0	80.7	25.0	97.4
Vomiting	83.3	75.7	22.7	94.1
Headache	50.0	88.6	27.3	95.4
Bradycardia	16.7	99.3	66.7	93.3
Radiological evidence of entrapment	100.0	97.9	80.0	100.0
Trapdoor fracture (as described by reporting radiologist)	33.3	94.3	33.3	94.3

Conclusions Whilst EOM restriction and diplopia have a well-established relationship with tissue entrapment, they are often difficult to accurately assess in children in the emergency room setting. Pain and edema frequently complicate the interpretation of these signs, and a lack of cooperation during physical examination may also obscure deficits. Vomiting, in comparison to diplopia, is a much more objective clinical sign that is equally as sensitive and has a similar negative predictive value. A history of nausea and/or vomiting is valuable when signs such as EOM restriction or diplopia are equivocal. In our study, radiological findings were predictive of entrapment, but a lack of consistent language in this area of study limits the external validity of these results. Unlike previous reports that emphasize the importance of a short interval to operation for patients with tissue entrapment, our study draws attention to the relationship between operation length and poorer ocular outcomes. Operation length may be a surrogate marker of case severity/complexity, surgical technique and/or surgeon experience; where possible, optimizing these factors may improve ocular outcomes.