Interdisciplinary Management of Minimally Displaced Orbital Roof Fractures: Delayed Pulsatile Exophthalmos and Orbital Encephalocele

Abstract

Traumatic orbital roof fractures are rare and are managed nonoperatively in most cases. They are typically associated with severe mechanisms of injury and may be associated with significant neurologic or ophthalmologic compromise including traumatic brain injury and vision loss. Rarely, traumatic encephalocele or pulsatile exophthalmos may be present at the time of injury or develop in delayed fashion, necessitating close observation of these patients. In this article, we describe two patients with minimally displaced blow-in type orbital roof fractures that were later complicated by orbital encephalocele and pulsatile exophthalmos, prompting urgent surgical intervention. We also suggest a management algorithm for adult patients with orbital roof fractures, emphasizing careful observation and interdisciplinary management involving plastic surgery, neurosurgery, and ophthalmology.

Keywords: management algorithm; orbital encephalocele; orbital roof fractures; pulsatile exophthalmos.

Fig. 1

CT scan of Patient 1: face, head, and brain with 1 mm slices. (a) Coronal view of bilateral minimally displaced orbital roof fractures. (b) Sagittal view of the left orbital roof fracture, which was more depressed than the right. (c) Coronal view of the left subdural hematoma (SDH) with 3 mm midline shift. (d) Coronal view of the left orbital encephalocele. (e) Coronal view of the bilateral orbital roof repair with split calvarial bone grafts. (f) Intraoperative picture of split calvarial bone grafts from the inner table of the patient's frontal bone.

Fig. 2

CT scan of Patient 2: face, head, and brain with 1 mm slices. (a) Coronal view of bilateral minimally displaced orbital roof fractures. (b) Sagittal view of the comminuted right orbital roof fracture, which was more depressed than the left. (c) Axial view of the right frontal lobe contusion. (d) Coronal view of the right orbital encephalocele with right frontal lobe contusion and worsening fracture displacement, on hospital day 4. (e) Coronal view of the right orbital roof repair with split calvarial bone graft. (f) Intraoperative picture of split calvarial bone graft from the inner table of the patient's right frontal bone.

Fig. 3

A suggested management algorithm for orbital roof fractures in adults.