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Plain skull X-ray showing a separate fracture in the left frontal region reaching down to the orbital rim.
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Growing skull fractures are rare complications of head trauma and very rarely arise in the skull base. The clinical and radiological finding and treatment of a growing fracture of the orbital roof in a 5-year-old boy are reported, and the relevant literature is reviewed. The clinical picture was eyelid swelling. Computed tomography (CT) scan was ex...
Context in source publication
Context 1
... to the emergency room after falling down from a height of 10 m. He had a brief loss of consciousness and vomited once. On examination, he was alert and crying. There were a marked left periorbital hematoma and left forehead swelling. Plain X-ray of the skull revealed a separate fracture of the left frontal bone reaching down to the orbital rim ( fig. 1). On CT scan, there were soft tissue swellings around the left orbit; the frontal fracture extended along the orbital roof ( fig. 2a), and a burst hematoma was seen in the left frontal lobe (fig. 2b). The patient was admitted to the hospital for 6 days, and he was discharged in a stable condition with his left per- iorbital ...
Citations
... CT scans are especially useful in detecting the bone fractures. [19][20][21] MRI is useful for distinguishing pseudomeningoceles from other pathologies and is more sensitive in showing their intra-orbital extension. 13,19 Associated pathologies, like encephalomalacia, subdural fluid collection, haematomas, and ventricular dilatation, can also be seen on CT and MRI. ...
Paediatric orbital trauma is uncommon, but it can be associated with significant morbidity. Traumatic pseudomeningocele is an infrequent complication of orbital trauma; it occurs due to an extradural collection of cerebrospinal fluid (CSF) that develops after a dural tear. Herein, we report a case of a seven-month-old male child who presented with eye swelling and suspicion of orbital cellulitis, along with a history of a road traffic accident. He was later diagnosed with traumatic orbital pseudomeningocele and underwent a left frontal craniotomy and duroplasty along with repair of medial orbital pseudomeningocele. Postoperatively, the child remained stable and resolution of proptosis was observed.
... İlk kez Dyke tarafından tanımlanan ve Leptomeningeal kist (LMK) olarak ta bilinen, büyüyen kafatası kırıkları (BKK) nadirdir (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12). Geniş serilerde görülme sıklığı %0,05-1,6 oranında bildirilmiştir (3,11). ...
... Çocukluk çağı kafa travmalarından sonra bir komplikasyon olarak ortaya çıkar (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11). Hastaların %50'si 1 yaşın altında, % 90'ı 3 yaşın altında olup fraktürün, kafatası büyümesinin en aktif olduğu zamana denk gelmesi gerekir. ...
... Bu nedenle dura kenarları görülene kadar kemik defektini büyütmek gerekir. Dura defekti kapatıldıktan sonra kranioplasti yapılır (1)(2)(3)(4)(5)(6)(7)(8). Bazı hastalarda gliotik beyin dokusunu da çıkarmak gerekebilir (7). ...
Growing skull fractures are poorly understood complications of pediatric skull fractures. The incidence of growing skull fractures ranges from less than 0.05% to 1.6%. The pathophysiology and some aspects of its management are still controversial. The most frequent location of Growing skull fractures was in the parietal and parieto-occipital region. Generally the patients suffered from headhache, vomiting and epileptic attacks. Every child with a skull fracture must be followed until the fracture heals
Background:
Growing skull fracture (GSF) is a rare condition that may complicate pediatric head trauma. Patients may present with delayed-onset neurological manifestations.
Aim:
This study aims to highlight the different presentations, methods of evaluation, treatment modalities, and outcomes in patients with orbital roof GSF.
Methods:
This retrospective multicentric cohort study reviewed the hospital records of children with GSF who presented at the Craniomaxillofacial Plastic Surgery Department, and Neurosurgery Department with Otorhinolaryngology Department (Maxillofacial unit), from 2011 to 2020. The collected data included age, gender, delay, manifestations, findings of imaging techniques, surgical treatment, complications, and satisfaction of patients' parents.
Results:
Twenty-eight patients with orbital roof GSF were included in this study. Most of the patients (82.1%) were boys, and the mean (SD) age was 5 (2) years old. Head trauma was caused by falls in all cases. Clinical manifestations included eyelid swelling (75%), pulsatile proptosis (25%), headache (17.9%), and seizures (10.7%). The mean (SD) diameter of bony defects was 24.3 (8.7) mm. Duraplasty alone was performed in 57.1%, while dura-cranioplasty was done in 42.9% of patients. Dural reconstruction was done using pericranial graft in 82.1% and artificial grafts in 17.9% of patients. Most of the parents (95%) were absolutely satisfied. No mortalities or recurrence of symptoms were recorded. The median follow-up period after surgery was 3.9 years.
Conclusion:
Orbital roof GSF should be considered among the differential diagnoses in pediatric patients with history of head trauma presenting with ocular and/or neurological manifestations. Duraplasty is mandatory in all cases, whereas cranioplasty is required mainly in cases with large bony defects more than 25 mm. Prognosis in most patients was good both subjectively and objectively.
Importance: There is controversy surrounding the management of orbital roof fractures. Guidelines with regard to when to operate and type of reconstruction are lacking. Categorizing these data will help clinicians make informed decisions about the management of orbital roof fractures and avoid preventable complications. Objective: To perform a systematic review evaluating underlying causes, associated complications, and management of orbital roof fractures including reconstructive options in the general population of children and adults. Evidence Review: A systematic review using the PubMed, EmBase, Cochrane, and MEDLINE databases identified relevant studies for inclusion. Studies were included from 1987 to 2017. Demographics, symptoms, management, reconstruction, and outcomes were reported following preferred reporting items for systematic reviews and meta-analyses guidelines. Inclusion criteria included articles discussing management of traumatic orbital roof fractures across all ages. Included studies were assessed for level of evidence. Findings: Forty-seven studies encompassing 526 patients met inclusion criteria. There were 28 case reports, 15 retrospective case series and 4 retrospective cohort studies. The most common etiologies were motor vehicle accidents (39.5%), falls (30.3%), and assault (11.8%). Periorbital ecchymosis, exophthalmos, and dystopia were the most common initial symptoms. In total, 60.0% of patients underwent surgical repair and 40% of patients were managed conservatively. The most common surgical approach was bicoronal (94.8%), followed by a superolateral orbital rim approach and transpalpebral (5.1%). A variety of grafting materials were utilized, including titanium miniplates (46.2%), bone graft (37.7%), porous polyethylene (2.8%), and silastic implants (2.8%). Overall patients undergoing surgery were adults with clinical symptoms including exophthalmos, diplopia, and gaze restriction as well as patients with dura exposure. Most patients undergoing surgery were those with concomitant fractures. The most common fractures among the surgical patients were frontal bone (32.2%), ethmoid (25.2%), and zygomaticomaxillary complex/zygoma (12.2%). Conclusions and Relevance: Management of orbital roof fractures varies based on individual clinical features including the presence of exophthalmos, gaze restriction, and concomitant injuries such as dural tears. Surgically, bicoronal approaches were performed most commonly along with reconstruction utilizing titanium miniplates. Conservative management was more common among the pediatric population. This systematic review demonstrates both conservative and surgical measures can lead to positive outcomes in appropriately selected patients.
The frontobasilar region of the upper craniofacial skeleton is divided into two anatomical areas. The frontal area F is comprised of the anterior cranial vault. The basilar area B is comprised of the superior and lateral orbital walls, the orbital apex, and the ethmoidal labyrinth. The anterior cranial vault is twice as strong as the adjacent bone structures [1, 2].
Orbital roof fractures associated with cranial and maxillofacial trauma are rarely encountered. Traumatic intraorbital encephaloceles due to orbital roof fractures developing in the early posttraumatic period are even rarer. A variety of materials, such as alloplastic implants or autogenous materials, have been used for the reconstruction of orbital roof, but data regarding the long-term results of these materials are very limited. We report a case of intraorbital encephalocele developing in the early posttraumatic period (2 days) in a child patient and the long-term results of titanium mesh used for the reconstruction of the orbital roof. The case is presented with a pertinent review of literature.
Aim:
The authors present a series of patients who developed a pseudomeningocele following fronto-orbital advancement and remodeling (FOAR), describing clinical presentation, investigations, and management. Risk factors are identified and preventative strategies suggested.
Materials and methods:
From 2002 to 2012, all patients who underwent FOAR at our unit were identified. Those who developed a pseudomeningocele were selected and case notes, scan imaging and photographs were reviewed.
Results:
Two hundred thirty-six FOAR operations were carried out over 12 consecutive years. Sixty-one of these patients were syndromic. A pseudomeningocele occurred in 6 patients. All affected cases were syndromic. Clinical features of presentation with orbital pseudomeningocele included orbital swelling, ptosis, proptosis, and/or hypoglobus. Raised intracranial pressure (ICP) was managed before pseudomeningocele repair in 2 patients, at the time of pseudomeningocele repair using an extra-ventricular drain (EVD) or lumbar drain in 4 patients. Decompression of the pseudomeningocele with excision and duraplsty was carried out in 5 patients, 1 patient required excision of gliotic brain and obliteration of dead space. Four patients had a calvarial graft to manage the bony defect and a further 2 had a titanium mesh. None of the patients had a recurrence of the pseudomeningocele or any long-term ocular or aesthetic complications.
Conclusion:
Pseudomeningocele has not previously been described in FOAR, but in a large series of consecutive patients, we have identified a 2.5% incidence. This incidence increases to 10% in the syndromic population of patients undergoing FOAR. The risk factors include a diagnosis of syndromic craniosynostosis, dural tear, hydrocephalus or raised ICP, infection, persistent cerebrospinal fluid (CSF) leak, or presence of dead space. Preventative strategies include CSF management before or post-FOAR. The ultimate treatment of the pseudomeningocele and growing fracture involves surgical decompression of the collection, a duraplasty, reconstruction of the orbital roof, and temporary CSF diversion.
To describe a series of orbital fractures and associated ophthalmic and craniofacial injuries in the pediatric population.
A retrospective case series of 312 pediatric patients over a 9-year period (2002-2011) with orbit fractures diagnosed by CT.
Five hundred ninety-one fractures in 312 patients were evaluated. There were 192 boys (62%) and 120 girls (38%) with an average age of 7.3 years (range 4 months to 16 years). Orbit fractures associated with other craniofacial fractures were more common (62%) than isolated orbit fractures (internal fractures and fractures involving the orbital rim but without extension beyond the orbit) (38%). Roof and medial wall fractures were most common (30% and 28%, respectively), followed by orbital floor (24%) and lateral wall (18%) fractures. Orbital roof fractures are the most common fracture in patients <8 years old, whereas orbital floor fractures are the most common fracture in patients older than 8 years. Eighty-seven patients (28%) underwent surgical repair. There is an increasing incidence of surgery in older patients (p = 0.02). Associated neurologic injuries were more common (23%) than associated ophthalmic injuries (20%).
Pediatric orbit fracture patterns are dictated by the age of the patient with respect to their craniofacial morphology and mechanism of injury. Orbital roof fractures are more likely to occur in younger patients and not require surgery, whereas orbital floor fractures are more common in older patients and are more likely to require surgery.
Growing fractures rarely arise in the skull base. Only six cases of orbital roof growing fractures were found in the relevant literature. We report two such cases. The first case was a 2-year-old girl who had progressive proptosis for 6 months following a mild head injury 1 year previously. The second case was a 9-year-old girl with a history of injury at the age of 3 months. She developed eye deviation and proptosis for 1 year. Computed tomography scan is excellent for demonstrating bony defects in the orbital roof, while magnetic resonance imaging is more sensitive in showing the intraorbital extension of a leptomeningeal cyst. Both patients were operated successfully and proptosis disappeared postoperatively. The exact pathophysiology of growing fractures is still debated in the literature, but a dural laceration along a fracture line is noted in all cases, and frontobasal brain injury seems to play an important role in the pathogenesis of the fracture growth. Growing fractures of the orbital roof should be suspected if ocular symptoms appear in a child who had sustained a head injury several months or years before.
