(77) Are Isolated Medial Orbital Wall Fractures Better Managed Surgically or Conservatively? A Systematic Review

Abstract: Currently, there is still not an agreed-upon algorithm for when to treat medial wall orbital fractures patients surgically or conservatively.1,2 We reviewed the literature on the management of isolated medial orbital wall fractures to understand when patients are treated surgically or conservatively and their postoperative complications. A comprehensive search was conducted in Cochrane, Medline, and Embase databases on 11/1/2020 to find published systematic reviews, case series, and clinical research articles from January 1960 – July 2019. This PRISMA-compliant review included studies on children or adults with isolated medial orbital fractures that discussed either surgical or conservative management. A total of 1,321 articles were reviewed, of which 55 papers met our inclusion criteria (44 case series and 11 case reports). We recorded the type of study reviewed, data collection date, publication year, mechanism of injury, and associated facial fractures. Data variables included patient demographics, operative data, and postoperative complications and were compared between the surgical management and conservative management cohorts. Statistical significance was calculated using unpaired two-tailed t-tests and conducted with R open-access statistical software with a P-value of < .05. Only 24 of the 55 studies reported average age (35.2 ± 5.6 years), 40 of the 55 studies (591 patients) reported on sex [445 males (75.3%) and 144 females (24.7%)]. Only 35 of the 55 studies (589 patients) reported on initial cause of fracture with 217 (36.8% ± 4.2) cases of assault, 83 (14.1% ± 5.2) cases of motor vehicle accidents, 77 (13.1% ± 6.0) cases of falls, and 40 (6.8% ± 7.9) cases of sports accidents. Only 50 of the 55 studies (883 patients) reported on initial presentation with 271 (30.7% ± 3.1) with diplopia, 215 (24.3% ± 3.3) with enophthalmos, 137 (15.5% ± 3.6) with limitation of ocular motility, 50 (5.7% ± 4.1) with medial rectus muscle involvement, 28 (3.2% ± 13.1) with visual acuity disturbances, 25 (2.8% ± 5.0) with periorbital edema, and 17 (1.9% ± 5.5) with ecchymosis. Only 7 of the 55 studies (123 patients) reported on concomitant facial fractures with 37 (30.1% ± 19.3) nasal bone fractures, 10 (8.1% ± 20.7) zygomatic arch fractures, and 2 (1.6% ± 30.3) mandibular fractures. Table 1 demonstrates characteristics of the two cohorts. Medial rectus involvement upon initial presentation was statistically different between surgical and conservatively managed groups (1 ± 0.4 vs 0 ± 0, P = .008). When analyzing postoperative symptom differences among 738 surgically treated patients and 214 conservatively treated patients, most experienced no symptoms (79.1% vs 85.0%, ns). Diplopia was the most common postoperative complaint for the surgically treated group (10.3%), whereas enophthalmos was the most common in the conservatively treated group (8.4%) (Table 2). Surgically managed patients had a higher incidence of diplopia (29.8% ± 6.7 vs 3.7% ± 2.3, P < .01) and concomitant injuries (15.2% ± 5.6 vs 0.0% ± 0, P = .01). Medial rectus involvement was a strong predictor of requiring surgical intervention which supports the view that medial rectus entrapment is an absolute indication for surgical interventions. Postoperatively, more surgically treated patients experienced diplopia and concomitant injuries due to the differences in initial presentation and severity. Surgical delays in treatment did not have a significant effect on patient outcomes. Overall, these differences in the presentation can help guide practitioners in making clinical decisions on whether to treat their patients surgically or conservatively.References1. Yenice O, Ogüt MS, Onal S, Ozcan E. Conservative treatment of isolated medial orbital wall fractures. Ophthalmic Surg Lasers Imaging. 2006 Nov-Dec;37(6):497-501. doi: 10.3928/15428877-20061101-11. PMID: 17152547.2. Edgin WA, Morgan-Marshall A, Fitzsimmons TD. Transcaruncular approach to medial orbital wall fractures. J Oral Maxillofac Surg. 2007 Nov;65(11):2345-9. doi: 10.1016/j.joms.2006.06.270. PMID: 17954337.

Patient Demographics and Clinical Characteristics of Surgical Management vs Conservative Management
Post-operative complications of surgically and conservatively treated patients