Worsening orbital roof "blow-in" fractures following traumatic brain injury: A report of two cases.

Background: Orbital roof fractures are often the result of high-velocity collisions and are seen in 1-9% of patients with craniofacial trauma. Although the majority of orbital roof fractures are displaced superiorly, a subset results in inferior displacement of fracture fragments, posing a risk for muscle/nerve entrapment and possible blindness. Many of these patients have severe traumatic brain injury (TBI) and, in addition to orbital fractures, also have elevated intracranial pressure (ICP). Management of depressed orbital roof fractures in the setting of severe TBI with elevated ICP represents a management dilemma.

Case description: Two cases of severe TBI with associated downward displacement of orbital roof fractures were reviewed. Both cases exhibited elevated ICP correlated with the degree of orbital roof fracture depression. Surgical intervention involving elevation and repair of the fractures was undertaken when there was a significant risk of injury to the extraocular muscles and/or the optic nerve due to the extent of the fracture depression.

Conclusion: Depressed orbital roof fractures may migrate in response to changes in ICP. Serial computed tomography scans and eye examinations may aid with determining the need for and timing of surgical intervention.