Cranial floor fracture: A growing orbital roof fracture with
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A 47-year-old male presented at level two County Medical Center as a Tier 2 trauma after his horse fell on him. He was brought in by ambulance with no recollection of the event. He was otherwise lucid. He sustained multiple injuries, including femoral neck fracture, c-spine fracture, t-spine fracture, and multiple rib fractures with flail chest. An epidural hematoma was discovered and proved stable overtime via serial CT imaging. Craniofacial injuries included an incomplete LeFort III type fracture pattern with his frontal bone involved. His midface remained stable through the integrity of the pterygoid plates.

During his inpatient observation period, this patient developed progressive left-sided proptosis, worsening ability for downward gaze, and radiographic evidence of cranial floor fracture progression with enlarging herniation causing mass effect within the left orbit. His original CT showed a 17x15mm defect with 5mm of displacement. However, in 4hours, the displacement became 8 mm. In 16 hours from the original scan, it became 10 mm, followed by 12mm at 36hours. This progressive worsening prompted confirmation of encephalocele with MRI.

He was brought to the operating room post-injury day 3 for his orbital roof fracture and encephalocele. A multidisciplinary approach was used. A trauma surgeon, plastic surgeon, and a neurosurgeon were involved in this operation. A coronal approach was used to gain access for a frontal craniotomy. The orbital floor was approached superiorly and plated with a contoured titanium mesh plate. Care was taken to ensure the plate did not encroach on the orbital nerve. Post-operative CT was performed and confirmed adequate plate placement. The patient’s remaining inpatient recovery period was relatively unremarkable. Following discharge, he followed up in the outpatient trauma, neurosurgery, and plastic surgery clinics. Now, the patient is doing well and his left eye function continues to steadily improve.