ORBITAL FLOOR FRACTURES AND THEIR TREATMENT

Orbital floor fractures can occur with or without any associated fractures of the middle third of the facial skeleton. Fifty-one patients with a unilateral "black eye" after motor vehicle accidents were reviewed. The fractures involving the orbital floor were analysed. The clinical signs and symptoms, with results ol radiological examination, are discussed. The various treatment modalities and their postoperative complications are discussed.     

下睑缘入路手术修复眶底骨折的临床评价

目的　探讨下睑缘入路手术修复眶底骨折的治疗效果。方法　 3 6例眶底骨折均伴有颧骨复合体骨折、双侧上颌骨骨折和鼻眶筛复合体骨折。以下睑缘入路羟基磷灰石人造骨眶底重建。结果　术后并发症包括睑外翻 2例 ,下睑撕裂 3例 ,巩膜暴露 2例。结论　下睑缘入路提供了足够的手术视野 ,既能修复眶下缘骨折 ,又能修复眶底缺损 ,术后并发症较少。     

Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis

PURPOSE: To assess the quality of information in the literature and suggest guidelines for repair of isolated orbital floor fractures. CLINICAL RELEVANCE: Orbital floor fractures are a common result of orbital injury. Enophthalmos, diplopia resulting from extraocular muscle dysfunction, and infraorbital nerve hypesthesia may occur. The indications and timing for fracture repair are still controversial. LITERATURE REVIEWED: A MEDLINE literature review was performed using PubMed. Articles published from 1983 to the present were retrieved using the key words, "orbital floor fracture, orbital trap-door fracture, and orbital blow-out fracture." Suggested indications and timing for repair of isolated orbital floor fractures were extracted from selected articles. Each recommendation was rated according to its importance in the care process and strength of evidence supporting the given recommendation. RESULTS: No prospective randomized clinical trials on the treatment of orbital floor fractures have been performed. Despite this, most recommendations were rated as most important to patient care (A) and had strong support for treatment (level I). CONCLUSIONS: The timing and treatment indications for orbital floor fractures are evolving. Nonresolving oculocardiac reflex, the "white-eyed" blowout fracture, and early enophthalmos or hypoglobus are indications for immediate surgical repair. Surgery within 2 weeks is recommended in cases of symptomatic diplopia with positive forced ductions and evidence of orbital soft tissue entrapment on computed tomography examination or large orbital floor fractures that may cause latent enophthalmos or hypo-ophthalmos.     

Force necessary to fracture the orbital floor

Current thought on the pathophysiology of orbital wall fractures postulates either a "hydraulic" or a "buckling" mechanism. Evidence from cadaver, dried skull, and theoretical model studies supports both theories. No in vivo data, human or nonhuman primate, are available that quantitate the force necessary to fracture the orbital floor by either of the two mechanisms. We developed an apparatus that delivers quantifiable force only to the globe, without occluding the orbital opening or striking the orbital rim. We used it on 11 anesthetized Macaca fascicularis monkeys. Following a single bilateral application, the orbits were exenterated, and the orbital walls and orbital contents were examined to determine the extent of injuries. Fractures were described, diagrammed, and photographed. Fracture of the orbital floor was consistently produced at and above a force of 2.08 J. Posterior ruptures of five eyes occurred over the same range. We provide the first accurate measurements of the force required to produce orbital blow-out fractures in a live primate model. We show that orbital floor fractures can occur at low energies with direct ocular trauma only ("pure" hydraulic mechanism). Orbital wall fractures failed to protect the globe from rupture in 23% of cases.     

Clinical recommendations for repair of orbital facial fractures

PURPOSE OF REVIEW: Orbital facial fractures are a common result of facial trauma. Enophthalmos, diplopia resulting from extraocular muscle dysfunction, and infraorbital nerve hypesthesia may occur. The indications and timing for fracture repair are debated. RECENT FINDINGS: The timing and treatment indications for orbital facial fractures are evolving. For orbital floor fractures, nonresolving oculocardiac reflex, the "white-eyed" blowout fracture, and early enophthalmos or hypoglobus are indications for immediate surgical repair. Surgery within 2 weeks is recommended in cases of symptomatic diplopia with positive forced ductions and evidence of orbital soft tissue entrapment on computed tomography examination or large orbital floor fractures, which may cause latent enophthalmos or hypo-ophthalmos. For midfacial, lateral, supraorbital, medial wall, and nasoethmoidal fractures, repair within 2 weeks is indicated to avoid difficult repair from immediate posttraumatic wound healing. SUMMARY: Orbital facial fracture management is germane to ophthalmologists, plastic surgeons, otolaryngologists, and others who treat patients.     

Nylon foil "wraparound" repair of combined orbital floor and medial wall fractures

PURPOSE: To evaluate a technique of implanting a single 0.4-mm-thick nylon foil (Supramid) continuously across combined medial wall and floor fractures within weeks of orbital trauma. METHODS: This retrospective, interventional case series includes patients with combined medial wall and floor fractures with or without external orbital and facial fractures, without prior surgery, and who were in the early posttrauma phase. One hundred two orbits in 98 consecutive patients were treated with a "wraparound" technique. The surgical technique is provided in detail. Comatose patients, those with cranial nerve palsies, severe globe injury, anophthalmia, or previous repair of the same fractures were excluded. Patients underwent surgery from 5 to 21 days after trauma. Postoperatively (average, 6.2 months), patients were evaluated for enophthalmos, extraocular motility, and diplopia. RESULTS: In 101 of 102 orbits, normal globe position, and full extraocular motility without diplopia was accomplished. One orbit had persistent enophthalmos, requiring a second procedure. This same patient had ipsilateral restriction in extreme upgaze, but no diplopia symptoms. This orbit had complete loss of inferomedial strut support. Overall, strut loss was not a risk factor for subsequent enophthalmos. No other patient had globe malposition, restrictive myopathy, or diplopia. Implant migration, hemorrhage, fistula, or infection was not observed. The transconjunctival and canthal wounds were hidden and tolerated by all patients with no eyelid cicatrization, webbing, or malposition. CONCLUSIONS: The "wraparound" technique for 0.4-mm nylon foil implantation continuously across orbital floor and medial wall fractures was associated with almost no enophthalmos and diplopia in this series.     

Sutureless transconjunctival repair of orbital blowout fractures

PURPOSE: To evaluate early postoperative results and complications in patients who underwent repair of isolated orbital floor blowout fractures with placement of nonfixed implants through a transconjunctival and sutureless incision. METHODS: We retrospectively reviewed 26 cases of isolated floor fractures repaired by this technique. Criteria for inclusion in this study were transconjunctival approach, nonfixed orbital implants, and sutureless closure. Early postoperative complications were evaluated. RESULTS: Twenty-six patients (16 male, 10 female) underwent repair of an isolated floor fracture and were followed after surgery for 1 to 26 months. No eyelid malposition, infection, or implant extrusion occurred. However, 1 patient (3.8%) had early migration of the orbital implant that did not require further intervention. CONCLUSIONS: Repair of orbital floor blowout fractures with a nonfixed implant through the transconjunctival approach and sutureless closure provides an excellent functional and cosmetic result.     

Complications of the orbital floor and maxillary sinus 30 years after Coe-Pak misplacement in the management of pan-facial fractures

We present the case of a woman who had sustained pan-facial fractures in a road traffic accident 30 years previously, and describe the ensuing unusual problems with the orbital floor and maxillary sinus as a consequence of unrecognised misplacement of a dental periodontal dressing material into the sinus. The subsequent management is discussed.     

眶底爆裂性骨折致眼球运动障碍的上颌窦手术进路治疗

目的 观察上颌窦进路手术治疗眶下壁爆裂性骨折所致眼球运动障碍的临床效果.方法 对12例12只眼眶下壁爆裂性骨折伴复视及眼球运动障碍者,眼眶CT显示:眼外肌眶内软组织嵌顿于眶下壁骨折区,伤后观察2周,复视及眼球运动障碍无明显改善,采用上颌窦进路行眶下壁骨折复位术.术后随诊3～6个月.结果 12例患者术中开放上颌窦后可清晰观察到眶下壁骨折区各个边界及眶内软组织嵌顿情况,术中均将嵌顿在眶底骨折处的眶内组织推送回眶内,眶底骨折复位.术后12例患者中10例各方向眼球运动不受限,无复视,2例正前方及下方无复视,向上方运动轻度受限.术后1例并发上颌窦炎,经上颌窦冲洗治愈.结论 上颌窦进路早期治疗单纯眶下壁爆裂性骨折所致眼球运动障碍是有效的.     

Bacterial endocarditis prophylaxis,an unfinished debate

We present the case of a woman who had sustained panfacial fractures in a road traffic accident 30 years previously, and describe the ensuing unusual problems with the orbital floor and maxillary sinus as a consequence of unrecognised misplacement of a dental periodontal dressing material into the sinus. The subsequent management is discussed.     

可吸收眶底板在眶底骨折中应用的近期效果

 目的 评价采用可吸收材料修复眶底骨折的临床效果。设计 回顾性病例系列。研究对象 北京同仁医院口腔科12例眶底爆裂性骨折眶下壁缺损面积<2.6 cm2的患者。方法 所有患者术中采用下睑缘切口进行眶底骨折整复,于眶底缺损浅面植入可吸收眶底板（型号851.852.01s,瑞士辛迪思公司）重建眶壁。所有患者术前、术后均拍摄双眶水平及冠状位CT,并进行比较。平均随访（6.4±1.8）个月。主要指标 眼部表现、眶壁修复情况及并发症。结果 术后5/12例患者复视和眼球运动受限消失,7/12例患者改善,未出现术后感染及植入物外露。所有患者术后眶下区麻木于3～6个月消失。术前、术后CT检查对比,所有患者眶底缺损均已修复,眶底植入物材料位置良好,未见眶内容物嵌入上颌窦内。结论 可吸收材料用于2.6 cm2以下的眶底骨折的修复重建近期效果良好。（眼科, 2014, 23： 247-250）
      

Measurement of globe position in complex orbital fractures. II. Patient evaluation utilizing a modified exophthalmometer.

Globe position was assessed by both the Hertel exophthalmometer and the modified external auditory canal (EAC)-fixated device in 27 patients with complex orbital fractures (18 tripod and 9 Le Fort fractures). Although 94% of the patients with tripod fractures had relative exophthalmos on the fracture side or no difference between eyes by Hertel exophthalmometry, greater than 30% of the same patients showed relative enophthalmos when measured by the EAC-fixated device. In three of four patients undergoing surgical repair of the orbital floor, modified exophthalmometry showed exophthalmos of greater than or equal to 2 mm postoperatively on the fractured side. The relatively low incidence of enophthalmos in tripod fractures indicates a need for selective orbital floor repair; the uniform exploration of the orbital floor should be discouraged. Multiple comminuted facial fractures (Le Fort II and III) showed a greater variability in globe position and a high frequency (90%) of enophthalmos, suggesting a need for early orbital repair in these patients. EAC-fixated exophthalmometry can provide meaningful information regarding globe position in orbitofacial fracture patients in which orbital rim-based methods are precluded.     

眼眶骨折的CT与临床（附62例分析）

作者分析６２例眼眶骨折的ＣＴ与临床资料。根据眼眶骨折的受力情况和骨壁特点将其分为５型：１．单眶壁直接骨折；２．多眶壁直接骨折；３．单眶壁爆裂骨折；４．多眶壁爆裂骨折；５．混合型骨折。眼眶骨折的ＣＴ征象为：骨连续性中断、骨质粉碎、骨质凹陷及眶壁曲度失常。爆裂骨折好发眶内侧壁和底壁，直接骨折以眶外侧壁较多受累。眼眶骨折的ＣＴ诊断具有重要的临床价值。此外，作者还对ＣＴ扫描技术和临床有关问题进行了讨论。     

Management of isolated orbital floor blow-out fractures: a survey of Australian and New Zealand oral and maxillofacial surgeons

Background: This is the first report of involvement of Australian and New Zealand oral and maxillofacial surgeons in the management of isolated orbital floor blow‐out fractures and was conducted to obtain comparisons with the results from a recent similar survey of British oral and maxillofacial surgeons. Methods: A questionnaire survey was sent to all 113 practising members of the Australian and New Zealand Association of Oral and Maxillofacial Surgeons in April 2002 with a second mailout 1 month later. Results: Sixty‐nine per cent of the respondents were referred isolated orbital floor blow‐out fractures for manage­ment, and just over half of these respondents estimated that 50% or more of the cases went to surgery. The materials most commonly used in orbital floor reconstruction were resorbable membrane for small defects and autologous bone for large defects. Conclusion: As in Britain, management of isolated orbital floor blow‐out fractures comprises part of the surgical spectrum for many oral and maxillofacial surgeons in Australia and New Zealand. The management protocol was observed to be very similar between the two groups.     

应用MIMICS制作个体化预成型钛网修复眶下壁骨折的临床研究

目的:探索应用Mimics软件快速制作个体化预成型钛网修复眶下壁骨折的临床效果和临床可行性。方法:本研究共包括10例单侧单纯性眶下壁骨折患者。均采用经下睑结膜切口修复眶下壁骨折。首先应用MIMICS软件重建患者眼眶的三维模型,然后将该3D模型在眶下壁上方平行切割,形成内含眶下壁缺损形态的2D模型,将该模型1∶1打印输出到纸张上,于术中消毒后作为模板。根据该模板塑型和修剪钛网,使个体化成型的钛网与眼眶缺损形态完全吻合,然后植入眶内。所有患者均于术后3d内复查眼眶三维CT,观察植入钛网的位置和形态,以此来评估该方法的临床可行性。结果:CT复查表明,全部患者的预成型钛网均达到精确重建眶下壁骨折缺损的目的。9例患者复视和眼球内陷得以治愈,1例患者内陷治愈残留下转复视。结论:应用Mimics软件快速制作个体化预成型钛网可以精确修复眶下壁骨折,该技术可以应用于临床。     

Orbital fractures in children

The aim of this article is to review data concerning paediatric orbital fractures. These fractures exhibit strong specificities because they occur in a growing face. Due to the craniofacial growing pattern and the peumatization of paranasal sinuses, there are differences in the anatomical location of orbital fracture with the age: before the age of seven they are mostly orbital roof and after seven they involve the orbital floor. The clinical diagnosis is confirmed with a computed tomography scan (CT scan), gold standard for the imaging in the orbital fractures. The magnetic resonance imaging (MRI) offers a better soft-tissue depiction and is useful when clinical data are not consistent with CT scan findings. The orbital fractures in children are rarely operated. In emergency the main surgical indications are the trap-door fracture involving the ocular muscles and the compressive haematomas. We hypothesize that the periosteum more likely than the bony structure is involved in the responsible trap-door fractures: the thickness and the elasticity of the periosteum leads to reposition the floor or the medial wall of the orbit to its initial position.     

Orbital fractures in children

PURPOSE: To describe the demographics, etiologic factors, clinical presentations, and outcomes of orbital fractures in children. METHODS: This was a retrospective case series of 96 consecutive patients under 18 years of age with orbital fractures presenting to the Massachusetts Eye and Ear Infirmary, including both hospitalized and nonhospitalized patients. RESULTS: Orbital fractures in children were most frequently the result of sports, assault, or motor vehicle accident. The majority of patients did not require hospitalization and were treated as outpatients. The medial wall and floor of the orbit were the most frequent locations of fracture. Approximately half of the patients in this series required surgery, most often for entrapment. There were no cases of persistent diplopia in patients in whom surgery was performed or was not indicated. Associated ocular injuries were observed in half of the patients. CONCLUSIONS: In this series of hospitalized and nonhospitalized patients, orbital fractures in children had a location pattern similar to that most frequently observed in adult patients (floor and medial wall). Orbital fractures in children frequently require surgery. The high prevalence of ocular injury in children with orbital fractures emphasizes the need for a comprehensive ophthalmic evaluation.     

儿童眼眶爆裂性骨折36例临床分析

目的 总结儿童眼眶爆裂性骨折的临床特点及治疗方法,提高对本病的认识.方法 对36例眼眶爆裂性骨折的儿童的致伤原因、就诊时间、手术时间、骨折类型、手术方式及预后情况进行回顾性分析.结果 36例眼眶骨折的患者中受伤原因依次为撞伤、摔伤、车祸;超过7岁的眼眶骨折患者26例,占72.3%;就诊时间1d至7个月,平均为28d;伤后至接受手术治疗时间,最短4d,最长60d,平均18天;发生于眶下壁19例,占52.7%;眶内壁6例,占16.7%;眶内下壁复合型骨折11例,占30.6%.保守治疗17例,复视消失15例;手术治疗19例,6个月内复视消失15例.结论 儿童眼眶爆裂性骨折多发生于眶底,好发年龄为大于7岁.保守治疗对儿童某些线性骨折有效.发生活板门样爆裂性骨折时,越早手术,效果越好.     

儿童眶壁爆裂性骨折的临床分析

目的分析儿童眶壁爆裂性骨折的特点，寻求有效的治疗措施。设计回顾性病例系列研究。研究对象12岁以下儿童眶壁爆裂性骨折患者59例（59眼）。方法观察患儿眼位、眼球内陷程度、眼球运动、复视情况，通过眼眶CT观察骨折位置、大小、肌肉嵌顿情况等。59眼中牵拉治疗5眼，行眶壁骨折整复术治疗54眼。主要指标骨折位置，眼位，眼球内陷程度，眼球运动，复视情况。结果59例患者治疗前均有复视，眼球运动受限，1例眼球轻微内陷。59例眼眶CT均显示眶壁骨折，其中眶底骨折57例，眶内壁骨折2例，眶底与眶内壁均骨折1例。牵拉治疗1-3次5例患者复视消失。整复手术治疗者于术后8个月内复视消失，伤后1周内手术者，术后1个月内复视消失。结论儿童眶壁骨折多发生于眶底，眼球内陷少且轻微。重度眼球运动障碍，有直肌嵌塞者，应及早手术；手术越早（〈1周），复视消失越迅速。牵拉治疗对儿童某些轻型骨折有效。     

Surgery on orbital floor fractures. Influence of time of repair and fracture size

51 patients with orbital floor fractures were studied retrospectively to evaluate results in relation to time of surgical repair and fracture size. Early repair (less than 2 months) gave better results than late repair (greater than 2 months) in regard to both enophthalmos and extraocular muscle dysfunction. Large fractures (greater than one-half floor or greater than or equal to 15 fracture volume units) were most likely to be associated with significant enophthalmos after surgery. We recommend tomography when necessary to estimate fracture size, and advise early repair of large fractures, preferably within two weeks after injury. Patients with significant extraocular muscle dysfunction due to tissue entrapment, regardless of fracture size, should be repaired early, preferably within 2 weeks after injury, if improvement does not occur spontaneously by that time.