爆裂性眶内下壁骨折病人眼外肌功能损伤性质的临床研究

目的探讨爆裂性眶内下壁骨折病人眼外肌损伤性质等临床特征与骨折形态改变特点的相关性。方法根据CT影像上眶内下壁骨折形态特点对52例单纯眶内下壁骨折进行了亚型分类,观察各亚型间病人的临床特征和眼外肌功能变化特点。结果以内壁骨折为主的眶内下壁骨折（IM-M型）病人中眼球内陷15/22例（68.2%）,眼球突出度相差平均值2.61±0.78mm,而以下壁骨折为主的眶内下壁骨折（IM-I型）病人眼球内陷28/30例（93.3%）,眼球突出度相差平均值3.66±0.93mm,后者眼球内陷发生率、眼球内陷程度显著大于后者（[x^2=5.61,p〈0.05）（r=3.725,p〈0.05）]。IM-I型病人发生复视13/22例（59.1%）,IM-1型病人发生复视24/30例（80.0%）,IM-I型复视发生率为59.1%（13/21）。二亚型间病人复视发生率无明显统计学差异（x^2=2.703,p〉0.05）。IM-M型眼外肌损伤以内直肌限制多见（14/22,63.6%）,IM-I型多见下直肌受限制（20/30,66.7%）。二亚型间同时发生内直肌和下直肌功能障碍的发生率（5/22,22.7%;8/30,26.7%）及发生单一一条眼外肌功能障碍的发生率（6/22,27.2%;11/30,36.7%）,无明显统计学差异（x^2=0.105,p=0.746;x^2=0.509,p=0.476）。二亚型间下斜肌麻痹的发生率分别为3/22和4/30,无统计学差异（p=0.315）,而影像学上则主要以内下壁偶角的骨折为特征。结论眶内下壁骨折病人眼外肌功能损伤改变及其他临床特征与和其骨折发生的形态学特点有直接关系,对眶内下壁骨折进行CT影像学亚型分类具有临床实用价值。     

爆裂性眶内壁骨折的诊断与处理

目的：探讨轻重型爆裂性眶内壁骨折的治疗方法及效果。方法：对收治的32例依据眶内壁骨折的内陷程度及并发症分为轻，重两型，轻型者采用保守治疗，重型者早期采取保守治疗，10后天，进行手术治疗，手术方法为内直肌牵引或经眶筛窦开放术。结果：轻型18例，治疗后均无复视，斜视，眼球运动障碍或眼球内陷等并发症。重型14例，手术后复视均缓解，斜视及眼球运动障碍1例，眼球内陷4例。结论：轻型患者保守治疗效果满意，重型患者视病情行内直肌牵引或经眶筛窦开放术，效果亦较满意。     

鼻内窥镜下经筛窦治疗爆裂性眶内壁骨折

目的探讨鼻内窥镜下经筛窦治疗爆裂性眶内壁骨折的临床疗效。方法25例爆裂性眶内壁骨折在鼻内窥镜下切除筛窦房隔及外伤损伤的眶纸板，将制备好的多孔硅胶片，凸面向外填塞进筛窦术腔，对眶纸板进行施压复位。结果随访3月-2年，治愈22例，占88．00％。2例术后残留周边复视，总有效率为96．00％。术后无眶内感染或其他并发症。结论鼻内窥镜下经筛窦治疗眶内壁骨折是有效的方法，疗效稳定，创伤小、手术时间短而且面部不留瘢痕，硅胶片可以长期存留。     

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。     

眼眶骨折的手术治疗

目的研究眼眶爆裂性骨折整复术中应用Medpor的疗效。方法对135例眼眶爆裂性骨折手术：眶内壁骨折患者采用内眦皮肤切口及结膜切口入路，眼眶下壁骨折，及下壁合并内壁骨折术中采用下睑缘或下穹隆手术切口入眶，将嵌顿于眼眶骨折处的下直肌、内直肌及其他软组织游离至眶内，插入修剪塑形后的Medpor板。结果术后眼球突出度较术前提高1．5～5．0mm，同对侧正常眼相比为-2～＋2mm（即内陷或突出2mm之间），外观上基本同受伤前相似，术后1月后复视消除103例（76．30％），术后3月复视消除128例（94．81％）。结论及时实施眼眶爆裂性骨折整复术合并Medpor板植入可有效矫正眼球内陷及复视。     

眶骨折整复术后视力丧失救治1例

患者女35岁左眼被拳击伤后10余天，眼球内陷、复视入院治疗。视力：右0．5，左0．6，左眼内陷。眼突出度15 89 13mm。双眼前节及眼底未见明显异常。CT示左眼眶内壁骨折，内直肌粘连，眶内容物部分嵌塞于筛窦内。患者为哺乳期妇女(产后6月余)。经常规检查后，全麻下行左眼结膜切口，前路开眶，分离粘连内直肌，并将脱出于筛窦内的     

鼻内镜下经鼻窦治疗眼眶爆裂性骨折临床观察

目的探讨鼻窦内镜经鼻窦治疗眼眶爆裂性骨折的手术效果.方法对7例眶底骨折并发下直肌等软组织嵌顿,4例眶内侧壁骨折并发内直肌等软组织嵌顿,1例眶内侧壁骨折合并眶底骨折下直肌等软组织嵌入上颌窦病例,应用鼻窦内镜经上颔窦、筛窦回复窦内嵌顿或陷入的眶内软组织并用医用硅胶膜板植垫骨缺损区.结果术后经计算机体层摄影(computeoItomk-graphy.CT),12例眼眶爆裂性骨折软组织嵌顿或陷入复位完全.经患者术后随访3至18个月,平均8.2个月功能障碍性复视症状完全消失,眼位正常,未发现植垫物排斥现象,且视力均有不同程度提高.结论眼眶爆裂性骨折可应用鼻窦内镜经上颌窦、筛窦内回复固定嵌顿的眶内软组织,并具有术中眼部组织损伤小等优点.     

眶骨膜下植入骨水泥矫正复视23例

眼部钝力伤常导致眶壁爆裂性骨折。这种骨折是一种特殊类型的眼眶外伤,骨折好发部位为眶底和内壁筛骨纸板处。该病在1884年由Mackenzie首先描述,其临床表现为复视、眼球运动受限,眼球内陷等。本文报告眶爆裂性骨折、眶内壁骨折23例(其中2例合并眶下壁骨折),经骨膜下植入骨水泥矫正复视,观察1年～3年,取得满意疗效。材料:国产骨水泥制成板状,为6mm×6mm×2mm至20mm×20mm×3mm,术前福尔马林熏蒸,消毒备用。2002年3月——2004年5月期间住院病人。诊断为:眶爆裂性骨折及眶内壁骨折23例(其中2例合并眶下壁骨折)。男15例,女8例,18岁～60岁。致伤…     

鼻内窥镜下经筛窦行眶内壁骨折整复术

探讨应用鼻内窥镜下经筛窦行眶内壁折整复术。方法前鼻孔入路,内窥镜观察下将嵌入筛房的眶脂肪及内直肌还纳回眶内,硅胶板修补充填孔洞。结果１６例患者,平均术后观察８个月,复视消失,眼球内陷矫正,无硅胶排异。结论内窥镜下经筛窦行眶内壁骨折整复术,具有无皮肤瘢痕,手术损伤小,并发症少,且手术安全可靠。     

经鼻窦内窥镜治疗眶内壁骨折合并内直肌嵌顿

目的探讨眶内壁骨折合并内直肌嵌顿的治疗方法。方法经鼻窦内窥镜治疗眶内壁骨折合并内直肌嵌顿12例(12眼),术前,术中、术后7d及术后3月以双马氏杆试验和三棱镜检查原在眼位斜视度和内转眼位斜视度。结果术后3月原在眼位斜视度比术前减少(7.83±1.70)△(q=34.84,P<0.01);内转眼位斜视度比术前减少(11.83±1.80)△,(q=42.53;P<0.01);复视和代偿头位减轻。结论以鼻窦内窥镜修复眶内壁骨折合并内直肌嵌顿,手术简便,不遗留皮肤瘢痕,对眶内组织损伤小,可迅速安全的还纳疝入筛窦的眶组织,使内直肌复位。     

Conservative treatment of isolated medial orbital wall fractures.

The decision to use surgical or nonsurgical treatment for orbital blow-out fractures is still controversial. Previously, it was advocated that all blow-out fractures should be treated surgically based on the conception that extraocular muscles were blown out and trapped in the fracture area. However, a shift to a more conservative approach occurred gradually, most likely due to the evidence of spontaneous improvement. The medical records of two patients who were diagnosed as having an isolated medial wall fracture with medial rectus muscle displacement into the ethmoid sinus, as demonstrated by computed tomography, were reviewed. Both patients showed improvement only with conservative therapy.     

Adult Medial Orbital Wall Trapdoor Fracture with Missing Medial Rectus Muscle

We report the case of a 28-year-old man presenting with a medial orbital wall trapdoor fracture with a missing medial rectus muscle. We believe this to be the first case report of an adult medial orbital wall trapdoor fracture. Trapdoor fractures most commonly occur in the pediatric population, and those involving the medial orbital wall generally occur in areas with less developed ethmoid air cells. Since the present case followed neither pattern, a different injury mechanism was considered. The ethmoid air cells in this case were well developed, which may have played an important role in the pathogenesis of this adult medial orbital wall trapdoor fracture. Based on our findings, we propose a possible mechanism for a medial orbital wall trapdoor fracture in an adult. The cellular frames enable the medial bone to shift just minimally, regardless of the high orbital pressure during a blow. The excess volume of the orbital content escapes into the cells through narrow cracks; therefore, after a blow, it cannot move back completely into the orbit. Consequently, it pushes the shifted bone towards the orbit, becoming trapped in a manner similar to that of a check-valve mechanism.     

未成年人眶壁爆裂性骨折的临床特点及治疗分析

目的 分析未成年人不同年龄眶壁爆裂性骨折的临床特点与骨折类型的相关性.探讨少年儿童眶壁骨折的治疗方案.方法 选取18岁以下眶壁爆裂性骨折患者69例,5～14岁组23例和15～18岁组46例.观察术前眼位和复视情况.眼球内陷程度和眼球运动,CT影像特点表现和术中所见,术后眼位、眼球内陷和眼球运动恢复情况.结果 5～14岁组伤后出现恶心、呕吐,眼球垂直运动受限的构成比高于15～18岁组(P均<0.05).5～14岁组眼球无内陷的构成比高于15～18岁组(P<0.05).5～14岁组眶下壁活板门样(trapdoor)骨折的构成比高于15～18岁组(P<0.05).CT显示为眶下壁线性骨折的20例患者术中发现16例骨折区呈trapdoor表现,下直肌嵌夹于骨折区呈紫红色肿胀.结论 5～14岁儿童生眶下壁trapdoor骨折的风险较高,确诊后早期手术对促进眼外肌功能恢复和减少复视残留具有重要意义.     

眼眶骨折200例临床分析

目的探讨眼眶骨折的病因、伤情和临床治疗方法。方法对200例眼眶骨折病因、损伤部位、伤情和治疗进行分析。认为在软组织裂伤缝合时尽可能早期行眼眶骨折整复。眶上壁骨折若视功能和眼位无明显改变者,不必行骨折整复。视神经孔骨折者,可以经筛窦进路行视神经探查。重度颜面凹陷畸形,需要行颧骨、上颌骨复位后钛板固定。内直肌嵌入筛窦,下直肌嵌入上颌窦,在眶内容还纳复位后分别用天然珊瑚人造骨板修复骨孔。结果眶壁重度粉碎性骨折51例行Ⅱ期骨折整复,其余均在软组织清创缝合时行I期整复,视功能均得到不同程度的恢复。结论眼眶骨折经早期和恰当方法整复,完全可以修复颜面畸形,并恢复眼球运动和视觉功能。     

Orbital imaging demonstrates occult blow out fracture in complex strabismus.

BACKGROUND: While strabismologists are familiar with diagnostic evaluation of suspected blow out fractures, unsuspected blow out fractures may further complicate difficult cases of strabismus not clinically supposed to be related to orbital trauma. METHODS: According to a prospective protocol, we studied five adults presenting with diplopia, and one with convergence-related asthenopia. No patient recalled or had any clinical suspicion of orbital fracture at initial evaluation. Surface coil magnetic resonance imaging of the orbits was performed at 312 microm resolution, slice thickness 2 mm. Quasicoronal images in central gaze were supplemented with eccentric gaze positions, and sagittal and axial images as indicated. RESULTS: Five patients had incomitant hypertropia, and one had abducens paralysis. Magnetic resonance imaging disclosed previously unsuspected blow out fractures in all six patients. Three patients had medial wall fracture, one bilaterally. Two patients had inferior wall fractures, and one inferomedial. Although only one patient had an extraocular muscle displaced into a sinus, all had evidence of orbital connective tissue distortion in the region of the rectus extraocular muscle pulleys influencing muscle paths. These effects altered the presentations of more familiar pathologies such as superior oblique palsy. After learning of the MRI findings, most patients then recalled orbital trauma from as early as childhood. CONCLUSION: Unsuspected blow out fractures occur and may confound the usual findings in complex strabismus. High-resolution orbital imaging can detect blow out fractures and clarify the pathophysiology, enabling appropriate surgical management.     

眼眶爆裂性骨折年龄因素与临床及影像学特点分析

目的 分析比较青少年和成年人眼眶爆裂性骨折(BOF)的临床、影像学特点及临床与影像学表现的相关性,以利于评估预后以及制定准确合理的治疗方案.方法 收集2006年10月至2008年12月住院且接受手术治疗、临床及影像学资料的BOF患者75例,分为青少年组(≤18岁,20例)和成年组(19～56岁,55例).总结其病史、临床、影像学特点及手术所见并进行统计学分析.结果 青少年组致伤原因主要为摔伤和拳击伤,其次为车祸、撞伤等,成年组致伤原因主要为拳击伤和车祸,其次为硬物击伤、摔伤等;两组之间性别及眼别构成比差别无统计学意义(P>0.05);青少年组术前双眼眼球突出度差值小于成年组(P<0.05);青少年组伤后出现恶心、呕吐症状的构成比高于成年组(P<0.05);两组受累眶壁之间的构成比差别有统计学意义(P<0.05);青少年组骨折区呈裂缝状或阀门样表现的构成比高于成年组(P<0.05);青少年组发生肌肉嵌夹的构成比高于成年组(P<0.05);青少年组手术见肌肉呈深紫色改变的构成比高于成年组(P<0.05).结论 青少年及成年人BOF的临床及影像学特点存在明显差异,结合临床及影像学特点综合分析对于评估患者病情及预后,及时准确地制定治疗方案有较大意义.     

手术显微镜下经泪阜部结膜切口整复爆裂性眶内壁骨折

目的探讨手术显微镜下经泪阜部结膜切口治疗眶内壁骨折的方法及效果。方法回顾性研究手术显微镜下经泪阜结膜切口进行眶内壁骨折复位手术30例,检查手术前后的视力、复视程度、眼球运动、眼球突出度及三维CT图像,并随访6～12个月。结果30例中29例手术后复视、眼球运动障碍、眼球内陷明显改善。1例眼球运动障碍术后仅得以改善。结论手术显微镜下经泪阜部结膜切口进行爆裂性眶内壁骨折复位术,效果良好。     

Medial rectus muscle incarceration in pediatric medial orbital wall trapdoor fractures

PURPOSE: We describe two cases of orbital trapdoor fractures with medial rectus muscle incarceration. METHODS: Small interventional case series. RESULTS: This is a retrospective university based report of two healthy males (11 and 14 years old) who developed diplopia following blunt orbital trauma. Both patients had decreased horizontal ocular motility of the involved eye with minimal additional evidence of trauma. Computed tomography (CT) demonstrated no significant bony displacement; however, the left medial rectus muscle was located within the ethmoid sinus in the first and had an abnormal size and shape in the second case. In both cases, during urgent surgical repair, the incarcerated medial rectus muscle was gently released from linear non-displaced medial wall fractures and ocular motility normalized postoperatively. CONCLUSIONS: In pediatric patients sustaining blunt orbital trauma, medial rectus incarceration should be considered and managed accordingly.     

Adult medial orbital wall trapdoor fracture with missing medial rectus muscle

We report the case of a 28-year-old man presenting with a medial orbital wall trapdoor fracture with a missing medial rectus muscle. We believe this to be the first case report of an adult medial orbital wall trapdoor fracture. Trapdoor fractures most commonly occur in the pediatric population, and those involving the medial orbital wall generally occur in areas with less developed ethmoid air cells. Since the present case followed neither pattern, a different injury mechanism was considered. The ethmoid air cells in this case were well developed, which may have played an important role in the pathogenesis of this adult medial orbital wall trapdoor fracture. Based on our findings, we propose a possible mechanism for a medial orbital wall trapdoor fracture in an adult. The cellular frames enable the medial bone to shift just minimally, regardless of the high orbital pressure during a blow. The excess volume of the orbital content escapes into the cells through narrow cracks; therefore, after a blow, it cannot move back completely into the orbit. Consequently, it pushes the shifted bone towards the orbit, becoming trapped in a manner similar to that of a check-valve mechanism.     

Isolated medial orbital wall fractures with medial rectus muscle incarceration

PURPOSE: To retrospectively review and analyze cases of isolated medial orbital wall fractures with medial rectus muscle incarceration presenting to a tertiary ophthalmic plastic surgery practice from 1997 to 2005. METHODS: Retrospective chart review and literature review. RESULTS: Nine cases of isolated medial wall fracture with medial rectus muscle incarceration are presented. The most frequently encountered clinical feature was adduction deficit on the affected side. Extraocular motility improved in all patients who underwent surgery, and mean postoperative enophthalmos was minimal. CONCLUSIONS: Isolated medial orbital wall fractures with medial rectus muscle incarceration are rare. Ocular motility abnormalities were the only indication of underlying fracture in the majority of our cases. Clinicians should be alerted to the anticipated presentation of medial wall fractures with incarceration of the medial rectus muscle, including the possibility of a "white eye" and normal abduction of the traumatized eye.