Floor Fractures Research Articles

Use of a dial tension gauge to assess quantitatively the intraoperative improvement of ocular movement after endoscopic transantral repair of fracture of the orbital floor

i l ractures of the orbital floor are common midfacial fractures. lthough conventional approaches such as the subciliary or ransconjunctival approach are usually used for such fracures, the endoscopic transantral approach is safe and reliable n suitably selected patients1 and has recently been used as inimally invasive treatment.1,2 Improvement of ocular movement after the repair of a racture of the orbital floor is generally confirmed by the orced duction test. However, such improvement is more ifficult to assess after the endoscopic transantral approach ithout direct visualisation of soft tissues above the orbital oor, because the assessment depends on the surgeon’s skill nd experience and there are few objective indicators. We eport the use of a dial tension gauge to assess quantitaively the intraoperative improvement of ocular movement fter endoscopic transantral repair of a fracture of the orbital oor. Under general anaesthesia, 5/0 nylon is sutured to the nsertion of the inferior rectus muscle so that the globe is ot injured by the conjunctiva being grasped at the inserion. This procedure is not as traumatic as multiple trials of

Prevalence of Diplopia and Extraocular Movement Limitation according to the Location of Isolated Pure Blowout Fractures

BackgroundIsolated pure blowout fractures are clinically important because they are the main cause of serious complications such as diplopia and limitation of extraocular movement. Many reports have described the incidence of blowout fractures associated with diplopia and limitation of extraocular movement; however, no studies have statistically analyzed this relationship. The purpose of this study was to demonstrate the correlation between the location of isolated pure blowout fractures and orbital symptoms such as diplopia and limitation of extraocular movement.MethodsWe enrolled a total of 354 patients who had been diagnosed with isolated pure blowout fractures, based on computed tomography, from June 2008 to November 2011. Medical records were reviewed, and the prevalence of extraocular movement limitations and diplopia were determined.ResultsThere were 14 patients with extraocular movement limitation and 58 patients complained of diplopia. Extraocular movement limitation was associated with the following findings, in decreasing order of frequency: floor fracture (7.1%), extended fracture (3.6%), and medial wall (1.7%). However, there was no significant difference among the types of fractures (P=0.60). Diplopia was more commonly associated with floor fractures (21.4%) and extended type fractures (23.6%) than medial wall fractures (10.4%). The difference was statistically significant (Bonferroni-corrected chi-squared test P<0.016).ConclusionsData indicate that extended type fractures and orbital floor fractures tend to cause diplopia more commonly than medial wall fractures. However, extraocular movement limitation was not found to be dependent on the location of the orbital wall fracture.

Preseptal transconjunctival vs. subciliary approach in treatment of infraorbital rim and floor fractures

Background:Injuries in the orbital region have profound functional as well as aesthetic implications. Treatment of orbital fractures remains one of the most controversial issues in maxillofacial trauma with regard to the classification, diagnosis, surgical approach and treatment.Purpose:This study evaluated and compared the efficacy of two most commonly applied approaches the preseptal transconjunctival with lateral canthotomy and the subciliary approach for the treatment of infraorbital floor and rim fractures.Patients And Methods:Twenty patients reported to G.D.C.R.I. Bangalore who suffered infraorbital floor and rim fractures, were randomly divided into two groups with 10 patients in each group. In one group, anatomic reduction and reconstruction was done with preseptal transconjunctival approach with lateral canthotomy and in the other group with subciliary approach.Results:In transconjunctival group, transient entropion was significant (30%). In subciliary group, transient ectropion was significant (30%).Conclusion:In our study, preseptal transconjunctival approach with lateral canthotomy and subciliary skin-muscle flap approach for the open reduction and rigid fixation of infraorbital floor and rim fractures had showed less morbidity and lesser risk of complications and given satisfactory results.

Pediatric Orbital Blow-Out Fractures: Surgical Outcomes.

The objective of this study was to evaluate the features, timing of intervention, complications, and outcomes of patients who underwent surgery for pediatric orbital blow-out fractures. This was a retrospective case review studying all cases of pediatric orbital blow-out fractures that underwent surgical intervention from 2000 to 2009 in a tertiary ophthalmic center in Singapore. Case notes review of all cases of pediatric orbital blow-out fractures repaired surgically was carried out for demographics, time to intervention, and outcome. How the various factors may affect the outcome was statistically analyzed. A total of 23 patients were reviewed. There were 21 patients (91.3%) with floor fractures, 1 (4.3%) with medial wall fracture, and 1 (4.3%) with combined medial wall and floor fracture. Of the 21 cases of floor fracture, 20 cases had radiological images available for review, 17 (85%) were linear, and 3 (15%) were open. Patients with open fractures were older with a mean age of 14.0 years as compared with 12.6 years in those with linear fractures. The mean duration from injury to intervention was 13.0 days. Preoperatively, 14 (60.9%) had diplopia, but only 4 cases (17.4%) had diplopia in extreme gaze at the last follow-up after surgery (18 months). Outcome was not affected by age, duration between injury and intervention, type of fracture, and nature of implants used. Our study demonstrated that pediatric orbital blow-out fractures had good outcomes. It might also suggest the possibility of not having to manage all linear fractures as a surgical emergency.

Combination of Transorbital and Endoscopic Transnasal Approaches to Repair Orbital Medial Wall and Floor Fractures

This study aimed to illustrate the effectiveness of the combination of the transorbital and the endoscopic transnasal approach in the repair of medial wall and floor orbital fractures in Chinese patients. A retrospective study was carried out on 25 Chinese patients (18 men and 7 women) with orbital medial wall and floor fractures. All patients had enophthalmos more than 2 mm, 23 had diplopia, and 11 had eye movement restriction. Bone defect involving both medial and inferior walls was found with computed tomographic scans in all patients. In all 25 patients, surgery was done by 1 surgeon group using the transorbital and the endoscope-assisted transnasal approach. The endoscope was used to give a clear view of the posterior edge of the fracture. Titanium meshes were used to repair fractures of the orbital floor and the medial wall. Porous polyethylene sheet implants were used to recover the orbital volume. All patients were followed up 12 months after surgery. Enophthalmos was corrected in all 25 patients immediately, diplopia disappeared or improved in 21 of 23 cases, and eye movement restriction was released or improved in all 11 patients. No significant complications occurred. The titanium mesh was completely covered by nasal mucosa at 1 month after surgery by an endoscopic check. The endoscope-assisted transnasal approach allows for excellent visualization of the extent of the fracture, particularly in areas that are difficult to visualize by conventional methods. The combination of the transorbital and the endoscope-assisted transnasal approach is a good way to reconstruct a large orbital wall fracture involving the floor and the medial wall.

Repeated Hemorrhage after Repair of Orbital Floor Fracture with a Silicone Implant

A 16-year-old girl was accidentally kicked in her right eye by her cheerleading teammate in an exercise. Upward gaze ability of her right eye was severely impaired and computed tomography (CT) showed a trapdoor fracture of the right orbital floor. After surgical exploration, a silicone implant was inserted. No bleeding was confirmed at this time. The next day, CT detected a hematoma on the right orbital floor. The hematoma was drained and meticulous cautery was used to control any potential bleeding. The same silicone implant was re-inserted. Irrespective of attempts to avoid hemorrhage, this occurred twice after the respective evacuations. During a fourth operation, we removed the silicone implant simultaneously with hematoma evacuation. No hematoma has occurred since, and the patient’s ocular movement has dramatically improved to a normal binocular single vision field. When repeated hemorrhages occur after an orbital floor fracture repair with insertion of a silicone implant, removal of the implant is an effective strategy to resolve the hemorrhage.

Thermal analysis of fractures at Cerberus Fossae, Mars: Detection of air convection in the porous debris apron

This study investigates the cause of high nighttime temperatures within Cerberus Fossae, a system of fractures affecting the Central Elysium Planitia. The inner parts (walls and floor) of the fractures are up to 40 K warmer than the surrounding plains. However, several temperature profiles exhibit a local temperature minima occurring in the central part of the fractures. We examined first the influence of cooling efficiency at night in the case of a strong reduction of the sky proportion induced by the fracture’s geometry. However, the lack of correlation between temperature and sky proportion, calculated from extracted Mars Orbiter Laser Altimeter (MOLA) profiles argues against this hypothesis. Albedo variations were considered but appear to be limited within the fractures, and are generally not correlated with the temperatures. Variations of the thermal properties of bedrocks exposures, debris aprons and sand dunes inferred from high-resolution images do not either correlate with temperature variations within the fractures. As none of these factors taken alone, or combined, can satisfactorily explain the temperature variations within and near the fracture, we suggest that geothermal heat transported by air convection within the porous debris aprons may contribute to explain high temperatures at night and the local minima on the fracture floor. The conditions for the occurrence of the suggested phenomenon and the consequences on the surface temperature are numerically explored. A conservative geothermal gradient of 20 mW/m 2 was used in the simulations, this value being consistent with either inferred lithosphere elastic thicknesses below the shield volcanoes of the Tharsis dome or values predicted from numerical simulations of the thermal evolution of Mars. The model results indicate that temperature differences of 10–20 K between the central and upper parts of the fracture are explained in the case of high Darcy velocities which require high permeability values (5 × 10 −6 m 2). The presence of coarse material composing the debris aprons may explain why this key criteria was met in the context of Cerberus Fossae.

Muscle Shape as a Predictor of Traumatic Enophthalmos

The literature on enophthalmos is reviewed to understand its etiology and its prevention following orbital fractures. Specifically, the importance of muscle shape changes in predicting enophthalmos is discussed. The indications for surgical repair of orbital blowout fractures are well established. However, 7 to 10% of patients still develop enophthalmos despite these criteria. Because late repair of enophthalmos is associated with poor esthetic and functional results, the sensitivity and specificity of the current indications need to be further improved. Increased orbital volumes after fracture together with soft tissue displacement and herniation are the two most important factors causing enophthalmos. The loss of both bone and periorbita as supporting structures is seen on coronal computed tomography scan as changes in shape of the extraocular muscles. In floor fractures, the inferior rectus changes from an ellipse to a more rounded shape. The same is true for the medial rectus in medial wall fractures. It is the degree of rounding measured as a ratio of height to width that has been shown to be predictive of enophthalmos. Therefore, because rounding signifies loss of bone and soft tissue support, it may be a more important indication for surgical intervention than fracture size alone.

One-Point Fixation of Tripod Fractures of Zygoma Through a Lateral Brow Incision

The aims of this report were to analyze the cases of lateral brow incision and 1-point fixation and to introduce the criteria for application of this selective approach.Among 70 patients with tripod fractures, 14 patients (20%) underwent 1-point fixation technique through lateral brow incisions. Preoperative and postoperative displacements of the infraorbital rim were radiologically measured.Of these patients, 7 cases (50%) were type III, 6 cases (43%) were type IV, and 1 case (7%) was type V according to the Knight and North classification. Simple fracture of the infraorbital rim was seen in 10 patients (71%), and comminuted fracture was seen in 4 patients (29%). In 11 patients, zygomaticofrontal sutures were fixed with square microplates with 4 holes and 0.5 mm in thickness, and straight miniplates with 4 holes and 1.0 mm in thickness were used in 3 patients. Of 14 tripod fractures, 6 (43%) were associated with floor fractures. Seven had displacement of the infraorbital rim (range, 2.0-7.6 mm; mean, 4.6 +/- 0.8 mm), and the other 7 had no displacement of the infraorbital rim. After surgery, step deformities of the infraorbital rims were improved (range, 0.1-3.8 mm; mean, 1.4 +/- 0.5 mm). All 14 patients were satisfied with their postoperative appearance.Indications for using 1-point fixation of the tripod fracture are (1) minimal or moderate displacement of the infraorbital rim in the tripod fracture of the zygoma, (2) no ocular signs of diplopia or enophthalmos, and (3) comminuted infraorbital rim fractures where internal fixation is difficult.

Endoscope-Assisted Repair of Pediatric Trapdoor Fractures of the Orbital Floor

The mechanism of injury, the clinical presentation, the natural history, and the indications for the treatment of orbital fractures in the pediatric population are less well described than they are in adults. The purpose of this study was to describe the specific characteristics and management of trapdoor fractures of the orbital floor in the pediatric population. We enrolled 18 pediatric patients younger than 13 years who underwent endoscopic reconstruction of trapdoor fractures of the orbital floor between March 2000 and October 2006 at the Gil Medical Center and the Ansan Hospital, Korea University. Causes, locations, and clinical characteristics such as restriction of extraocular muscle movement were reviewed retrospectively. Ten of 18 patients (55.6%) exhibited nausea and vomiting, which rapidly resolved after surgery. Surgery was undertaken within 2 weeks after injury (82.3%), and most of the extraocular muscle movement restrictions improved within 2 months postoperatively. Temporary postoperative hypertropia occurred in 5 floor fractures (5/16, 31.2%). Trapdoor fractures of the orbital floor revealed a high incidence of persistent diplopia associated with extraocular muscle and soft tissue entrapment in the pediatric population, but actual entrapment of the muscle belly was confirmed in only 27.8% of patients endoscopically. Temporary hypertropia (31.2%) occurred in trapdoor fractures of the orbital floor but improved after 2 months of follow-up in every patient. Marked motility restriction and nausea/vomiting are predictive of trapdoor fractures. Prompt surgical intervention is needed in patients with such symptoms.

“Sutureless” Repair of Orbital Floor and Rim Fractures

“Sutureless” Repair of Orbital Floor and Rim Fractures

“Sutureless” Repair of Orbital Floor and Rim Fractures

“Sutureless” Repair of Orbital Floor and Rim Fractures

Accuracy and Predictability in Use of AO Three-Dimensionally Preformed Titanium Mesh Plates for Posttraumatic Orbital Reconstruction

The aim of this study was to prospectively evaluate the accuracy and predictability of new three-dimensionally preformed AO titanium mesh plates for posttraumatic orbital wall reconstruction.We analyzed the preoperative and postoperative clinical and radiologic data of 10 patients with isolated blow-out orbital fractures. Fracture locations were as follows: floor (N = 7; 70%), medial wall (N = 1; 1%), and floor/medial wall (N = 2; 2%). The floor fractures were exposed by a standard transconjunctival approach, whereas a combined transcaruncular transconjunctival approach was used in patients with medial wall fractures. A three-dimensional preformed AO titanium mesh plate (0.4 mm in thickness) was selected according to the size of the defect previously measured on the preoperative computed tomographic (CT) scan examination and fixed at the inferior orbital rim with 1 or 2 screws. The accuracy of plate positioning of the reconstructed orbit was assessed on the postoperative CT scan. Coronal CT scan slices were used to measure bony orbital volume using OsiriX Medical Image software. Reconstructed versus uninjured orbital volume were statistically correlated.Nine patients (90%) had a successful treatment outcome without complications. One patient (10%) developed a mechanical limitation of upward gaze with a resulting handicapping diplopia requiring hardware removal. Postoperative orbital CT scan showed an anatomic three-dimensional placement of the orbital mesh plates in all of the patients. Volume data of the reconstructed orbit fitted that of the contralateral uninjured orbit with accuracy to within 2.5 cm(3). There was no significant difference in volume between the reconstructed and uninjured orbits.This preliminary study has demonstrated that three-dimensionally preformed AO titanium mesh plates for posttraumatic orbital wall reconstruction results in (1) a high rate of success with an acceptable rate of major clinical complications (10%) and (2) an anatomic restoration of the bony orbital contour and volume that closely approximates that of the contralateral uninjured orbit.

Comparison of various approaches for exposure of infraorbital rim fractures of zygoma

The aim of this study was to randomly compare four incisionssubciliary, subtarsal, infraorbital and transconjunctival with lateral canthotomy for treatment of orbital rim or floor fractures. 40 patients with zygomatic complex fractures either isolated or in association with pan facial fractures, were selected for the study. They were divided into four groups of 10 patients each, Group I-Transconjunctival with lateral canthotomy, Group II-Subciliary [single eyelid incision], Group III-Subtarsal incision, and Group IV-Infraorbital incision. The following parameters were compared a) The average time from incision to fracture exposure b) The amount of exposure of the site provided c) The aesthetic appearance of the 'scar' d) Complications e) Factor of 'time' - its effect on scar and complications. The study revealed that all four incisions provided adequate exposure of fracture site and transconjunctival (22 minutes) required the maximum time for exposure. The complications included ectropion in group I and prolonged edema in group IV. Group II and III patients had relatively lesser number of complications. Group IV patients had visible scar as compared to no scar in group I patients. We conclude by saying that transconjunctival approach provides an excellent aesthetic result when done meticulously. However the subciliary and the subtarsal incisions provide a more rapid, direct approach to the orbital floor and infraorbital rim with minimal morbidity and an aesthetically acceptable scar. The infraorbital incision is the least acceptable aesthetically.

テルダーミスを用いた骨形成性上顎洞手術

Osteoplastic maxillary antrostomy is performed to restore the normal anatomy and physiology of the maxillary sinus. Although endoscopic sinus surgery has been employed since the 1980s, antrostomy through the canine fossa is still required in cases such as an inverted papilloma originating from the maxillary sinus or a blow-out fracture of the inferior orbital floor. Herein, we demonstrate a new procedure using a collagen sponge (Terudermis®, Olympus Terumo Biomaterials Co., Ltd., Tokyo, Japan) to support the free bone flap of the anterior wall of the maxillary sinus. The collagen sponge also promotes epithelialization of the maxillary sinus. We employed this procedure in 11 cases, including five cases involving repair of a blow-out fracture of the inferior orbital floor, two to remove fungal growth from the maxillary sinus, three to remove an inverted papilloma of the maxillary sinus, and one for removal of an odontogenic maxillary cyst. In all cases, the maxillary sinus was epithelialized without infection, except for one recurrent case of papilloma. In seven of the 11 cases, postoperative CT was performed, showing that the bony flap was maintained in the original position. This new method simplifies osteoplastic maxillary surgery and reduces the surgical time.

Multiple Fractures Involving the Orbit and Incidental Finding of Large Fourth Ventricular Epidermoid

Epidermoid tumors located in the fourth ventricle are exceedingly rare, and the patients usually present with headaches, vertigo, and/or disequilibrium. We discuss the management of orbital floor and lateral wall fracture in a patient who was also incidentally diagnosed to have a large fourth ventricular epidermoid cyst. Although because of their availability and ease of use many allografts have been described, when available, the use of similar membranous bone of equivalent thickness makes the bone graft ideally suited for reconstruction of the orbital floor.

Pathogenesis of Canalicular Lacerations

To assess the pathogenesis of canalicular lacerations. This is a retrospective, clinical case series of 236 patients who sustained a canalicular laceration. All patients who presented to the oculoplastic service of 3 individuals (D.R.J., S.M.G., L.A.M.) from May 1, 1998 to September 30, 2007, with a canalicular laceration were included in the study. Case histories were carefully reviewed in an attempt to classify the mechanism of injury as: "direct (penetrating) injury," "indirect (avulsive)," or "diffuse (avulsive)." Associated injuries (floor fractures, soft tissue lacerations, etc.) were also recorded. Of the 236 patients reviewed, direct canalicular injuries were detected in 128 (54.2%), indirect injuries were detected in 60 (25.4%), and diffuse injuries were detected in 48 (20.3%). Avulsive blunt injuries (due to indirect or diffuse trauma) therefore accounted for 45.7% of the lacerations whereas direct penetrating injuries accounted for 55.2% of the canalicular lacerations. Other injuries associated with the trauma occurred in 152 of the 236 patients (64%). Lacerations involving other portions of the eyelids, periocular area, and face made up the greatest number of associated injuries, and occurred with equal frequency in the direct penetrating group and the indirect/diffuse (avulsive injury) group. Associated injuries more serious in nature including orbital fractures, globe rupture, other body injuries, and head trauma were more commonly seen when diffuse trauma was involved. Direct, indirect, or diffuse forces may injure canaliculi but direct penetrating injuries were more common than avulsive injuries. More serious injuries (orbital fractures, globe rupture, other body injuries, and head trauma) were more commonly seen when diffuse trauma was involved.

Nylon Foil “Wraparound” Repair of Combined Orbital Floor and Medial Wall Fractures

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. 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. 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. 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.

The Transcaruncular Approach to Orbital Fracture Repair

The transcaruncular approach to the medial orbit is growing in popularity and although reported complications are minimal, ophthalmic and orthoptic sequelae can occur after any conjunctival surgery and nonophthalmic surgeons should be aware of these. This study aims to document these sequelae in a cohort of patients having transcaruncular surgery. A retrospective case series of all consecutive patients undergoing orbital fracture repair through a transcaruncular approach for medial wall and floor fractures in two centers over a 2-year period was examined. Computed tomography findings, pre- and postoperative ophthalmic and orthoptic findings, including ocular motility (with Hess chart evaluation), Hertel exophthalmometry, slit lamp biomicroscopy examination, follow-up time, and occurrence of complications were recorded. Thirteen patients, mean age 34 years (range, 18-82 years), underwent repair for medial wall (n=5) or combined medial wall and orbital floor (n=8) fractures with median a follow up of 7 months (range, 2-18 months). Preoperative ocular injuries included conjunctival chemosis, eyelid swelling, subconjunctival hemorrhage, retinal haemorrhage, traumatic uveitis and traumatic mydriasis, eye movement restriction, and enophthalmos (range, 3-4 mm). Postoperatively, corneal epitheliopathy with reduced vision (6/60), orbital inflammation, inferior oblique underaction, and superomedial fornix symblepharon at the caruncular incision sight each occurred in one patient along with extensive subconjunctival hemorrhage and a suture-related conjunctival granuloma in others. All patients experienced an improvement in diplopia and globe restriction. Ophthalmic complications can occur with this approach, and so it may be advisable to seek an ophthalmic opinion with the aim of comanagement in planning this approach.

Combined Inferior and Medial Surgical Approaches and Overlapping Thin Implants for Orbital Floor and Medial Wall Fractures

To evaluate the clinical outcome of combined orbital floor and medial wall fracture repair using overlapping thin implants. A retrospective chart review was conducted on 19 fracture repairs performed by one surgeon using thin overlapping implants inserted through transcaruncular and inferior fornix incisions. Nineteen combined medial wall and floor fractures were repaired in 18 patients (14 male, 4 female). The median age was 37 years (range, 13-60 years). The median trauma-to-surgery interval was 9 days (range, 1 day to 6 years). Two overlapped implants (0.2-0.4 mm) were used in 12 fracture repairs, and 3 overlapped implants (0.2-0.3 mm) were used in 7 fracture repairs. Materials included prepunched nylon foil in 18 fractures and, in one fracture, high-density polyethylene. Follow-up time ranged from 1 month to 53 months (median, 7 months). No complications occurred during the postoperative follow-up period. Clinically significant enophthalmos was not observed after treatment. The repair of combined orbital floor and medial wall fractures using thin overlapping implants inserted through transcaruncular and inferior transconjunctival incisions is a safe, effective, and cosmetically sensitive surgical technique.