Medial Wall Fractures Research Articles

Inlay Implanting Technique for the Correction of Medial Orbital Wall Fracture

For blowout fractures of the medial orbital wall, the goals of treatment are complete reduction of the herniated soft tissue and anatomical restoration of the orbital wall without surgical complications. Surgeons frequently worry about damage to the optic nerve caused by dissection when the part over the posterior ethmoidal foramen is fractured. The authors performed small incision and inlay implantation of porous polyethylene for reconstruction of medial orbital wall fractures. Between January of 2007 and December of 2009, 55 patients were included in an analysis of the outcome of corrected medial orbital wall fractures. For 55 patients with posterior comminuted fractures of the medial orbital wall, insertion of porous polyethylene into the ethmoid sinus was performed in multiple layers, through the transconjunctival approach. In all cases, the orbital cavity was restored to its normal anatomical shape. The associated ocular problems disappeared except for mild enophthalmos in three patients and diplopia in one patient. There were no serious surgical complications associated with inlay implantation. The advantages of the inlay technique include the anatomical reconstruction of the orbital wall, the avoidance of optic nerve injury, the simplicity of the procedure, and consequently the absence of surgery-related complications. This technique is presented as one of the preferred treatments for posterior comminuted fractures of the medial orbital wall.

Postoperative Neurogenic Blepharoptosis after Repair of a Medial Orbital Wall Fracture Using the Transcaruncular Approach

Postoperative Neurogenic Blepharoptosis after Repair of a Medial Orbital Wall Fracture Using the Transcaruncular Approach

Temporary Severe Neurogenic Blepharoptosis after Reconstruction of Orbital Medial Wall Fracture

Temporary Severe Neurogenic Blepharoptosis after Reconstruction of Orbital Medial Wall Fracture

La voie d’abord combinée transcaronculaire-transconjonctivale dans l’approche des fractures orbitaires de la paroi médiale. Technique chirurgicale

The ideal approach to orbital medial wall fractures remains controversial. Only the coronal approach exposes the medial wall completely. The transcaruncular approach enables a clear and wide view of the medial wall without any visible scar compared to usual transcutaneous techniques. This approach can be combined with a transconjunctival approach, thus providing an extended exposure of the whole medial wall and the orbital floor. The conjunctival incision is performed with a needle electrocautery in the groove between the plica semilunaris and the caruncle. It is extended laterally within the inferior conjunctival fornix for 20mm to the lateral palpebral commissure. The sub-conjunctival dissection to the posterior lacrimal crest is performed with Stevens scissors through an avascular plane along the medial wall behind Horner's muscle. The periosteum is incised behind the posterior lacrimal crest. The sub-periosteal periorbital dissection is continued medially thus exposing the insertion of the inferior oblique muscle which is coagulated and cut over the inferior orbital rim. Reconstruction is performed after exposing the complete fracture after freeing the periorbital tissue. The periorbita is sutured with interrupted 5-0 Vicryl stitches. The inferior conjunctiva and the caruncle are closed with a continuous 6-0 Maxon suture.

Medial wall blow out fractures in children

Background Fractures of the facial skeleton in children are relatively uncommon in comparison with adults. Within the orbital region fractures are recognised to be rare due the timing of development of the maxillary and frontal sinuses which are not fully developed until 12 years of age. We have recently seen several cases of medial wall fractures in children, which according to the existing literature should be exceptional. This prompted a review of the unit database to clarify the incidence and identify common aetiological factors for these injuries. Method Retrospective case note review using the ACFU database. Results Six cases were identified with a most cases occurring in males. The aetiology was found to be variable in each case with no identifiable pattern and the subsequent management reviewed. Conclusion These six cases highlight that this pattern of fracture can occur more commonly than the existing literature suggests and this should be remembered by those who treat facial trauma in children.

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.

Role of Sagittal Reformatted Computed Tomographic Images in the Evaluation of Orbital Floor Fractures

The sagittal plane computed tomographic (CT) scan has been proposed as the most important radiologic view in the diagnosis of orbital floor fractures. Before the advent of high-resolution CT, several articles were published in the radiology literature debating the need for direct sagittal views, which required cumbersome patient positioning. Today, the ability to easily create high-quality sagittal reformations requires reassessment of the importance of this view in the evaluation of orbital floor fractures. Computed tomographic studies of 24 orbital floor fractures for which coronal and sagittal images were available were included. Five independent reviewers evaluated all image sets and recorded maximum fracture width, depth, posterior shelf length (PSL), and presence of medial wall fracture and of trap door deformity. Direct fracture width measurements were obtained via coronal images, whereas depth and PSL were measured directly in the sagittal plane. Indirect measurements in a given plane were obtained by counting the number of slices in which the fracture was present and multiplying by the slice thickness. Cronbach alpha analysis was used to provide an intraclass correlation coefficient, where greater values signify less interreviewer variability. The Cronbach alpha values for width, depth, and PSL were 64%, 59%, and 85% in the coronal view and 76%, 55%, and 51% in the sagittal view, respectively. The alpha values for presence/absence of medial wall fracture and trap door deformity were greater in the coronal view at 73% and 55%, respectively. The intrareviewer variability was not significantly correlated with the degree of patient rotation or CT scan slice thickness. The interreviewer variability was significantly less among attending reviewer then resident reviewers. There was less interreviewer variability when the measured variables were assessed indirectly (width was best assessed in the sagittal plane, and depth and PSL were best assessed in the coronal view). These findings support the idea that additional views aid the surgeon's ability to further define fracture anatomy than might be possible with any single view, thereby improving preoperative planning and reconstructive strategies.

Efficacy of Transcaruncular approach to reconstruct isolated medial orbital fracture

Traditional approaches used to repair medial orbital wall fracture include transcutaneous incision such as advocated by Killian and Lynch, or coronal approach. Transcaruncular approach provides an anatomically safe and efficient alternative, allowing generous exposure without the cutaneous scar. Patients presenting with medial orbital wall fractures were identified through the trauma database over a 5year period. Data of twelve consecutive patients who presented with isolated medial wall fracture and treated via a transcaruncular approach were analysed. The extent of the injury, operative and follow up details were documented. There were ten male patients and two female patients. On computed tomography, vertical defect ranged from 8 to 16mm (mean 12mm) and longitudinal defect ranged from 14 to 31mm (mean 22mm). All but three patients were followed up for 9months postoperatively. Two patients were assessed as having a slightly enlarged caruncle on the operated side, but neither patient was aware of this. Of the 2 patients who complained of diplopia, only one had objective restriction beyond 30° of abduction from primary gaze. Transcaruncular approach allows satisfactory exposure for repair of isolated medial orbital wall fracture. It is an anatomically safe and efficient technique, with superior cosmetic result. Postoperative morbidity is minimal and follow up data demonstrates no permanent complications.

Use of Titanium Mesh for Reconstruction of Extensive Defects in Fronto-orbito-ethmoidal Fracture

Traumatic injuries treatment of the fronto-naso-orbito-ethmoidal region has been one of the most challenging treatments within maxillofacial surgery, particularly of extensive orbital defects, very common in this type of pathologic condition. A 48-year-old man involved in a car collision presented an extensive bilateral fracture of the orbit medial wall, nasal bones, the nasal septum, and the frontal anterior table. The clinical and tomographic findings concluded the diagnosis of a maxilla and fronto-naso-orbito-ethmoidal fracture. Among the variety of biomaterials, the titanium mesh was elected because of the extension and magnitude of the bone defect, obtaining this way esthetic and functional results with better prognosis.

Cerclage Wire-Plate Composite for Fixation of Quadrilateral Plate Fractures of the Acetabulum: A Checkrein and Pulley Technique

Acetabular fractures with complete or incomplete quadrilateral plate separation frequently present with central displacement of the femoral head. Failure of stable fixation of medial wall fractures leaves residual subluxation despite reduction of other fracture components. Several fixation techniques may be either technically demanding or insufficient for stable fixation in conditions of comminution, osteoporosis, or neglected injuries. The proposed wire-plate composite uses a reconstruction spring plate over the pelvic brim for medial wall buttressing. One hole on its true pelvic limb provides a pulley to deviate a cerclage wire or cable passed through the greater sciatic notch into the true pelvis. This enhances buttressing against medial protrusion. Application through anterior approaches is simple and fixation is reliable in difficult fractures without the risk of joint penetration because all quadrilateral plate buttressing implants remain extraosseous.

Modified Ilioinguinal Approach to the Acetabulum and Pelvis from beneath the Inguinal Ligament: A Subinguinal Approach

The ilioinguinal approach is favoured for fractures of the anterior part of the pelvis, but it is associated with some technical difficulties and it is not suitable for some complex fractures. In 2008, a modified ilioinguinal approach was introduced by Farid Yr which afforded visualisation of the inside and outside of the pelvis. The approach involves retroperitoneal access below the inguinal ligament to preserve the integrity of the inguinal canal and allows exposure of anterior and medial wall fractures as well as the anterior hip capsule. Despite the dimensions of the procedure, closure is anatomical because repair of the inguinal canal floor is not required. We report the use of this approach in 17 patients with T-type fractures of the acetabulum, transverse fractures of acetabulum, Tile C1 pelvic fractures, malunion of the pelvis and acetabular dysplasia. The approach is recommended in complex cases of acetabular surgery (including obese or muscular patients) and complicated or old fractures in which a better exposure is required. It is useful in visualisation of the anterior wall and labrum and intra articular structures, and in viewing the internal anatomy of the pelvis and acetabulum. It may be a suitable approach for periacetabular osteotomy.

Broad Application of the Endoscope for Orbital Floor Reconstruction: Long-Term Follow-Up Results

Transantral endoscopic repair of orbital floor fracture minimizes the risk of implant misplacement and avoids complications associated with traditional lower eyelid approaches. Contrary to most publications, its application is not limited to early intervention of pure orbital blow-out fractures. The authors present their results of broad application of this technique, with longer-term patients' follow-up. A retrospective review of 32 patients over a 10-year period (March of 1998 to June of 2008) was performed. The mean duration of follow-up was 27.5 months (range, 4 months to 10 years). Sixteen patients (50 percent) had associated zygoma, inferior orbital rim, and Le Fort I fractures. Twenty-five patients (78.1 percent) had enophthalmos, with 14 of these cases being 2 mm or more in severity. Diplopia was present in 15 patients (46.9 percent) preoperatively. Operations were performed within 2 weeks for 25 patients (78.1 percent). Twenty-eight patients required orbital floor reconstructions. Four of five patients with associated orbital medial wall fractures underwent simultaneous orbital medial wall reconstruction. All patients had successful reduction of orbital fractures. Two patients had residual enophthalmos of 1 mm postoperatively. Due to delay in surgery and the nature of injury, only 11 of the 15 patients with diplopia had complete resolution after surgery. One patient required drainage of recurrent sinusitis 1 year after surgery. In suitably selected patients with orbital floor fractures, the transantral endoscopic approach is safe and reliable. Delayed surgery or associated zygomaticomaxillary complex fractures are not contraindications for the use of this technique. Long-term follow-up showed maintenance of the surgical results.

A Case of Acquired Brown Syndrome after Surgical Repair of a Medial Orbital Wall Fracture

A case of acquired Brown syndrome caused by surgical repair of medial orbital wall fracture is reported in the present paper. A 23-year-old man presented at the hospital with right periorbital trauma. Although the patient did not complain of any diplopia, the imaging study revealed a blow-out fracture of the medial orbital wall. Surgical repair with a calvarial bone autograft was performed at the department of plastic surgery. The patient was referred to the ophthalmologic department due to diplopia that newly developed after surgery. The prism cover test at distant fixation showed hypotropia of the right eye, which was 4 prism diopters (PD) in primary gaze, 20 PD in left gaze, while orthophoric in right gaze. Eye movement of the right eye was markedly limited on elevation in adduction with normal elevation in abduction with intorsion in the right eye present. Forced duction test of the right eye showed restricted elevation in adduction. Computerized tomography scan of the orbits showed the right superior oblique muscle was entrapped between the autografted bone fragment and posterior margin of the fracture. When repairing medial orbital wall fracture that causes Brown syndrome, surgeons should always be careful of entrapment of the superior oblique muscle if the implant is inserted without identifying the superior and posterior margin of the orbital fracture site.

White-Eyed Medial Wall Orbital Blowout Fracture

The white-eyed orbital floor blowout fracture is most commonly seen in children and adolescents. The orbital floor is the most common fracture location with entrapment of inferior orbital contents and/or the inferior rectus muscle in a "trapdoor" fashion. Other sites may also be fractured either simultaneous to the floor or in isolation. The authors describe an isolated orbital medial wall fracture with entrapment of the medial rectus muscle in an adolescent and discuss treatment options.

Medial Wall Fracture: An Update

This article is a review of the literature and update for management of medial orbital wall fractures. A retrospective review of the literature was performed via PubMed to review the diagnosis and management of medial wall orbital fractures. Medial wall orbital fractures though commonly accompanying orbital floor fractures can also occur alone. There are two primary theories explaining the pathophysiology of medial wall fractures: the hydraulic theory and buckling theory. Most fractures do not require treatment. "White-eyed" trapdoor fractures necessitate immediate surgery to reduce the risk of muscle fibrosis. Trapdoor fractures are more common in the pediatric population. The vast majority of nondisplaced fractures without entrapment do not require surgery. Evaluating patients with medial wall fractures requires evaluation of muscle motility and relative enophthalmos. Patients with entrapped muscles require immediate treatment to prevent permanent injury to the muscle.

A Consecutive Case Review of Orbital Blowout Fractures and Recommendations for Comprehensive Management

The orbital blowout fracture is a common facial injury, but full consensus has not been reached regarding its optimal management. The authors retrospectively explored consecutive cases of blowout fractures and proposed new recommendations for treatment. Two hundred eight newly registered patients were selected from the database of Nagasaki University Hospital over the past 5 years. One hundred nine patients in the authors' department were then reviewed regarding computed tomographic classification of fracture types, preoperative complaints, and outcomes. Of the 208 patients reviewed, 43 underwent surgical repair: 37 for diplopia and 14 for enophthalmos, including eight patients who were treated for both conditions. Regarding floor fractures, the punched-out type fracture was the most common, but the burst type was associated with the highest likelihood of undergoing surgery. For medial wall fractures, the punched-out type dominated, but the overall operative incidence was lower than that observed for the floor fractures. For diplopia, more than half of the operations were performed within 2 weeks, but only two cases were performed within 3 days. For enophthalmos, over 60 percent of operations were carried out after 1 month. Two cases, later discovered to involve muscle strangulation, continued to demonstrate residual diplopia in ordinary use, and two patients continued to show enophthalmos. However, overall outcomes were considered satisfactory. If computed tomographic findings disclose a linear fracture with muscular strangulation, urgent surgery must be performed. However, for linear fractures without impaction of the muscle, or punched-out or burst type fractures, close observation for days may be appropriate. In addition, surgical intervention can be performed electively when diplopia persists for several days of observation.

CT evaluation of orbital blowout fracture.

Objective To analyzed and summarized clinical situations and CT signs of orbital blowout fracture, deeply investigate CT signs of old orbital blowout fracture. Methods 239 patients with orbital blowout fracture proved by CT scan from December 2004 to October 2006 were retrospectively analysed their CT signs and clinical sings and symptoms. Results In the study of 239 eases （241 eyes）, the orbital blowout fracture of simple medial wall,simple inferior wall and multi walls were respectively in 130 cases （132 eyes）, 31 eases （31 eyes） and 63 eases （63 eyes）, Complicated fracture were identified 15 cases, extraoeular muscles thickening were 182 eases, orbital content hernia into accessory nasal cavity were 28 eases, intraorbit hemorrhage were 43 eases, intraorbit pneumatosis were 39 cases, accessory nasal cavity hydrops were 142 cases, soft tissue where surrounding of orbit and eyelid engorgement were 176 cases. Diplopia,muscular apparatus dyscinesia,and endophthalmos were respectively in 86 cases, 125 cases, and 27 cases. Injured above three months in these study were 22 cases, orbital wall hollowed 22 eyes 30 orbital cavity enlargement accompany enophthalmos were 13 cases, extraocular muscles thickening were 16 cases 21 strips. Conclusion CT scan was the first election for examine method that to evaluate orbital blowout fracture and prognosis. Medial orbital wall fracture was the most common orbital blowout fracture; orbital wall became hollow in old orbital blowout fracture; orbital cavity enlargement accompany enophthalmos were resulted in severity fracture; extraocular muscles thickening may exist a long term. Key words: orbit ; blowout fracture ; tomography, X- ray computed

Modified Technique for Endoscopic Endonasal Reduction of Medial Orbital Wall Fracture Using a Resorbable Panel

To describe a modified technique using resorbable panel for endoscopic endonasal reduction of medial orbital wall fracture. A prospective, small interventional case series involving 2 patients with medial orbital wall fractures that were treated with the modified technique. Postoperatively, patients were evaluated for visual acuity, enophthalmos, extraocular motility, and diplopia. Both patients recovered completely without any residual eye symptoms or complications, and postoperative CT showed a completely resolved medial orbital wall. The modified technique for endoscopic endonasal reduction using a resorbable panel was effective for the reconstruction of orbital wall fractures, without complications. The modified technique may be expected to have advantages over the conventional endoscopic approach using a Silastic sheet and Merocel because it does not require long-term nasal packing, and the resorbable panel supports the orbital contents longer.

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.

Endoscopic Reduction of Medial Orbital Wall Fractures Using the Rolled Silastic Sheet Technique

Endoscopic reduction has become common for reducing medial orbital wall fractures because of its various advantages. Nevertheless, there is no standard method of nasal packing to support the orbital contents to maintain the reduction. We evaluated the outcomes of endoscopic reduction of medial orbital wall fractures using the rolled Silastic sheet technique. Seventeen patients who underwent endoscopic reduction of medial orbital wall fractures were analyzed. They were diagnosed using 3-mm facial computed tomography and treated surgically under general anesthesia in our department between February 2006 and March 2008. Postoperatively, they were followed for at least 3 months. The 17 patients comprised 13 men and 4 women ranging in age from 18 to 71 years (mean, 40.8 years). There were no significant intraoperative or postoperative complications. All 17 patients showed complete resolution of their symptoms after surgery. The technique using the rolled Silastic sheet for medial orbital wall fractures supports the safety and efficacy of endoscopic reduction.