Medial Wall Fractures Research Articles

The Subinguinal Retroperitoneal Approach for Fractures of the Acetabulum: A Modified Ilioinguinal Approach

The classic ilioinguinal approach is a standard procedure with reportedly high success rates in many displaced fractures of the acetabulum. Intraarticular visualization and exposure of the anterior wall and the quadrilateral plate are its main limitations. We propose a subinguinal approach based on the principle used for oncologic procedures that naturally require large exposures. The approach involves a retroperitoneal access below the inguinal ligament to preserve the integrity of the inguinal canal and allow ample exposure of anterior and medial wall fractures as well as the anterior hip capsule. Despite the apparent magnitude of the procedure, closure is fairly simple and anatomical because repair of the inguinal canal floor is not required. This modification may compensate for the limitations of the classic approach without additional risks or morbidities.

Tension pneumo-orbit treated by endoscopic, endonasal decompression: case report and literature review

We present a 38-year-old man with a tension pneumo-orbit following medial orbital wall fracture, managed with endoscopic decompression. A case report and a review of the world literature concerning the aetiology, clinical features and management of medial orbital wall fractures are presented. Our patient presented with a post-traumatic tension pneumo-orbit exacerbated by air travel and nose-blowing. Computed tomography revealed a fracture of the ethmoid bone, and intra-orbital emphysema causing proptosis. Management with endoscopic, endonasal surgery produced excellent results, with decompression achieved and immediate and sustained improvement in visual acuity. A search of the world literature revealed no documented cases of tension pneumo-orbit as a complication of medial orbital wall fracture. Endoscopic sinus surgery is currently used in the management of nasal and sinus diseases and their orbital complications. We discuss this extended indication of endoscopic surgery, and its advantages over other surgical approaches.

Massive Orbital Emphysema-An Unusual Clinical Presentation of Isolated Medial Orbital Wall Fracture

Orbital emphysema is an unusual complication of orbital fractures which are the common sequelae of periorbital trauma. Most cases are due to inferior orbital wall fractures. Here we report a case with an unusual clinical presentation of isolated left medial orbital wall fracture complicated with massive orbital emphysema. Without ophthalmic or neurologic defect, conservative management with cold compression and analgesics was prescribed. He was also advised not to blow his nose. On follow-up at 1 and 4 months, the orbital emphysema subsided, and the patient remained free of any optic impairment. Relevant literature is also reviewed.

Use of titanium implants for orbital reconstruction—case series

Purpose: The purpose of study is to highlight the application of various types of titanium orbital implants. Materials: A series of patients were operated with involvement of orbital floor, roof, lateral and medial wall fracture using various types of titanium implants. Intraoperative handling and adaptability. Patients were followed postoperatively for diplopia, enopthalmos and other complications.

Endoscopic management of medial orbital wall fracture with medial rectus insertion

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人筛窦的眶组织,使内直肌复位。

Verification of clinical precision after computer-aided reconstruction in craniomaxillofacial surgery

Computer-aided surgery (CAS) has proved to be useful in reconstructive craniomaxillofacial surgery. Preoperative creation of virtual models by segmentation of the computerized tomography (CT) dataset and mirroring of the unaffected side allows for precise planning of complex reconstructive procedures. The aim of this study was to evaluate the accuracy of the preoperative planning and the postoperative result regarding the skeletal reconstruction. In a first step, the symmetry of unaffected human skulls and faces were evaluated by 20 midface CT data of skulls and 20 surface-scan data of healthy individuals. By mirroring and adjusting the original and mirrored datasets using a 3-dimensional modeling software, an automatic measurement procedure could evaluate the mean and the maximal modulus of the distances between both datasets. In a second step, 18 consecutive cases were selected which had been treated with CAS support. Group 1 consisted of orbital floor and/or medial wall fractures (n = 12), group 2 consisted of zygomatic bone fractures (n = 4), and group 3 included 2 patients who were treated by secondary orbital reconstruction including reosteotomy of the zygomatic bone (n = 2). To verify the surgical result, the preoperative CT dataset including the virtual planning and the postoperative CT dataset were compared by using image fusion. Additionally, postoperative surface scans and the clinical symptoms of the patients were evaluated. No differences between the skull and face symmetry were found. Mean values for distances considering the skull symmetry were 0.83 mm for male and 0.71 mm for female and for the face symmetry 0.65 mm for male and 0.76 mm for female. Comparing the preoperative planning with the postoperative outcome, a mean accuracy of 1.49-4.12 mm with maximum modulus of 2.49-6.00 mm was achieved. Orbital true-to-original reconstructions and the secondary reconstructions were more precise than the reposition of the zygomatic bones. The postoperative acquired surface scans resulted in mean distances from 0.89 to 1.784 mm. Despite these deviations, all patients demonstrated satisfying clinical outcome. The natural asymmetry in humans influences the accuracy of preoperative planning procedure, when the mirroring tool is used. The accuracy transforming the preoperative planning to the surgical reconstruction using CAS depends on location, surgical approach, and matter of reconstruction.

Resources: Internet Resources for the Independent Medical Evaluator – 2007

Abstract Rating patients with head trauma and multiple neurological injuries can be challenging. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, Section 13.2, Criteria for Rating Impairment Due to Central Nervous System Disorders, outlines the process to rate impairment due to head trauma. This article summarizes the case of a 57-year-old male security guard who presents with headache, decreased sensation on the left cheek, loss of sense of smell, and problems with memory, among other symptoms. One year ago the patient was assaulted while on the job: his Glasgow Coma Score was 14; he had left periorbital ecchymosis and a 2.5 cm laceration over the left eyelid; a small right temporoparietal acute subdural hematoma; left inferior and medial orbital wall fractures; and, four hours after admission to the hospital, he experienced a generalized tonic-clonic seizure. This patient's impairment must include the following components: single seizure, orbital fracture, infraorbital neuropathy, anosmia, headache, and memory complaints. The article shows how the ratable impairments are combined using the Combining Impairment Ratings section. Because this patient has not experienced any seizures since the first occurrence, according to the AMA Guides he is not experiencing the “episodic neurological impairments” required for disability. Complex cases such as the one presented here highlight the need to use the criteria and estimates that are located in several sections of the AMA Guides.

Clinical observation of the extraocular muscle function changes in blow-out fracture of medial orbital wall

目的 探讨眶内壁爆裂性骨折患者眼外肌损伤性质等临床特征与骨折形态学特点的相关性.方法 根据眶内壁爆裂性骨折的部位和形态学特点,对82例单纯眶内壁骨折进行CT亚型分类:Ⅰ型:整个筛骨纸板粉碎性骨折,筛窦为眶内软组织所填充,内直肌向内明显弯曲、移位;Ⅱ型:筛骨纸板局部骨折,筛窦基本完整,骨折片与眶壁之间形成夹角,内直肌周围软组织嵌顿于骨折区.观察两亚型间患者的眼外肌功能变化特点和相关临床特征.结果 Ⅰ型眶内壁骨折的骨折位置偏后、面积较大,眼肌功能损伤性质以内直肌麻痹为主(14/20);Ⅱ型眶内壁骨折的位置偏前,面积较小,眼肌功能损伤以内直肌运动受限为多见(27/38).Ⅰ型眶内壁骨折患者眼球内陷发生率及内陷程度均明显高于Ⅱ型眶内壁骨折(Z=-6.075,P＜0.05;t=3.365,P＜0.05).而复视发生率明显低于Ⅱ型眶内壁骨折(Z=-2.187,P＜0.05).结论 眶内壁骨折患者眼外肌功能损伤改变等临床特征与骨折的形态学特点有关;眶内壁骨折CT影像学亚型分类具有临床实用价值。

Insufficiency Fracture of the Acetabular Medial Wall

Acetabular insufficiency fractures are much less common than acetabular fractures associated with trauma. They most commonly occur in postmenopausal women with a history of rheumatoid arthritis or pelvic irradiation. We present the case of a 93-year-old man with an atraumatic pelvic insufficiency fracture of the fossa acetabuli. The patient had 2 predisposing risk factors: osteoporosis and lower-extremity reconstructive surgery.

Endoscope-Assisted Repair of Medial Orbital Wall Fractures Using a Retrocaruncular Approach

s t p i c t w b a outine computed tomography (CT) scan of facial rauma now shows more medial orbital wall fractures han noted previously. Also, the incidence of this racture has increased in recent years owing to a rise n the incidence of high-energy impact orbital trauma nd in sport activities. The indications and timing for his fracture repair remain controversial. In our center, reatment is performed in cases of fractures that exceed cm in size or small fracture sizes ( 1 cm) with linical problems. Operative treatment becomes unecessary unless a displaced medial wall fracture shows linical diplopia, enophthalmos, any signs of herniation f orbital contents into the ethmoid sinus, or true ncarceration of medial rectus muscle, resulting in the imitation of ocular motility; or massive orital emphysema with secondary ophthalmic probems, such as a rapidly progressive proptosis and isual loss. Numerous surgical approaches have been used in xploratory surgery of medial orbital wall fractures; it emains a challenging area for surgeons due to techical difficulties and postoperative scars. Compared ith the cutaneous approaches, the transconjunctival nd retrocaruncular approaches not only provide an ppropriate exposure but avoid postoperative scars nd webbing. Evolving these surgical techniques ith lesser side effects, and an increasing demand of atients toward cosmetic rehabilitation, have led to the se of endoscope for disfiguring injuries. It is clear that he role of endoscope in this fracture repair recently has een shown with the advent of improved technology of

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.

Urazy oczodołu

Single or multifragmental orbital fractures may be a difficult diagnostic and therapeutic dilemma. Dislocation of the orbital contain into maxillary and ethmoid sinus may take place during trauma. The main topics: is when and what surgical technique should be applied in these cases.Material consists of retrospective analysis of 23 cases with fracture of medial and interior wall of orbit hospitalized in ENT Department of Medical University in Gdansk from 1999 to 2005. External ethmoidectomy was performed in cases with medial wall fracture and loose bone fragments are removed with reposition of orbit tissue. Transantral approach was applied in cases with inferior wall fractures. Loose bone fragments were replaced with autogenic bone or fascia graft, or synthetic material--bone cement.Complete or partial recovery was achieved in 91% of cases. Only in 2 cases (9%) recovery was not obtained after surgery--in these cases treatment started later then 60 days after fracture.In our opinion the optimal results of surgery may be achieved when treatment is begining before 14 day after fracture. If the later treatment is applied the worse results are achieved. Most of the cases must had been completed by rehabilitation after surgery.

The White-Eyed Medial Blowout Fracture

The pediatric white-eyed blowout fracture with entrapment of the inferior rectus muscle is well recognized as an easily missed injury with significant morbidity if left untreated. A series of five isolated medial orbital blowout fractures with medial rectus muscle entrapment is described. The purpose of this study was to define this injury pattern and its clinical outcome. A retrospective review of the presentation, management, and clinical outcomes of identified cases was conducted. Early exploration and release of the entrapped muscle combined with implant reconstruction of the medial orbital wall within 2 weeks resulted in complete resolution of diplopia and full recovery of extraocular movements. Delayed treatment and release of the soft tissues without orbital wall reconstruction were associated with restricted gaze and diplopia. Similar outcomes were confirmed on analysis of other reported cases. Orbital floor blowout fractures in the pediatric population have a high incidence of muscle entrapment that must be recognized and treated early to avoid muscle necrosis and permanent ocular restriction from fibrosis. Medial orbital wall fractures with entrapment are rare, but early recognition and operative release of the entrapped muscles result in better outcomes.

Endoscopic intranasal reduction of the orbit in isolated blowout fractures

Conclusion. Endoscopic intranasal reduction of the orbital floor with a detachable temporary balloon, or of the medial orbital wall with a silastic sheet and Merocel® packing, provided good functional results and definite advantages. We suggest that these techniques are another surgical alternative for isolated orbital floor or medial wall blowout fractures that do not accompany any associated fractures of the orbital rim. Objectives. Extended applications of endoscopic sinus surgery have reported endoscopic intranasal reduction or reconstruction of the orbital wall with good functional and cosmetic results. We present our experience with endoscopic intranasal reduction of the orbit in isolated orbital floor and/or medial wall blowout fractures, treated by reduction of the orbital floor with a detachable temporary balloon, or of the medial orbital wall with a silastic sheet and Merocel packing. Subjects and Methods. Floor reduction: After creating a wide middle meatal antrostomy, herniated orbital contents and fracture-displaced floor are mobilized and reduced. The orbital floor is supported by a saline filled balloon, which is connected with an infant feeding catheter and passed through the middle meatal antrostoma. After confirming the reduction of the orbital floor by postoperative CT, the catheter is ligated and cut in short to keep it in the nasal cavity. Medial wall reduction: After completing an intranasal ethmoidectomy, herniated orbital contents and fractured lamina papyracea are mobilized and reduced. The shape of the medial orbital wall is fixed by a silastic sheet and Merocel® packing saturated with an antibiotic solution. Surgery was performed when the eye function could be accurately assessed, usually at 7 to 10 days following the injury. Temporary supporting of the orbital wall with a detachable temporary balloon, or a silastic sheet and Merocel® packing was removed 4 weeks after surgery in the out-patient clinic. Results. We have experienced 40 cases of endoscopic intranasal reduction of the orbit in blowout fractures. CT scan confirmed isolated orbital floor fracture in 11 patients, isolated medial wall fracture in 17 patients, and combined fractures of the orbital floor and the medial wall in 12 patients. Twenty five patients had diplopia, 20 patients had limitation of eye movement, and 14 patients developed enophthalmos. Thirty three of the 40 patients recovered completely without any residual eye symptoms or complications.

Correlation Between Ocular Motility and Evaluation of Computed Tomography in Orbital Blowout Fracture

To investigate outcomes of management of blowout fracture patients evaluating computed tomography (CT) findings and diplopia. Single-center retrospective interventional consecutive case series. This study included 113 cases of pure blowout orbital fracture with diplopia. We investigated patients' satisfaction based on percentage of Hess area ratio (HAR%) on the Hess chart, evaluating fracture type and number of points of contact of extraocular muscles to the fracture edge (points of muscle contact) based on CT. Of the patients with HAR% > 85%, most experienced no diplopia. Sixty-two (55%) of 113 patients underwent surgical repair to improve diplopia, and 31 (50%) of 62 patients had surgery within three days after injury. A favorable outcome with HAR% > 85% was seen in 81 (72%) of 113 patients. Of 32 patients with two points of muscle contact at one extraocular muscle, 15 patients (47%) improved with a final HAR% > 85%. None of the four patients with medial wall fracture and two points of muscle contact had improved in their final HAR% > 85%. Thirty (97%) of 31 patients with either floor or medial wall fracture and no muscle involvement had a favorable outcome regardless of fracture type. Initial CT findings of the rectus muscle was strongly correlated with a mean initial HAR% (r = -0.94) and a mean final HAR% (r = -0.87). The clinical manifestations and prognosis of patients were approximately predicted through the analysis of CT on fracture type and number of points of contact of an extraocular muscle to the fracture edge.

THE CLASSIC: Intrapelvic Protrusion of the Acetabular Component Following Total Hip Replacement

THE CLASSIC: Intrapelvic Protrusion of the Acetabular Component Following Total Hip Replacement

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.

Reconstruction of Internal Orbital Wall Fracture with Iliac Crest Free Bone Graft: Clinical, Computed Tomography, and Magnetic Resonance Imaging Follow-Up Study

The purpose of this study was to clinically and radiologically assess the outcome of internal orbital reconstruction with an iliac bone graft. Twenty-four consecutive patients with unilateral orbital wall fractures were enrolled in this prospective study. A medial cortical wall from the anterior ilium was used for reconstruction. At each follow-up visit, globe posture, diplopia, and eye movements were assessed. Coronal and sagittal computed tomography and magnetic resonance imaging were used to observe graft posture, bone defects, and intraorbital soft-tissue changes. Most fractures (46 percent) were pure orbital floor fractures. The mean follow-up was 7.8 months. One patient with medial wall and floor fractures required reoperation because of insufficient bone graft. At the last follow-up, this was the only patient (4 percent) with both enophthalmos (2 mm) and hypophthalmos (3 mm). Five patients (21 percent) had hypophthalmos (> 1 mm) at the end of the study. Resorption and remodeling were detected in all grafts, but no grafts were totally resorbed. Sagittal or coronal bone graft postures were assessed as good in 18 orbits (75 percent). Bone defects (> 10 mm) at reconstructed areas were detected in 13 orbits (54 percent). Scar tissue was observed only in three reconstructed orbits (13 percent). Diplopia in central field of vision was registered in seven patients preoperatively but in none at the end of the study. The resorption rate was high, but most of it was advantageous remodeling. Overall outcome was good. Secondary operations led to poor outcomes. Thin computed tomography and magnetic resonance imaging sections (< or = 2 mm) are needed to evaluate accurately bone graft placement and posture and orbital volume.

Individually preformed titanium mesh implants for a true-to-original repair of orbital fractures

The purpose of this investigation is to present the results using preoperatively-formed titanium mesh implants for a true-to-original primary repair of extensive orbital floor and medial wall fractures. Individually preformed implants were used to repair extensive orbital floor injuries in 19 patients at the University Hospital, Freiburg. The form of the orbital floor and walls was analysed by preoperative diagnostic CT scan data. The form of the virtual reconstructed orbit was transformed into a model of the orbital cavity by a template machine. Postoperative imaging by or CT scan verified the exact 3D reconstruction of the orbital cavity ‘true to original’. None of the patients demonstrated diplopia or enophthalmos postoperatively. Using individually preformed titanium mesh implants, the accuracy of the 3D orbital reconstruction was within a range of 1 mm. The reconstruction using preformed implants proved to be less time consuming, more precise and less invasive, compared to ‘free hand’ efforts, for the repair of orbital injuries using titanium mesh and calvarial grafts.

O.371 The endoscopically assisted retro-caruncular approach for medial orbital wall fracture

O.371 The endoscopically assisted retro-caruncular approach for medial orbital wall fracture