Muscle Incarceration Research Articles

Pediatric Orbital Fractures: Outcomes in Relation to Time of Surgery.

Orbital trapdoor fractures in children and adolescents can cause persistent problems with vision and appearance. Early surgery is recommended, although, because of the rarity of these fractures, there is a lack of evidence regarding the optimal timing of surgery.The objective of this study was to examine the effect of the time from trauma to surgery on the recovery time and severity of diplopia in children and adolescents with orbital trapdoor fractures. A retrospective cohort study was performed of all orbital fractures in children and adolescents aged 0 to 20 years, treated at a tertiary referral center in 2005-2017. Data relating to demographics, cause of injury, surgery, time of follow-up, and final outcomes were extracted. The cases of trapdoor fracture were specifically examined with regard to the time from trauma to surgery and diplopia at last follow-up, which was the primary outcome. One hundred thirty-five patients, aged 2.4 to 20 years (mean 17.0), were treated for orbital fractures during the period; 37 (27%) had an isolated orbital floor fracture and 12 (9%) had a trapdoor fracture. All patients with trapdoor fractures underwent surgery; the mean time to surgery was 11.9 days in 2007-2011 and 1.1 days in 2012-2017. Although statistical significance cannot be proven in this small and retrospective study, a shorter time from trauma to surgery seems to lead to fewer problems with diplopia and 2 patient cases that highlight this are presented. Delayed surgical intervention in pediatric orbital trapdoor fractures increases the risk of delayed recovery and persistent diplopia. Other factors, such as the degree of muscle incarceration and necrosis and the surgeon's experience and skill, may, however, also influence the outcomes.

Factors influencing surgical outcomes in orbital trapdoor fracture

This study is aimed to determine the appropriate timing of performing surgical reduction on trapdoor fractures for bringing out better visual outcomes and the factors influencing surgical outcomes in this special subgroup of fracture victims. Data for 72 patients of orbital trapdoor fracture were analyzed retrospectively. Post-operative diplopia is the main posttreatment outcome of orbital bone fracture reduction. The receiver-operating characteristic (ROC) analysis indicated the cut-off point of surgical reduction timing at day 10 post-fracture. The rate of postoperative diplopia showed a significant difference between patients who underwent surgical reduction within 10 days and those who did after 10 days of injury (5.3% vs. 38.2%). Multivariate analysis revealed that preoperative infra-duction limitation (p = 0.02), muscle incarceration (p = 0.01), duration from injury to surgical reduction (p = 0.004), and postoperative supra-duction limitation (p = 0.004) were independent factors for poor surgical outcomes. In younger patients with head injury, the diagnosis of orbital trapdoor fracture should be kept in mind. Timely recognition and surgical reduction, especially within 10 days, can result in better visual outcomes without the occurrence of postoperative diplopia.

Prediction of late enophthalmos using quantitative measures in isolated medial orbital wall fracture: Multiple regression analysis

Enophthalmos is one of the most distressing complications of orbital fracture, and when faced with a blowout fracture, plastic surgeons often find it difficult to determine the need for surgical correction. Although a number of studies have been conducted on this topic, no study has yet been performed using a set of measurable parameters. We quantitatively measured orbital fracture areas (OFA), volumes (OFV), and medial rectus muscle cross-sectional ratios in patients with an isolated medial orbital wall fracture defect during a 5-year period from 2014 to 2018. Only conservatively treated patients constituted the study cohort. Enophthalmos was measured by two plastic surgeons at ≥6 months after trauma. We analyzed correlations between various parameters and degrees of late enophthalmos in the study cohort. Significant correlations were observed between several parameters and late enophthalmos. Multiple regression analysis resulted in the following coefficients: -0.449 is constant (p = 0.017), 0.596 and 0.460 for OFA (p = 0.000) and OFV (p = 0.005), respectively. However, no significant relationship was observed between enophthalmos and medial rectus muscle cross-sectional ratios (p=0.340). The results of this study enable the degree of late enophthalmos in conservatively treated patients to be predicted using OFV and OFA values. We suggest five indications that require surgical correction without long-term clinical follow-ups: (1) OFA≥1.90cm2, (2) OFV≥1.00cm3, (3) 1.30 OFA+OFV>5.32, (4) signs of muscle incarceration, and (5) signs of severe retrobulbar hematoma. The more satisfactory the five indications are, the greater is the need for surgery.

Dehiscence of the lamina papyracea

We report the case of a 35 year old patient presenting with acute onset of right periocular pain with palpebral edema due to nose blowing with absence of trauma. Early assessment showed periorbital emphysema without ophthalmological involvement, normal pupillary light reflex and visual acuity. Computerized tomography (CT) scan of facial and orbital bones objectified right pneumo-orbita with orbital fat herniation via a partial agenesis of the lamina papyracea, without muscle incarceration. Emphysema gradually reduced after two weeks by applying pressure dressing associated with broad spectrum antibiotic therapy as well as following the rules for cleanliness (avoiding closed glottis efforts, nose blowing…). Pneumo-orbita is defined by the presence of orbital air. It is mainly caused by a trauma but few cases of spontaneous dehiscence have been reported. The opening of the lamina papyracea, acting as an antireflux valve, prevents air outlet. CT scan is essential to confirm the diagnosis. It most often has a spontaneous resolution but the presence of hyperpression, that can be responsible for ischemic optic neuropathy or occlusion of the central artery of the retina, require a rigorous monitoring in order to implement possible urgent decompressive intervention.

Pure Orbital Trapdoor Fractures in Adults: Tight Entrapment of Perimuscular Tissue Mimicking True Muscle Incarceration with Successful Results from Early Intervention

Orbital trapdoor fractures (OTFs) entail entrapment of intraorbital soft tissues with minimal or no displacement of the affected bones and are almost exclusively seen in children. This article aimed to report the diagnosis and treatment of an OTF of the floor in an adult patient and to critically review the literature regarding the management aspects of this specific subset of orbital blowout fractures in adults. A 29-year-old man presented with limitations of vertical right eye movements owing to blunt orbital trauma. The patient mainly complained of double vision in upper gazes and some episodes of nausea. Neither floor defect nor significant bone displacement found on orbital computed tomography, while edema of inferior rectus muscle was apparent. The patient underwent surgical repair 5 days later; a linear minimally displaced fracture of the floor was recognized and complete release of the entrapped perimuscular tissues was followed. Within the first week postoperatively, full range of ocular motility was restored, without residual diplopia. This case was the only identified pure OTF over a 6-year period in our department (0.6% of 159 orbital fractures in patients >18 years). By reviewing the literature indexed in PubMed, a very limited number of either of isolated case reports or retrospective case series of pure OTFs has been reported in adults. Contrary to the typical white-eyed blowout fractures, the literature indicates that OTFs in adults seem to not always constitute absolute emergency conditions. Although such fractures need to be emergently/ immediately treated in children, in the absence of true muscle incarceration, adults may undergo successful treatment within a wider but either early or urgent frame of time. Adults frequently exhibit vagal manifestations and marked signs of local soft tissues injury.

Pediatric orbital wall fractures: Prognostic factors of diplopia and ocular motility limitation.

ObjectivesTo investigate the factors affecting recovery of diplopia and limited ocular motility in pediatric patients who underwent surgery for orbital wall fracture.DesignRetrospective observational case series.MethodsIn this retrospective observational case series, 150 pediatric patients (1–18 years old) who were diagnosed with orbital medial wall or floor fracture and underwent corrective surgery between 2004 and 2016 at Seoul National University Bundang Hospital were included. The medical records of patients with orbital medial wall or floor fracture were reviewed, including sex, age, diplopia, ocular motility, preoperative computed tomographic finding, and surgical outcomes. Factors affecting recovery of diplopia and ocular motility limitation were analyzed.ResultsOf the 150 patients (134 boys; mean age, 14.4 years) who underwent corrective surgery for orbital wall fracture, preoperative binocular diplopia was found in 76 (50.7%) patients and limited ocular motility in 81 (54.0%). Presence of muscle incarceration or severe supraduction limitation delayed the recovery of diplopia. In case of ocular motility limitation, presence of muscle incarceration and retrobulbar hemorrhage were related with the delayed resolution. Multivariate analysis revealed supraduction limitation (Hazard ratio [HR] = 1.74, 95% confidence interval [CI] = 1.19–2.55), larger horizontal orbital floor defects (HR = 1.22, 95% CI = 1.07–1.38), and shorter time interval to first visit (HR = 0.73) as negative prognostic factors for the recovery of diplopia. In addition, muscle incarceration (HR = 3.53, 95% CI = 1.54–8.07) and retrobulbar hemorrhage (HR = 3.77, 95% CI = 1.45–9.82) were found as negative prognostic factors for the recovery of motility limitation.ConclusionsPresence of muscle incarceration and retrobulbar hemorrhage, horizontal length of floor fracture, supraduction limitation, and time interval from trauma to first visit were correlated with the surgical outcomes in pediatric orbital wall fracture patients. These results strengthen that the soft tissue damage associated with bony fracture affects the orbital functional unit. When managing children with orbital wall fracture, meticulous physical examination and thorough preoperative computed tomography based evaluation will help physicians to identify damage of orbital functional unit.

Orbital trapdoor fractures: different clinical profiles between adult and paediatric patients

BackgroundTo compare clinical findings of orbital trapdoor fractures between adult and paediatric patients.MethodsPaediatric patients were categorised into two groups by age: children (0–9 years) and adolescents (10–19 years). Adult patients...

Prognostic Factors of Orbital Fractures with Muscle Incarceration.

BackgroundAmong the various signs and symptoms of orbital fractures, certain clinical findings warrant immediate surgical exploration, including gaze restriction, computed tomographic (CT) evidence of entrapment, and prolonged oculocardiac reflex. Despite proper surgical reconstruction, prolonged complications such as diplopia and gaze restriction can occur. This article evaluated the prognostic factors associated with prolonged complications of orbital fractures with muscle incarceration.MethodsThe medical records of 37 patients (37 orbits) with an orbital fracture with muscle incarceration from January 2001 to January 2015 were reviewed. The presence of Incarcerated muscle was confirmed via CT, as well as by intraoperative findings. Various factors potentially contributing to complications lasting for over 1 year after the injury were categorized and analyzed, including age, cause of injury, injury-to-operation time, operative time, fracture type, nausea, vomiting and other concomitant symptoms and injuries.ResultsAll patients who presented with extraocular muscle limitations, positive CT findings, and/or a positive forced duction test underwent surgery. Of the 37 patients, 9 (24%) exhibited lasting complications, such as diplopia and gaze restriction. The mean follow-up period was 18.4 months (range, 1–108 months), while that of patients who experienced prolonged complications was 30.1 months (range, 13–36 months). Two factors were significantly associated with prolonged complications: injury-to-operation time and nausea/vomiting. Loss of vision, worsening of motility, and implant complication did not occur.ConclusionsPatients who present with gaze limitations, with or without other signs of a blow-out fracture, require a thorough evaluation and emergent surgery. A better prognosis is expected with a shorter injury-to-operation time and lack of nausea and vomiting at the initial presentation.

The study of operation timing for simple orbital wall fracture

Objective To investigate the operation timing and surgery technique for simple orbital wall fracture. Methods The data of 352 eyes of 352 patients with simple orbital wall fracture were retrospectively analyzed. They had been treated at Shanxi Provincial Eye Hospital from Jan. 2010 to Dec. 2012. Those patients included 298 men (84.7%) and 54 women (15.3%). The age ranged from 17 to 62 years. The follow-up time was from 2 to 4 weeks. The patients were divided into four groups according to the surgery time between injury and surgery. Patients in group A (68 cases) received surgery 7 to 9 days after the injury. Patients in group B (187 cases) received surgery 10 to 19 days after the injury. Patients in group C (82 cases) received surgery 20 to 45 days after the injury. Patients in group D (15 cases) received surgery 46 to 90 days after the injury. The surgery indications including the following symptoms and clinical signs: endophthalmos of the injuried eye was ≥2 mm; diplopia in front view or peripheral view, the orbital image identified obvious extraocular muscle displacement, distortion or incarceration; and the fracture window was>2 cm2 or the orbital wall displacement was>3 mm. The conditions of endophthalmos and diplopia were analyzed before and after the surgery. Results After the surgery the endophthalmos in the four groups were corrected. The best surgery time for orbital fracture with diplopia was 7-9 days after the injury. The best surgery time for orbital fracture with simple endophthalmos was 7-9 days or 46-90 days after the injury. Conclusion The operation timing of simple orbital wall fracture is very important. To make individualized treatment according to the duration of the injury and the imaging diagnosis, is necessary for getting the best surgical effect. Key words: Fracture, orbital wall; Surgery timing

Endoscopic Management of Orbital Fractures

The main indications for surgical correction of orbital fracture are diplopia, enophthalmos, signs of herniation of orbital contents into the ethmoid and maxillary sinuses, orbital muscle incarceration leading to reduced ocular motility, decreased visual acuity, persistent infraorbital hypoesthesia, and hypo-ophthalmia. The location of the fracture is important in determining the treatment approach. Endoscopic repair of orbital fractures has received increased attention since the development of better endoscopic materials and high-tech fiberoptics. This article reviews the endoscopic treatment of orbital fractures.

Combination of Guided Osteogenesis With Autologous Platelet-Rich Fibrin Glue and Mesenchymal Stem Cell for Mandibular Reconstruction

This study examined whether a combination of autologous platelet-rich fibrin glue (PRFG) with mesenchymal stem cells (MSCs) and MEDPOR as guided tissue regeneration (GTR) could act as an osteogenic substitute and whether this treatment yields faster new bone formation than MEDPOR alone or PRFG plus MSC. MSCs were harvested and isolated from the bone marrow of dog ilium. Full-thickness bony defects (1.5×1.5 cm) were created in the bilateral mandible angles of the dog. Treatments for bone defect in each group were as follows: group I (n=4), MEDPOR sheet as GTR and autologous PRFG/MSCs admixtures; group II (n=4), autologous PRFG/MSCs admixtures; group III (n=4), MEDPOR sheet as GTR; and group IV (n=4), control (empty defect). The percentage of new bone regeneration in computerized tomography at 2 months and 4 months was calculated by Analyze version 7.0 software. The mandibles were harvested from all specimens at 4 months, and the grafted sites were evaluated by gross, histologic, and X-ray examination. By radiographic analysis at 16 weeks posttransplantation, it was shown that an average of 72.8%±8.02% new bone formation in group I, 53.34%±6.87% in group II, 26.58%±6.41% in group III, and 15.14%±2.37% in group IV. Histologic examination revealed that the defect was repaired by typical bone tissue in groups I and II, whereas only minimal bone formation with fibrous connection was observed in the groups III and IV group. Besides, muscle incarceration was found in groups II and IV without MEDPOR as GTR. Autologous PRFG plus osteoinduced MSCs have good potential for bone regeneration. In combination with MEDPOR as GTR, bone regeneration is enhanced by preventing soft tissue ingrowth hindering bone regeneration.

High Resolution Magnetic Resonance Imaging With an Orbital Coil as an Alternative to Computed Tomography Scan as the Primary Imaging Modality of Pediatric Orbital Fractures

The computed tomography (CT) scan is currently the gold standard in the imaging of orbital fractures. The weak points of this imaging modality, however, include restricted soft tissue depiction as well as the radiation. Both attributes are of particular importance in children because of the high rate of trapdoor fractures and the radiation to the lens. Although magnetic resonance imaging (MRI) is not associated with these drawbacks, it has not been established in the primary diagnosis of pediatric orbital fractures. The aim of our study was to establish the use of MRI with a special orbital coil for the primary diagnosis of pediatric orbital trauma. In our retrospective study, 14 pediatric patients presented to our department with a blunt orbital trauma from 2003 to 2007. Twelve of 14 patients with orbital floor fractures required surgical reconstruction. Until 2004, imaging was carried out by plain x-rays and CT scan for a decision regarding the necessity of surgery. Since introducing the MRI microscopy orbital coil in 2004, CT scans have been replaced by MRI for the primary fracture diagnosis in 8 pediatric cases. Kappa statistics have been applied to assess inter- and intraobserver reliability for CT scans and MRI. This study shows our experiences using MRI in combination with conventional x-rays to determine the operative approach in 2 of the 8 pediatric cases suffering from blunt orbital trauma. The most common causes for pediatric orbital trauma in our collective were accidents. In 8 cases using MRI as the primary imaging modality, depiction of the fracture dislocation and differentiation of the adjacent fatty and muscle tissue was excellent and indication for surgery was distinct. MRI reached a high intra- and inter-rater agreement level (kappa=0.80). MRI combined with a microscopy orbital coil is a valuable alternative to the CT scan in the primary diagnosis of pediatric orbital fractures. Floor fractures, and particularly muscle incarceration, should be diagnosed by high resolution MRI combined with a microscopy coil instead of CT to avoid radiation to the lens and to obtain a better soft tissue depiction.

A Clinical Feature of the Patients of Orbital Wall Fracture With Diplopia

Purpose: To analyze the clinical features of orbital wall fracture with diplopia between the surgical treatment group and the conservative treatment group. Methods: The study comprised of 109 eyes of 109 patients with orbital wall fracture and diplopia. The patients were divided into two groups: the surgical treatment group (59 cases) and the conservative treatment group (50 cases). The groups were analyzed retrospectively according to age, gender, cause, CT, the period and severity of diplopia, and enophthalmos with time. Results: In the conservative treatment group, 38 cases (64.4%) had medial wall fracture, and the average fracture size was 26% of the inferior wall and 33% of the medial wall. In addition, at the first visit, the patients showed diplopia within 45.5 degrees, and diplopia disappeared completely within 17 days on average (57 cases, 96.6%). In the group that underwent the reconstruction of orbital wall fracture, 27 cases (54.0%) had inferior wall fracture, and the average fracture size was 41% of the inferior wall and 35% of the medial wall. Additionally, in the first visit, the patients showed diplopia within 20.3 degrees. The muscle incarceration occurred in 12 cases (24%). In the surgical treatment group, diplopia disappeared completely within 30 days on average (45 cases, 90.0%). Conclusion: In the group of conservative treatment, they showed diplopia within 45.5 degrees at the first visit. Diplopia disappeared completely within 17 days on average (57 cases, 96.6%). In the group of surgical treatment, they showed diplopia within 20.3 degrees at the first visit. Diplopia disappeared completely within 30 days on average (45 cases, 90.0%).

Prognosis of orbital floor trapdoor fractures with or without muscle incarceration

This study investigated postoperative prognosis of orbital floor trapdoor fractures with or without muscle incarceration by retrospectively reviewing medical records and computed tomography scans of appropriate patients. Orbital floor trapdoor fractures were present in nine orbits of nine patients with muscle incarceration and in ten orbits of ten patients without muscle incarceration. All patients were operated on within a couple of days after admission and were observed for more than 6 months postoperatively. Mean time interval between injury and surgery was 4.8 days (range, 1–14 days) in patients with muscle incarceration and 10.3 days (range, 3–31 days) in patients without muscle incarceration. Postoperative fields of binocular single vision fully improved in all patients excluding two patients with muscle incarceration and in all patients without muscle incarceration. Insufficient improvements of ocular movements were observed in two patients with muscle incarceration who had late surgical interventions. Orbital floor trapdoor fractures showed good prognosis in patients with muscle incarceration with emergent surgical intervention, or in patients without muscle incarceration.

Isolated Medial Orbital Wall Fractures With Medial Rectus Muscle Incarceration

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. Retrospective chart review and literature review. 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. 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.

Wirksame Entlastung einer großen Muskelhernie durch lokale Botulinumtoxin-Anwendung

A 53-year-old patient developed an impairing muscle hernia when a fascia lata graft was harvested as a substitute for a cruciate ligament of the knee and closure of the defect was not possible. The fascial defect enlarged with time, extending along the whole upper leg. The large muscle protrusion and incarceration in the distal fascial slit was extremely painful during walking and getting up from a chair. Since autologous grafts were disregarded because of the high tissue pressure and alloplastic substitutes seemed problematic, the large hernia was successfully reduced by local muscle denervation with injections of botulinum-A toxin into the protruding vastus lateralis muscle. This procedure achieved relief of pain and enabled the patient to walk without complaints. Side effects were not observed.

Medial orbital blow‐out fracture: A case report

A case report of orbital blow-out fracture with medial rectus muscle entrapment is described. Over one-third of the patients with blow-out fractures of the orbital floor also sustain medial wall injury. Five previous case reports of medial entrapment are reviewed. The mechanism of injury is hydraulic, and the medial muscle incarceration in the fracture may produce an orbital retraction syndrome. Exploratory surgery is recommended through an external orbito-ethmoid approach.