Pure Orbital Floor Fractures Research Articles

"Trap Door" Orbital Floor Fractures in Adults: Are They Different from Pediatric Fractures?

Background:“Trap door” orbital floor fractures are usually seen in children. In the linear fracture type, a break occurs in the bones of the orbital floor that permits orbital tissue to prolapse into the fracture site during fracture formation. The bony fragments of the fracture then return to their original position, entrapping the prolapsed orbital tissue. In the hinged fracture type, the fractured part of the floor is minimally displaced into the maxillary sinus and acts as the hinge of a “swinging door” entrapping the orbital tissue.Methods:We report on a series of 10 adult patients with hinged orbital floor fractures.Results:The mean patient age was 35 years. Seven patients had a pure orbital floor fracture and the remaining 3 patients had fractures of both the orbital floor and the inferior orbital rim. All 10 patients had diplopia in the upgaze. None of the patients had signs of the oculocardiac reflex. None of the CT scans showed a “tear-drop” sign. However, the sagittal CT scans showed evidence of entrapment of the inferior rectus. All patients had a small area of a slightly depressed orbital floor at the site of entrapment, without a bony defect. All patients underwent surgery through an infraorbital incision and a titanium mesh was used in all patients. There were no postoperative complications. All patients regained full range of motion of the globe.Conclusion:This is the first series in the literature that reports on the characteristics and outcome of trap door orbital floor fractures in adults.

OUTCOME FOLLOWING ORBITAL FLOOR FRACTURE RECONSTRUCTION USING SILASTIC IMPLANTS

Background: Orbital floor fracture is typically present with peri-orbital ecchymosis, subconjunctival hemorrhage, enophthalmos and diplopia. The goals of reconstruction are to restore the volume and shape of the orbital cavity with autogenous or alloplastic materials. However, no gold standard exists for orbital implants to treat orbital floor fractures and remains controversial. Silicone was one of the most common biocompatible materials used for orbital floor reconstruction.
 Objective: The study aimed to evaluate the outcomes of patients reconstructed using silastic sheets in the case of orbital wall fractures.
 Methods: A multi-center, retrospective study of patients with orbital floor fractures was conducted from January 2010 to December 2019. Inclusion criteria included patients with orbital floor fractures and reconstruction using silastic sheets. Patients with orbital floor fractures and treated with other materials were excluded. The database included age, sex, cause of injury, size of floor defects, associated injury, underlying complication and period of follow-up.
 Results: A total of 32 patients with orbital floor fractures divided in 20 patients from Phramongkutklao Hospital and 12 patients from Songkla Hospital were included. Twenty-five patients were male (78.13%). Mean age of patients was 35.62 years (range, 15 to 62 years). Causes of injury included traffic accident (78.13%) and body assault (18.75 %). Pure orbital floor fractures were found at 31.25%. Associated injuries included fractured zygoma 43.75%, nasal bone 21.87% and fractured maxilla 12.50%. Average size of defects was 2.01 cm2. Average time to follow-up was 2.69 years. Complications were found in three cases (extrusion of silicone sheet, loss of sensation and dystopia). Extrusion was found 2 months postoperation and removal of silicone sheet was performed. Complete recovery of sensation of the infra-orbital nerve was shown at 6 months postoperation.
 Conclusion: No gold standard exists for implants to treat orbital floor fractures. Orbital floor reconstruction using silastic sheets involves a low complication rate and satisfactory outcome. Herein, silastic sheets can be safely used for orbital wall augmentation and provides good long term outcomes.

Early Hypoglobus in Orbital Floor Reconstruction With Resorbable Implants.

Among the variety of materials developed for facial bone surgery, resorbable implants are widely used in orbital wall reconstruction. There are many advantages in selecting resorbable implants, such as minimal foreign body reaction and adjustability within the damaged orbital floor. Resorbable implants are supposed to remain in place over 1 to 2 years to hold the structure of immature healing tissue surrounding the bony defects. However, some patients who have undergone orbital wall reconstruction surgery with resorbable implants suffer from early hypoglobus. This retrospective study was performed from January 2014 to August 2019 and follows 39 patients with unilateral pure orbital floor fractures. All orbital floor reconstruction was performed using resorbable implants via the transconjunctival approach. Exophthalmometer measurements and CT scans showing the degree of implant sagging were used to provide an index of hypoglobus. Most patients showed hypoglobus over 3 to 4 months follow-up. The size of bony defect in the orbital floor showed positive correlation with follow-up exophthalmometer measurement and degree of implant sagging. Orbital floor reconstructed with resorbable implant tends to lose load-bearing strength gradually, especially in large bony defects. Therefore, surgeons should be cautious about using resorbable implants for the maintenance of reconstructed orbital floor, especially in large bony defects.

Fisher’s story: orbital floor fracture

Most face traumas affect young adults in the male population. Orbital fractures can have important consequences and are called blow-out, when there is a collapse of the floor or medial wall of the orbit, causing loss of ocular content. They are classified into two types: pure and impure. The diagnosis is made through a detailed physical examination associated with computed tomography. The forms of treatment, surgical or conservative, as well as the most opportune moment to approach surgically the blow-out orbital fractures, immediate or late, are controversial subjects in the literature. The objective of this work is to report an unusual case of pure blow-out orbital floor fracture with functional repercussions to the patient, treated surgically with success.

Evaluation of a Radiological Score in the Management of Pure Fractures of the Orbital Floor.

The authors had for aim to further assess the predictive power and the relevance of a previously published radiological decision taking score for pure fractures with recording of clinical data. The authors retrospectively included all patients managed in the authors' department for a pure orbital floor fracture, from June 2012 to November 2013. The authors collected clinical data including diplopia and enophtalmos, at initial status and after 3-months of follow-up. The radiological data was also recorded: rate of the fractured orbital floor, maximal height of periorbital tissue herniation, and a 4-grade muscular sub score. The treatment determinants were assessed by univariate analysis, with χ tests or Fisher exact tests for qualitative variables, and Student t tests for quantitative ones. A multivariate analysis was then performed with a stepwise logistic regression. The authors included 90 patients. The authors proposed a simple score (with a specificity of 79% and a sensitivity of 56%) for the indication to operate, using the rate, which was a significant predictor of treatment in the multivariate analysis. The authors' study is another step in the standardization of treatment decision for pure orbital floor fractures. The proposed score requires further clinical research to be validated but already helps to compare series of patients.

The use of reformatted Cone Beam CT images in assessing mid-face trauma, with a focus on the orbital floor fractures.

Background and aimThis study aims at evaluating the reliability on specific multi-planar cone beam computer tomography (CBCT) reconstruction in the orbital floor fractures.MethodsCBCT examination of the mid-face fractures area involving the floor of the orbit was performed in a number of 93 trauma patients by two independent radiologists. Both radiologists assessed the axial, coronal and sagittal sections and also the oblique coronal and sagittal extracted sections evaluating the location of the orbital fractures, its size and displacement, the involvement of the infra-orbital foramen, herniation of fat or muscle within the maxillary sinus, the overall type of the fracture and the implication of lateral or medial orbital wall. We also registered the section that provided better confidence of both examiners in visualizing the fracture of the orbit floor and the presence of herniated soft tissue, on different reformatted sectioning.ResultsThe presence of pure fracture of the orbital floor was detected in 11% of patients. The association of the orbital fractures with the zygomatic fractures was identified in the majority of the patients. In 86% of patients the displacement of the floor of the orbit was visualized, and in almost 30% of cases more than 50% of the orbital floor was involved in the fracture. Regarding the confidence between examiners, they were more confident using the oblique sagittal CBCT reformatted images for fracture detection and bone displacement evaluation, as for the soft tissue herniation the oblique coronal sections provided the highest level of confidence.ConclusionMid-face trauma involves the orbital floor in the majority of situations. CBCT allows to obtain oblique images extracted from the three dimensional (3D) data that provide high confidence level in assessing pure orbital floor fractures.

Pure orbital blowout fractures reconstructed with autogenous bone grafts: functional and aesthetic outcomes

The purpose of this study was to investigate the ophthalmic clinical findings following surgical reconstruction with autogenous bone grafts of pure blowout fractures. A retrospective review of 211 patients who underwent surgical repair of an orbital fracture between October 1996 and December 2013 was performed. Following data analysis, 60 patients who were followed up over a period of 1 year were included. A solitary floor fracture was present in 38 patients and a floor and a medial wall fracture in 22 patients. Comparing preoperative findings between these two groups, preoperative diplopia and enophthalmos were almost twice as frequent in the group with additional medial wall fractures: diplopia 8% and 14% and enophthalmos 18% and 55%, respectively. One year following surgery there was no diplopia present in either group. In the solitary floor fracture group, 3% still had enophthalmos. It can be concluded that at 1 year following the repair of pure orbital floor fractures using autogenous bone, good functional and aesthetic results can be obtained. In the group with both floor and medial wall fractures, no enophthalmos was found when both walls were reconstructed. When the medial wall was left unoperated, 29% of patients still suffered from enophthalmos after 1 year.

A Protocol to Reduce Interobserver Variability in the Computed Tomography Measurement of Orbital Floor Fractures.

Orbital fracture detection and size determination from computed tomography (CT) scans affect the decision to operate, the type of surgical implant used, and postoperative outcomes. However, the lack of standardization of radiological signs often leads to the false-positive detection of orbital fractures, while nonstandardized landmarks lead to inaccurate defect measurements. We aim to design a novel protocol for CT measurement of orbital floor fractures and evaluate the interobserver variability on CT scan images. Qualitative aspects of this protocol include identifying direct and indirect signs of orbital fractures on CT scan images. Quantitative aspects of this protocol include measuring the surface area of pure orbital floor fractures using computer software. In this study, 15 independent observers without clinical experience in orbital fracture detection and measurement measured the orbital floor fractures of three randomly selected patients following the protocol. The time required for each measurement was recorded. The intraclass correlation coefficient of the surface area measurements is 0.999 (0.997-1.000) with p-value < 0.001. This suggests that any observer measuring the surface area will obtain a similar estimation of the fractured surface area. The maximum error limit was 0.901 cm(2) which is less than the margin of error of 1 cm(2) in mesh trimming for orbital reconstruction. The average duration required for each measurement was 3 minutes 19 seconds (ranging from 1 minute 35 seconds to 5 minutes). Measurements performed with our novel protocol resulted in minimal interobserver variability. This protocol is effective and generated reproducible results, is easy to teach and utilize, and its findings can be interpreted easily.

Influence of time on the management of complications of orbital floor fracture

Purpose The aim of this work is to evaluate the influence of time elapsed between the occurrence of orbital floor fracture and management on improvement of complications. Patients and methods This is a prospective comparative interventional study that including 17 patients with pure orbital floor fracture (without involvement of the orbital rim) who presented to Mansoura Ophthalmic Center from January 2012 to September 2012; they presented with diplopia with or without enophthalmos. For all cases, computed tomography-coronal cuts were performed. For all cases, repair of the orbital floor fracture was performed using a titanium mesh. For cases that had persistent diplopia after repair because of restrictive myopathy, adjustable inferior rectus recession was performed. Those who did not achieve correction after recession were corrected by prisms. Cases were followed for 6 months after surgery. Results This study included 17 cases with pure orbital floor fracture. They were divided into two groups according to the time of presentation after trauma: group A included seven (41.2%) patients who were operated within 3 weeks of trauma and group B included 10 (58.8%) patients who were operated after 3 weeks up to 6 months of trauma. In group A, all cases presented with diplopia in up gaze; however, one (14.3%) case presented with enophthalmos more than 2 mm. In group B, all cases presented with diplopia in up gaze and three (30%) of them presented with enophthalmos more than 2 mm. In group A, diplopia and enophthalmos were completely resolved after surgical repair of orbital floor fracture; however, in group B, diplopia improved only in two (20%) cases, but cases of enophthalmos were completely resolved. Among the remaining eight (80%) patients with persistent diplopia who underwent adjustable inferior rectus recession, seven (70%) patients improved and only one (10%) patient had persistent diplopia that was corrected with prisms. Conclusion Early repair of orbital floor fracture (within 3 weeks) leads to complete improvement in diplopia; however, late repair in most of the cases needs inferior rectus recession and sometimes prism correction. However, enophthalmos is not affected by the time of repair.

Transantral Orbital Floor Fracture Repair Using a Folded Silastic Tube.

ObjectivesThe purpose of this study was to evaluate the advantages and limitations of using a silicon tube to support the fractured orbital floor by a transantral approach.MethodsA retrospective study was conducted from January 2000 to December. 2011 in 51 patients with pure orbital floor fractures. The patients underwent reduction surgery via a transantral approach for inserting a folded silastic tube to support the fractured orbital floor in the maxillary sinus. A chart review of preoperative and postoperative ocular symptoms, operation records, and complications was maintained.ResultsIn 18 out of 25 patients with diplopia, postoperative improvement was seen. In 13 out of 15 patients with extraocular muscle limitation, postoperative improvement was seen. Enophthalmos resolved postoperatively in four of five patients. Postsurgical complications occurred in three patients: an overcorrection, an infection in the maxillary sinus, and an implant extrusion, all of which were resolved by revision surgeries.ConclusionDuring the course of the study, we sensed reduction using a folded silastic tube via a transantral approach as an easy and effective technique with good postoperative results, and minimal implant related complications. This novel procedure is recommended as a surgical option for the reduction of orbital floor fractures.

Management of Pure Orbital Floor Fractures: A Proposed Protocol to Prevent Unnecessary or Early Surgery

Purpose: To present a case series review of management of pure orbital floor fractures and propose a protocol.Methods: A retrospective review of medical records and computed tomography (CT) scan findings was completed. Fractures were classified into either trap-door, floor-fracture with incarcerated tissue, or depressed floor-fragment fractures. Criteria for surgical success were: enophthalmos <1mm; no hypoglobus/hyperglobus; extra-ocular muscle restriction <5° in upgaze but normal in all other positions on Hess chart; and no diplopia other than in extreme upgaze (5°).Results: A total of 79 patients with orbital floor fractures were identified. There were 6 trap-door type fractures, 42 floor fractures with incarcerated tissue, and 31 depressed floor-fragment type fractures. Thirty-six patients were managed conservatively (antibiotics and observation). In nine of these, surgery was avoided by adhering to our protocol of delayed repair. Forty-three had surgical intervention: 6 were trap-door-type, 18 had a floor fracture with incarcerated tissue and 19 were of the depressed floor-fragment variety. All trap-door fractures underwent early repair (6/43, 14%), the rest had delayed repair (37/43, 84%). Four of 6 trap-door fractures had a successful outcome (66.6%). All 18 fractures with incarcerated tissue underwent successful delayed repair. Seventeen of 19 patients with depressed floor-fragment fractures were treated successfully surgically. The follow-up ranged from 12–64 months. The overall success rate was 85.3%.Conclusion: Non-trap-door type of floor fractures can have a successful outcome with delayed repair. This can avoid unnecessary surgery in selected cases. A management protocol is proposed.

Reconstruction of Small Orbital Floor Fractures With Resorbable Collagen Membranes

Orbital floor fractures are the most common facial fractures. The goals of orbital floor fracture repair are to free incarcerated or prolapsed orbital tissue from the fracture defect and to span the defect with an implant to restore the correct anatomy of the orbital floor and the pretrauma orbital volume. No consensus exists on the choice of implants to be used for orbital floor reconstruction, and several implant materials are available.Our study intended to evaluate, for the first time, the effectiveness and complications related to the use of a resorbable collagen membrane in the reconstruction of small pure blow-out fractures. From October 2008 to November 2010, 23 patients who underwent reconstruction of the orbital floor using a resorbable collagen membrane following fracture were included in this study. At the 6-month follow-up, only 2 patients (9%) reported postoperative complications secondary to the operative procedure (surgical approach, orbital floor dissection), but these were not directly related to the use of the membrane. In 12 cases, a computed tomography scan revealed new bone formation beneath the membrane.On the basis of this data, we believe that the use of a resorbable collagen membrane is a safe and effective alternative for reconstruction of small (<3 cm(2)) pure orbital floor fractures.

Reconstruction of Post-traumatic Internal Orbital Wall Defects with Titanium Mesh

The management of orbital injuries is one of the most interesting and difficult areas in facial trauma. The improper reconstruction of the orbit frequently results in ophthalmic complications. Though a number of materials are available for use in orbital wall reconstruction, at present titanium mesh could be considered to be the ideal orbital floor repair material. The study involved patients with symptomatic zygomatico-orbital fractures requiring orbital wall reconstruction. Under general anaesthesia the floor of orbit was explored and reconstructed with contoured titanium mesh after repositioning of the entrapped orbital contents. The patients were on periodic follow-up for 6weeks where clinical and radiographic data were recorded. Ten male patients age ranging from 22 to 53years (mean 29.88years) received titanium implants for impure orbital fractures (eight patients) and pure orbital floor fractures (two patients). The main cause of fractures was road traffic accidents. They also complained of enophthalmos (n=7), diplopia (n=4), infraorbital nerve paresthesia (n=6), dystopia (n=1) and epiphora (n=2). No implant extrusion or infection was seen. The symptoms were corrected in six patients with enophthalmos, three with diplopia, four with infraorbital nerve paresthesia and all patients with epiphora. Dystopia persisted post-surgically in one patient. Titanium orbital implants were used to confirm titanium as a useful repair material for orbital floor fractures. Their use leads to less morbidity as no donor site operation is needed. Also it provides favourable healing as it is biocompatible.

Orbital Floor Fracture Reconstruction Using Conchal Auricular Cartilage Graft

Orbital Floor Fracture Reconstruction Using Conchal Auricular Cartilage Graft

Orbital Floor Fracture Reconstruction using Conchal Auricular Cartilage Graft

Orbital Floor Fracture Reconstruction using Conchal Auricular Cartilage Graft

Surgical Management of Orbital Trapdoor Fracture in a Pediatric Population

Orbital trapdoor fractures are pure orbital floor fractures with herniation and entrapment of the orbital contents, leading to restricted eye movement and diplopia. Trapdoor fractures in children have been discussed widely in published reports; however, the treatment policy and outcome remain controversial, although early treatment has been advocated. Our retrospective study analyzed the long-term results of pediatric patients undergoing surgery for trapdoor fractures to determine the outcome in relation to the type of fracture and the timing and technique of intervention. The present study included 24 patients (age range 6 to 16 years) who underwent surgery for trapdoor fractures from 1998 to 2007. The demographic, etiologic, radiologic, and surgical findings, interval between trauma and surgery, surgical techniques, and complications were recorded. Diplopia, ocular motility, dysesthesia, and scar quality were recorded at follow-up. The follow-up duration averaged 36 months. At follow-up, 1 (8.3%) of 12 patients who underwent surgery within 24 hours (urgent treatment) had residual diplopia. In contrast, 3 (37.5%) of 8 patients who underwent surgery 24 to 96 hours (early treatment) and 4 (100%) of 4 who underwent surgery after 96 hours (late treatment) had diplopia. No sensory deficit of the skin or unesthetic eyelid scar was noted. We found a correlation between the outcome and the timing of surgery for trapdoor fractures in the pediatric population. The success rate was significantly better when the fractures were treated within 24 hours of the injury. The results of the present study have strengthened the assertion that trapdoor orbital fractures pose a true surgical emergency.

Retrospective survey of 150 surgically treated orbital floor fractures in a trauma referral centre

We present the epidemiology associated with 150 cases of orbital floor fractures surgically treated at a trauma centre. A 3-year analysis of patients surgically treated for orbital floor fractures at the University Hospital Virgen del Rocio, Sevilla, Spain, was conducted. Data regarding patient demography, signs and symptoms of presentation, cause and nature of injury, associated facial fractures, surgical approaches, materials used for orbital floor reconstruction and ocular damage were collected. Statistical analyses were conducted, including chi-squared and Fisher tests, odds ratios and confidence intervals. Men comprised 66.7% of the patients, and those aged 20–39 years were the most frequently affected. Male patients outnumbered female patients by a 2:1 ratio and were involved in a wider range of behavioural patterns resulting in orbital floor fractures. Motor vehicle accidents were the main cause, followed by physical assaults. The most common signs and symptoms associated with orbital floor fractures were periorbital ecchymosis and diplopia. Corneal abrasion was the most frequent positive ocular finding. This was followed in frequency by traumatic ocular globe rupture. However, most ocular injuries were of minor character. The ratio of impure to pure orbital floor fractures approached 3:1. We report results from one of the current largest series of surgically treated orbital floor fractures in a trauma referral centre. The most susceptible population included young men, and motor vehicle accident was the predominant mechanism. Further analysis of impure and pure orbital floor fractures revealed important differences in several demographic aspects such as mechanism of injury and signs and symptoms of presentation.

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.

Porous Polyethylene Implants in Orbital Floor Reconstruction

Villarreal, Pedro M. M.D., Ph.D.; Monje, Florencio M.D., Ph.D.; Morillo, Antonio J. M.D.; Junquera, Luis M. M.D., D.M.D., Ph.D.; González, Cristina C.N.S.; Barbón, Juan J. M.D. Author Information

Trapdoor fracture of the orbit in a pediatric population.

Orbital-floor blowout fractures of the trapdoor variety, first described by Soll and Poley, have also appeared in the French and Japanese literature. The trapdoor fracture is described as a pure orbital-floor fracture, linear in form and hinged medially, which allows herniation of orbital contents through the fracture and then entraps these herniated contents. A review of the orbital-floor fracture literature reveals a high incidence of persistent diplopia associated with ocular-muscle entrapment, which may later necessitate corrective surgery of extraocular muscles. Recent publications in the ophthalmologic literature have stressed the importance of early surgical intervention. This article reports a retrospective series of 19 pediatric patients (age range, 5 to 16 years) who presented to two institutions. All patients had radiographic confirmation of a trapdoor fracture. Physical examination demonstrated a high association between these fractures and restricted ocular motility (17 of the 19 patients). In the cases with trapdoor fracture and restricted ocular movement, early intervention was associated with better postoperative function. It is thus recommended that the symptomatic trapdoor orbit fracture be considered an urgent indication for surgical intervention. Practitioners therefore must have a high index of suspicion for these injuries. Prompt diagnosis is critical to maximize clinical outcome.