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Orbital Floor Fracture

Orbit Floor Fracture

Orbital floor fracture results from facial trauma. This type of fracture is mostly seen in young men and is often a result of motor vehicle accident or violence. Features include edema, decreased mobility of extraocular muscles, and visual disturbances.


Presentation

Orbital floor fractures (OFFs) occur frequently, mainly in the context of trauma from physical altercations or road traffic accidents [1]. The main demographic characteristic that presents with this type of injury is the involvement of young men [2]. Orbital floor fracture can either be direct or indirect, where direct involves the orbital rim while indirect are exclusive to the orbital floor. On inspection, periorbital edema and bruising may be observed. In those who have sustained direct fractures, palpation may reveal a tender 'step-off' area on the orbital rim.

OFFs usually present with a combination of visual disturbances and eye movement dysfunction that include diplopia, proptosis, displacement of the eyeball in the orbit, either posteriorly (enophthalmos) or inferiorly (hypoglobus), and muscle or nerve entrapment. Hypesthesia, dysesthesia, and hyperalgesia are all signs of nerve injury. Extraocular muscle entrapment is evidenced by restricted ocular movements and the presence of an oculocardiac reflex, characterized by bradycardia, syncope, and nausea [3].

Children frequently have an atypical presentation, often described as 'white-eyed' orbital floor fracture, due to the absence of significant ecchymosis and erythema. Radiological signs are often minimal, and orbital emphysema may be present [4] [5].

Furthermore, "trapdoor" fractures are mostly seen in children. These involve muscle (inferior rectus) entrapment, however, they present with little sign of bone displacement or serious injury [6]. They usually exhibit a disturbance in ocular movements. This is important for physicians to note, as delayed treatment leads to permanent neuromuscular complications.

Plethora
  • There is a plethora of literature on different reconstruction methods. Autogenous bone and cartilage grafts from various areas have been used in the reconstruction of the floor.[ncbi.nlm.nih.gov]
Fracture
  • RESULTS: There were 3 linear, 20 trapdoor-type and 7 blowout fractures. There was a tendency toward a higher incidence of linear fractures at younger ages and of blowout fractures in older patients.[ncbi.nlm.nih.gov]
  • IMPORTANCE: The timing and indications for repair of orbital floor fractures have been controversial. Current practice dictates that fractures involving more than 50% of the orbital floor should be repaired.[ncbi.nlm.nih.gov]
  • Progressively larger orbital floor fractures were made and CT scans were taken before fractures and after each fracture to assess the shape of the inferior rectus muscle.[ncbi.nlm.nih.gov]
  • Pupillary function must be assessed before surgical repair of an orbital floor fracture as damage of the pupillary fibers can occur secondary to the orbital floor fracture.[ncbi.nlm.nih.gov]
  • Residual diplopia was more common in patients with trapdoor fracture.[ncbi.nlm.nih.gov]
Diplopia
  • PURPOSE: The purpose of our study was to investigate whether the occurrence of preoperative diplopia determines the incidence of postoperative diplopia after orbital floor repair.[ncbi.nlm.nih.gov]
  • Residual diplopia was more common in patients with trapdoor fracture.[ncbi.nlm.nih.gov]
  • Nine patients showed a complete improvement of their diplopia. Two patients with posterior fractures showed persistent diplopia, which was well managed by prisms.[ncbi.nlm.nih.gov]
  • For patients with severe limitation of ductions, early surgical repair within 7 days of injury resulted in more rapid improvement of ductions and diplopia than surgery performed later.[ncbi.nlm.nih.gov]
  • Postoperative diplopia, enophthalmos, eye motility, cosmetic appearance, and complications were documented.[ncbi.nlm.nih.gov]
Enophthalmos
  • Our patient had delayed enophthalmos in a manner similar to silent sinus syndrome or imploding antrum syndrome.[ncbi.nlm.nih.gov]
  • Postoperative diplopia, enophthalmos, eye motility, cosmetic appearance, and complications were documented.[ncbi.nlm.nih.gov]
  • Silent sinus syndrome was first described as spontaneous enophthalmos and hypoglobus associated with subclinical maxillary sinusitis without prior trauma or surgery.[ncbi.nlm.nih.gov]
  • She had no limitation of extraocular movements nor enophthalmos. Following conservative treatment, she had a left persistent orbital pain and left monocular diplopia.[ncbi.nlm.nih.gov]
  • A total of 24 patients (11%) had an exophthalmos and 13 (9%) an enophthalmos. Most patients (69%) complained of infraorbital dysesthesia.[ncbi.nlm.nih.gov]
Strabismus
  • Despite the publication of multiple studies suggesting neuroimaging criteria for associated extraocular muscle entrapment, restrictive strabismus related to blowout fracture remains a clinical diagnosis.[aao.org]
  • Orbital Floor Fracture Orbital Floor Fracture Orbital Trauma, Emphysema Orbital wall fracture secondary to trauma Periorbital hematoma Phthisis Bulbi After Injury Retrobulbar Hemorrhage Secondary to Peribulbar Anesthesia Tumors, Neoplasma Retina Sclera Strabismus[atlasophthalmology.net]
  • However, strabismus surgery (eye muscle surgery) is sometimes necessary for persistent double vision. Occasionally, persistent double vision can be treated with non-surgical methods (prism glasses or botulinum toxin injections). Updated 03/2017[aapos.org]
  • Clinical signs include ecchymosis, crepitus, bone step-off, ptosis, enophthalmos and strabismus. Diplopia and limitation of ocular movement are caused by various conditions.[reviewofophthalmology.com]
Unilateral Proptosis
  • Abstract Three patients developed unilateral proptosis 13, 16, and 20 years after repair of blow-out fracture with orbital floor Teflon implants. In one patient trauma preceded the onset of proptosis.[ncbi.nlm.nih.gov]
Anisocoria
  • Although the orbital fracture was repaired, anisocoria persisted 18 months after the initial trauma.[ncbi.nlm.nih.gov]
Suggestibility
  • This finding suggests that compromised blood supply to the intraorbital fat may cause anaerobic cellulitis or enophthalmos.[ncbi.nlm.nih.gov]
  • Obstruction of the maxillary sinus ostium by orbital contents carries the potential for delayed-onset enophthalmos and therefore suggests an additional indication for orbital floor fracture repair.[ncbi.nlm.nih.gov]
  • The posterior location of the fractures suggests that surgical manipulation of or near the ciliary ganglion may account for these phenomena.[ncbi.nlm.nih.gov]
  • Bilateral chronic sinusitis suggested an anatomical predisposition to sinusitis unrelated to the prior trauma.[ncbi.nlm.nih.gov]
  • In the third case, no cyst-like structure or "cyst" contents were identified; however, fibrous tissue containing hemosiderin-laden macrophages suggested the presence of an organized hemorrhage.[ncbi.nlm.nih.gov]
Epistaxis
  • About the Author More Articles Hereditary Hemorrhagic Telangiectasia - May 25, 2016 Hereditary Hemorrhagic Telangiectasia: Septal Perforation and Nose Bleeds - May 23, 2016 Hereditary Hemorrhagic Telangiectasia: Epistaxis and Septal Perforation - May[ohniww.org]
  • The most common symptoms are bruising, tenderness and swelling around the eye; redness of the eye; double vision, or diplopia (seeing two images at the same time); numbness of the cheek, nose or teeth; and nose bleeds (epistaxis) [See figure 1].[aapos.org]
  • […] inferior rectus and sometimes the inferior oblique muscles Enophthalmos Usually following initial swelling and proptosis Patient reports feeling of pressure in orbit when attempting to blow nose Facial anesthesia due to entrapment of the infraorbital nerve Epistaxis[learningradiology.com]
  • […] such as a blow from a fist or a small ball striking the eye/orbit at high speed. symptoms — pain (especially on vertical movement), local tenderness, diplopia (especially on vertical gaze), eyelid swelling and crepitus after nose blowing Examination: epistaxis[lifeinthefastlane.com]
Facial Pain
  • Keywords Accidental Falls — Emphysema/etiology — Face — Facial Pain/etiology — Female — Follow-Up Studies — Humans — Mediastinal Emphysema/etiology — Middle Aged — Neck/pathology — Orbital Fractures/complications/surgery — Reconstructive Surgical Procedures[archive-ouverte.unige.ch]
  • For example, nerve diseases like trigeminal neuralgia or Bell's palsy sometimes cause facial pain, spasms and trouble with eye or facial movement. Birth defects can also affect the face.[icdlist.com]
Hematuria
  • F Keenan EpistaxisWilliam W Dexter410411 410 ExerciseInduced Asthma Lisa Barkley 414415 414 External Ear ChondritisAbscess Assaad J Sayah 420421 420 Folliculitis Elizabeth Austin Leland S Rickman 426427 426 Gonococcal Disease David Levine 432433 432 Hematuria[books.google.com]
Paresis
  • Abstract Six patients had both restriction and paresis of the inferior rectus muscle after blowout fracture of the inferior orbital floor.[ncbi.nlm.nih.gov]
  • Muscle avulsion should be considered in the management of orbital fracture if orbital tissue entrapment and nerve paresis are excluded as causes of reduction in ocular motility.[ncbi.nlm.nih.gov]
Hyperactivity
  • The vagal sequelae of the reflex, including gastric hyperactivity and headache, were experienced approximately 1 week after the injury and caused the patient to be misdiagnosed with gastroenteritis and status migrainosus, on 2 separate hospital visits[ncbi.nlm.nih.gov]
Slurred Speech
  • Get help immediately if the injured person has A headache that gets worse or does not go away Repeated vomiting or nausea Convulsions or seizures An inability to wake up Dilated (enlarged) pupil in one or both eyes Slurred speech Weakness or numbness[icdlist.com]

Workup

As OFFs are sustained via trauma, the initial workup should involve a primary survey and detailed physical examination. Subsequent examination of the globe is important, as patients may have sustained injuries to its structures which can be sight threatening and may need to be addressed urgently. The latter include retinal detachment, corneal abrasion, and neuropathy [7]. Patients may also have acute closed angle glaucoma, vitreous hemorrhage, and globe rupture. Patients may complain of loss of color vision and a deterioration in visual acuity. Presentations lacking visual symptoms do not rule out the possibility of globe injuries [8]. Elements that should be evaluated are the location and extent of damage, the presence of hemorrhage, globe injury, and soft tissue entrapment [9].

The principal imaging technique used is computed tomography (CT). This is a precise imaging modality in the assessment of the integrity of skeletal structures of the orbit. Furthermore, the use of CT scanning is useful in predicting the outcome of injury [10]. Entrapment of muscle can be evaluated by forced ocular supraduction or infraduction. However, this is only done if CT assessment does not yield clear results.

X-rays are no longer routinely requested, having been largely replaced by CT. The former may detect fat prolapse through what is known as the "tear drop" sign, in addition to the fluid collection in the maxillary sinus and orbital emphysema. Magnetic resonance imaging (MRI) has the advantage of being able to show multiple planes and is best in visualizing soft tissue injuries.

Atelectasis
  • This clinical entity has later been described after trauma in which damage to the ostiomeatal complex leads to atelectasis of the maxillary sinus.[ncbi.nlm.nih.gov]
Hyponatremia
  • Sayah 420421 420 Folliculitis Elizabeth Austin Leland S Rickman 426427 426 Gonococcal Disease David Levine 432433 432 Hematuria W Mark Peluso Michael J Henehan 438439 438 Herpes Gladiatorum Julie Kerr 444445 444 Hypertension John MacKnight 450451 450 Hyponatremia[books.google.com]

Treatment

  • Statistical analysis of parameters of sight acuity before and after treatment was performed. The Wilcoxon test was used for dependent measurements (repeated), visual acuity after treatment was significantly higher than before.[ncbi.nlm.nih.gov]
  • We describe the treatment of each case individually; in most cases, the implant was removed. All 12 patients had a satisfactory outcome after treatment. CONCLUSIONS: Proptosis presenting 2 months or more after orbital floor fracture is rare.[ncbi.nlm.nih.gov]
  • The treatment consists of spanning the floor defect with a material that can provide structural support and restore the orbital volume.[ncbi.nlm.nih.gov]
  • Surgical repair of orbital fractures with implants is a widely used treatment modality. While a variety of established complications are associated with this technique, most are directly understood and treated.[ncbi.nlm.nih.gov]
  • Discussion : There are several options for treatment of an orbital wall fracture.[ohniww.org]

Prognosis

  • […] continuation of the internal orbital buttress, supporting the orbital contents from posterior intraorbital soft tissue herniation volume 1.5 cm 3 a linear relationship between the volume of intraorbital contents and depth of enophthalmos 7 Treatment and prognosis[radiopaedia.org]
  • What’s the likely prognosis? Discussion External examination of our patient showed evidence of substantial bruising. Additional testing included a study of ocular motility to confirm the full range of motion.[reviewofoptometry.com]

Etiology

  • The authors report, discuss, and propose an etiology of an abnormal pupil in a child with an orbital floor fracture before surgical repair. A case report is described.[ncbi.nlm.nih.gov]
  • Keywords Accidental Falls — Emphysema/etiology — Face — Facial Pain/etiology — Female — Follow-Up Studies — Humans — Mediastinal Emphysema/etiology — Middle Aged — Neck/pathology — Orbital Fractures/complications/surgery — Reconstructive Surgical Procedures[archive-ouverte.unige.ch]
  • The primary predictor variables were a number of demographic, etiologic, and operative factors that might influence the occurrence of diplopia. The secondary outcome variable was diplopia.[ncbi.nlm.nih.gov]
  • The etiology for the facial trauma is commonly a motor vehicle accident or an interpersonal altercation.[ispub.com]

Epidemiology

  • Eye Injury Registry is a federation of state eye injury registries that maintains a standardized database, with the goal of better understanding the epidemiology and outcomes of ocular trauma.[aao.org]
  • More recently, there has been success with endoscopic, or minimally invasive, approaches. [16] Epidemiology [ edit ] Orbital fractures, in general, are more prevalent in men than women.[en.wikipedia.org]
Sex distribution
Age distribution

Pathophysiology

  • ANATOMY AND PATHOPHYSIOLOGY Of the bony orbit, the thin portion is defined posterolaterally by sphenomaxillary fissure but without any distinct border medially.[e-acfs.org]

Prevention

  • Repair of orbital floor fractures often involves the reduction of the herniated orbital contents and implantation of a sturdy, inelastic material to prevent the orbital contents from prolapsing into the maxillary sinus.[ncbi.nlm.nih.gov]
  • This case demonstrates that orbital floor implants should not be placed too anteriorly or too medially in the anatomic region of the lacrimal sac and that they should be fixed to prevent implant migration.[ncbi.nlm.nih.gov]
  • The integrity of the orbit and its contents must be preserved to prevent complications after alterations secondary to trauma. There is a plethora of literature on different reconstruction methods.[ncbi.nlm.nih.gov]
  • That part was fixed with 2 absorbable screws to prevent the sheet from crumpling. Orbital floor fractures of 6 patients (3 posterior-one-half defects and 3 posterior-two-thirds defects) were repaired using PLDLA sheets.[ncbi.nlm.nih.gov]
  • However, suspected trapdoor fractures should be repaired within 1 week after injury in order to prevent fibrosis from developing in orbital tissues owing to entrapment by bone fragments.[ncbi.nlm.nih.gov]

References

Article

  1. Yilmaz M, Vayvada H, Aydin E, Menderes A, Atabey A. Repair of fractures of the orbital floor with porous polyethylene implants. Br J Oral Maxillofac Surg. 2007;45(8):640–644.
  2. Gomes PP, Passeri LA, Barbosa JR. A 5-year retrospective study of zygomatico-orbital complex and zygomatic arch fractures in Sao Paulo State, Brazil. J Oral Maxillofac Surg. 2006;64(1):63–67.
  3. Simon GJ, Syed HM, McCann JD, Goldberg RA. Early versus late repair of orbital blowout fractures. Ophthalmic Surg Lasers Imaging. 2009;40(2):141–148.
  4. Burnstine MA. Clinical recommendations for repair of orbital facial fractures. Curr Opin Ophthalmol. 2003;14(5):236-240.
  5. Egbert JE, May K, Kersten RC, Kulwin DR. Pediatric orbital floor fracture: Direct extraocular muscle involvement. Ophthalmology. 2000;107(10):1875-1879.
  6. Bansagi ZC, Meyer DR. Internal orbital fractures in the pediatric age group: characterization and management. Ophthalmology. 2000;107(5):829–836.
  7. Cook T. Ocular and periocular injuries from orbital fractures. J Am Coll Surg. 2002;195(6):831–834.
  8. Mellema PA, Dewan MA, Lee MS, Smith SD, Harrison AR. Incidence of ocular injury in visually asymptomatic orbital fractures. Ophthal Plast Reconstr Surg. 2009;25(4):306–308.
  9. Zilkha A. Computed tomography of blow-out fracture of the medial orbital wall. AJR Am J Roentgenol. 1981;137(5):963-965.
  10. Bruneau S, De Haller R, Courvoisier DS, Scolozzi P. Can a Specific Computed Tomography-Based Assessment Predict the Ophthalmological Outcome in Pure Orbital Floor Blowout Fractures? J Craniofac Surg. 2016;27(8):2092-2097.

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Last updated: 2019-06-28 10:42