J Plast Surg Hand Surg, 2014; Early Online: 1–6 © 2014 Informa Healthcare ISSN: 2000-656X print / 2000-6764 online DOI: 10.3109/2000656X.2014.960524
ORIGINAL ARTICLE
Analysis of unilateral complex orbital fractures with a new treatment algorithm Mehtap Karamese1, Osman Akda g1, Muhammed Nebil Selimoglu1, Tugba Gun Koplay1, Berker Bakbak2, Mustafa Koplay3 & 1 Zekeriya Tosun Department of Plastic Reconstructive and Aesthetic Surgery, Medicine Faculty, Selcuk University, Konya, Turkey, 2Radiology Department, Medicine Faculty, Selcuk University, Konya, Turkey and 3Ophthalmology Department, Medicine Faculty, Selcuk University, Konya, Turkey Journal of Plastic Surgery and Hand Surgery Downloaded from informahealthcare.com by Selcuk Universitesi on 01/20/15 For personal use only.
1
Abstract The aim of this study is to investigate preoperative and postoperative properties, the management of unilateral complex orbital fractures, and to offer an algorithm for orbital fractures. For this research study, 248 patients with orbital trauma were evaluated according to an offered algorithm. Diplopia, enophthalmos, dystopia, infraorbital nerve dysfunction, and ocular movement limitations were documented for clinical assessment. Orbital rim displacement and an orbital volume check with computed tomography (CT) were used for indication of surgery. The injured orbital volume was compared with the healthy orbital volume in the preoperative and postoperative periods. In total, 58 patients required operations among the 248 patients, according to the algorithm. The preoperative mean injured orbital volume measurements of the operated patients were statistically different than the healthy orbital volume measurements (30.13 cm3 ± 2.69 cm3 and 27.15 cm3 ± 1.29 cm3, respectively). In the postoperative period, there was no difference between the injured and healthy orbital volume. In conclusion, an algorithm may facilitate the approach to unilateral complex orbital fractures. Ophthalmic examination, rim displacement, and the measurement of orbital volume using computed tomography are key points of orbital fractures with regard to management. Key Words: Orbital fracture, orbital volume, enophthalmos, algorithm for unilateral orbital fracture, trauma, craniofacial, plastic surgery
Introduction The orbit occupies the middle section of the face, enabling the craniofacial junction, and is, unfortunately, vulnerable to trauma [1]. Orbital bone structures establish a “shock absorbing system” by means of different thicknesses of bone in different areas for the protection of nervous and vascular structures and the globe itself. The floor of the orbit as well as the roof of the maxillary sinus are sites of frequent fractures because they have paper-thin structures. The volume employed by the eye and adnexa may expand or contract secondarily to orbital fractures [2]. Orbital volume changes occur in both blow out fractures and complex orbital fractures, which also involve the rim and the adjacent parts, such as maxillary and zygomatic fractures [3]. Orbital fractures cause functional and aesthetic problems, like visual disturbances, damage to the extraocular muscles, changes in facial appearance, ecchymosis, and lacerations. The symptoms that patients can experience include enophthalmos, exophthalmos, dystopia, diplopia, and infraorbital nerve dysfunction [1]. Orbital fractures are usually evaluated with radiological criteria with respect to fracture size and displacement of bone fragments. In routine clinical practice, fractures are not evaluated with the volume of the orbit because the measurement of the orbital volume is labour intensive, difficult to use in a clinical setting, and time consuming. An algorithm is an effective method expressed a set of rules that precisely defines a sequence of treatments, and management of any medical problems. Since the management of orbital trauma varies widely according to surgeon, an algorithm should be developed. We have developed a treatment algorithm which
includes the analysis of the orbital volume and ophthalmic symptoms; and found it to be useful for unilateral orbital fractures. An algorithm may facilitate the approach in patients who have insignificant symptoms with orbital trauma. Reconstruction of the orbital volume, realignment of the orbital rim, restoration of the continuity of the orbital floor, and isolation of the orbital contents from the paranasal sinus cavities are required in the surgical treatment of orbital fractures [4]. Postoperative complications are associated with the timing of the surgery, meticulous dissection, and the proper alignment of fractures and soft tissue components [5]. The replacement of the orbital volume should not be delayed and the orbital contents must be replaced and supported with special materials in order not to induce late complications such as enopthalmos. This study is aimed to present the treatment algorithm for orbital fractures, the analysis of 248 patients with orbital trauma by algorithm and preoperative examination, and the early and late postoperative symptoms of 58 patients who were operated on due to unilateral complex orbital fractures. Materials and methods This study was designed and approved by the institutional ethical committee, and all patients were provided with informed consent for their management procedure. Between 2009–2013, 248 patients with unilateral orbital trauma had fractures or not and who were suitable for the algorithm were evaluated using the algorithm and treated. Fifty-eight patients required an operation according to the algorithm, in which 248 patients were assessed in terms of
Correspondence: Mehtap Karamese, MD, Assistant Professor, Selcuk Üniversitesi, Tıp Fakültesi Hastanesi, Alaaddin Keykubat Kampüsü, Selçuklu, Konya, Türkiye. Tel: 0090 332 241500. Fax: 0090 332 2416065. E-mail: [email protected] (Received 11 June 2014; accepted 27 August 2014)
Journal of Plastic Surgery and Hand Surgery Downloaded from informahealthcare.com by Selcuk Universitesi on 01/20/15 For personal use only.
2 M. Karamese et al. preoperative, early postoperative, and postoperative properties. Paediatric patients and bilateral orbital fractures were excluded from this study.
preoperative period. The patients were re-assessed after a mean follow-up period of 12 months (8–19 months), and their ophthalmologic examinations were carried out.
Clinical examination Preoperative ophthalmologic examinations consisted of inspection with respect to periorbital ecchymosis, oedema, and ocular movement limitation (OML), infraorbital nerve dysfunction (IOND), diplopia, enophthalmos, and dystopia. Enophthalmos was defined as “to be present if the affected side showed more than 2-mm retro-placement of the eye globe compared with the normal side” [6]. Diplopia was considered significant if it did or did not exist in the primary gaze or reading position. OML was considered to be significant as the presence or absence of the disturbance of eyeball motility. Infraorbital nerve dysfunction (paraesthesia or anaesthesia) was noted as present or absent in all patients with unilateral orbital traumas. Orbital traumas were managed by the algorithm (Figure 1), and patients with enophthalmos or diplopia or dystopia alone were sent to surgery; patients with only ocular movement restrictions or infraorbital nerve dysfunction, or no sign of enophthalmos, diplopia, or ocular movement restrictions, were evaluated with CT for orbital rim assessments. If there was displacement of the orbital rims, the patients were sent to surgery. In patients with non-displaced rims, the radiologist was asked to measure the orbital volumes. If the orbital volume was calculated to be not equal to the healthy orbit, these patients were sent to surgery. If the orbital volume was normal, the patients were observed. Postoperative orbital volume values of the patients were compared with their healthy orbits, and the ocular complaints were also compared to those in the
CT evaluation and measurement of orbital volume Computed tomography (CT) was used to detect the transverse fracture size, presence of significant soft tissue herniation, and to calculate the orbital volume. CT scans were performed with a 4-detector multislice CT scanner (Toshiba Aquilion, Tokyo, Japan), and the images were obtained using continuous 3-mm-thick axial slices in a high resolution osseous window level setting. These images were then transferred to a processing workstation for further analysis with specialised software (Syngo.via, Breemen Mittle, Germany). In addition to the traditional axial images, multiplanar reconstructions (MPR) and three-dimensional volumerendering (3D VR) images were used to assess in detail the transverse fracture and orbital volume, when necessary, in patients who had non-displaced rims. Coronal images were drawn on each section of the orbital borders, and the orbital volumes were calculated automatically using a special software program [7]. Surgical procedure Patients were operated on after the resolution of swelling (mean 5th day; 2–7 days) [8]. The surgeries were performed by the same surgical team, and the subciliary approach was used routinely to gain space for the insertion of larger mesh plates and to repair the inferior orbital wall [8]. Periorbital bone fractures were re-aligned, and 1.3 mm or 1.5 mm titanium plates and screws (Synthes, Balsthal, Switzerland) were placed
Unilateral orbital trauma
Clinical examination IOND (+) OML (+) No clinical sign (only ecchymose/lid edema)
Diplopia (+) Enophthalmos (+) Distopia (+)
(CT evaluation for operation plan)
Chceck orbital rims
Normal orbital rims
Displaced orbital rims
Check orbital volume Increased/ decreased orbital volume Surgery
Normal orbital volume Observation
Figure 1. Algorithm for unilateral orbital fracture.
Algorithm for unilateral orbital fractures
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across the fractured segments. For reconstruction of orbital floor defects, appropriately sized and shaped titanium mesh plates and 1.0 or 1.3 titanium micro screws (Synthes) were used. Release of the soft tissue contents from their displaced positions or adherent structures was the most important issue in our treatment. Restriction or tethering of the globe was confirmed by “forced duction testing”. The skin was closed with 6/0 absorbable suture subcutaneously, and the frost traction [1] suture was removed at 48 hours. After 5 days, massage was recommended. Statistical analysis Statistical analyses were performed using SPSS 15.0 for Windows (SPSS Inc., Chicago, IL). Data are shown as the mean ± standard deviation, range, and percentages (%). The Mann Whitney U-test was used for comparing two groups and the paired t-test was used for preoperative and postoperative results. The results were considered to be statistically significant when the p-value was less than 0.05. Results We evaluated 248 patients with orbital trauma according to our algorithm (Figure 2). Diplopia was seen in 13 patients (5.2%), enophthalmos was seen in nine patients (3.6%), and dystopia was seen in one patient (0.4%) and they were examined in detail in order to send to surgery. The patients with ocular
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movement limitations (28 patients; 11.2%) and infraorbital nerve dysfunction (10 patients; 4.0%) were evaluated with CT for the orbital rims. Among the patients with ocular movement limitations: only five patients had infraorbital rim displacement by infraorbital rim fractures and impure blow-out fractures and they were sent to surgery; 23 patients with ocular movement limitations had normal orbital rims, but increased orbital volume was found in three of them by blow-out fracture, and they were also operated on; six of 10 patients with infraorbital nerve dysfunction had displacements of the infraorbital rim and they went to surgery; and four of the patients with infraorbital nerve dysfunction had normal orbital rims and normal orbital volumes, and they were observed. Of the patients, 187 (75.4%) had ocular trauma but had no sign of diplopia, enophthalmos, or ocular movement limitations, and were also evaluated with CT: three of the 187 patients had displacement of the orbital rims and were operated on; 18 patients had normal orbital rims but abnormal orbital volumes (increased orbital volume by blow-out fracture). In total, 58 patients of 248 evaluated patients (23.3%) (33 men and 25 women) were sent to surgery, and the mean age was 33.1 years (ranging from 19–67 years). All patients had full visual functions in their postoperative ophthalmic examinations. While diplopia was seen in six of the
Orbital trauma (248 patients)
Clinical examination
IOND (10 patients) OML (28 patients) No sign (187 patients)
Diplopia (13 patients) Enophthalmos (9 patients) Distopia (1 patients)
Check rim
Displaced rims (surgery) 5 patients (among OML) 6 patients (among IOND) 3 patients (among no sign)
Non displaced orbital rims 23 patients (with OML) 4 patients (with IOND) 184 patients (with no sign)
Check orbital volume Surgery 23 patients Abnormal Surgery 18 (among no sign) 3 (OML)
Normal
Observation (190 patients)
Figure 2. Patients on algorithm.
4 M. Karamese et al.
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Table I. Preoperative and postoperative symptoms of 58 patients.
Diplopia Ocular movement limitations (OML) Enophthalmos Exophthalmos Ectropion Dystopia Infection Infraorbital nerve dysfunction (IOND) Mesh plate extrusion/displacement Orbital adherence syndrome
patients in the early period, no diplopia was seen in their late period examinations. None of the patients had ocular movement limitations either in the early period or late period. Infraorbital nerve dysfunction was seen in 18 patients in the early period, but it was resolved during the late follow-up. One patient had an infection in the wound site and it was treated with oral antibiotics (Table I). The mean preoperative volume of the injured orbits was 30.1 cm3 (± 2.6 cm3), and the measurement of the postoperative injured volume was (mean) 27.1 cm3 (± 1.2 cm3). There was a statistically significant difference between the preoperative and postoperative orbital volumes (p = 0.0001). The mean volume of the healthy orbits was 27.9 cm3 (± 1.8 cm3), and there was no statistically significant difference between the postoperative injured and non-injured orbital volumes (Figures 3 and 4). In the first postoperative 4-weeks period, 68.9% of the patients had ectropion, and massage was recommended during this period. With the exception of two patients, the ectropion healed over time. These two patients did not agree to undergo an additional operation for the treatment of ectropion. Enophthalmos was found in two patients during the late period examinations. In the orbital CT scans of these patients, their orbital volumes were found to be similar to that of the other eye. Exophthalmos was found in four patients during their early period examinations. In their orbital volume measurements with CT, three of these had congruent orbital volumes with their other eye, but one had a contracted orbital volume. While three patients gained a normal appearance over time, one of the patients with a narrowed orbital volume was administered another operation to reposition the titanium mesh plate. Dystopia developed in one patient in the early postoperative period. Through re-operation, the zygoma was re-positioned.
a
Early postoperative (24 hours–4 weeks) 6 — — 4 40 1 1 18 — —
Preoperative 13 28 9 — — 1 — 10 — —
b
Figure 3. CT imaging of a 24-year-old man with unilateral maxillofacial trauma.
Late postoperative (8–12 months) — — 2 1 2 1 — — — —
Neither titanium mesh plate extrusion or displacement, nor any orbital adherence syndrome was seen in any patient. Patients (190 patients; 79%) who were not operated on according to the algorithm were observed and evaluated with inspection and ophthalmic examination for 8–12 months and no complications such as diplopia, enophthalmos, or dystopia were seen. Discussion This study showed that the proposed algorithm can be used appropriately in orbital traumas, and may provide a treatment opportunity for the patients that are passed over without a volume check. Due to the changeability inside an orbital fracture, with regard to fracture type, fracture site, and concomitant soft tissue injuries, there exists some controversy in management. The management of orbital fractures varies widely and is related to the surgeon’s decision more than any accepted consensus, due to different clinical symptoms. Additionally, evaluating diplopia and enophthalmos is difficult in the early posttraumatic period. Although the surgical approach and materials used for floor reconstruction have often been presented in the literature, management accuracy has rarely been reported. An algorithm
a
b
c
d
Figure 4. Postoperative images and orbital volume measurement of the same patient.
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Algorithm for unilateral orbital fractures for the management of orbital traumas has been used for many years in our clinic. In the literature, many algorithms were reported to be associated with blow out fractures [9]. Millman et al. [10] presented an algorithm related to orbital prolapse, responding to systemic steroids. Our algorithm includes clinical examination, rim fractures, and volume measurements in unilateral orbital fractures. In our study, we encountered enophthalmos, diplopia, and dystopia in 23 patients who were operated on among 58 patients with clinical examinations, and they were sent to operation based on the algorithm. Issues that must be kept in mind are that surgical plans for the patients were created with CT examinations. Of the patients, 187 had no symptoms like enophthalmos, diplopia, OML, or ION dysfunction; however, 21 patients detected by CT evaluation were operated on due to both orbital volume changes and orbital rim displacement. The rim examination of patients with facial fractures may be the first step in the evaluation of the position and the width of the fracture; however, the orbital rim may be non-displaced, and the orbital floor may be fractured due to a special organisation of the orbit [11]. The algorithm stands out in checking the orbital volume with any signs of enophthalmos, diplopia, or OML. In our study, through checking the orbital volume, we had an opportunity for surgical intervention preventing 21 patients from late complications, such as enophthalmos and dystopia. An increase in the orbital volume is more frequent than a decrease in the orbital volume in facial traumas. Fractures in the orbital floor or lateral portion of the orbit may cause an increase in the orbital volume [12]. In cases reported in the literature, such as orbital volume increases, the cause is usually blow out fractures [13]. Although the most obvious symptom of orbital volume increase is expected to be enophthalmos, enophthalmos cannot be identified immediately after a trauma. However, retrobulbar and infraorbital tissue oedemas and haematomas may conceal the emergence of this symptom during the early examination of the patient. Enophthalmos requires surgery, and it is known that early surgical intervention can improve the outcomes [1]. Therefore, CT images should be taken as the basis for surgical indication in orbital fractures, even if there is a normal appearance during inspection [14]. In our study we evaluated all patients with CT so as not to neglect any patient that requires surgical procedures. Surgeons evaluate orbital fractures with radiological criteria such as fracture size, displacement of the bone fragments, and comminution [7]. The measurement of the orbital volume is labour intensive, difficult to use in a clinical setting, and time consuming. The orbital volume must be assessed and compared both preoperatively and postoperatively. In our study, we used CT to measure the orbital volume and reached orbital volumes that are congruent with the other eye in the postoperative period. Achieving the integrity and volume of the orbital bone is the primary objective of the surgery. The aim of the postoperative CT examinations is to check whether or not the same volume as that of the other eye could be achieved. Enophthalmos was seen to continue clinically in two of our patients. The postoperative inspection findings of the patients in the late period are also important in that they show the response of periorbital soft tissue to the treatment. Since the
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integrity of the bone structure supporting the soft tissue was impaired at the time of trauma, re-modelling is done according to the periorbital ligament structures. Proper bone fixations that are made without losing time ensure the protection of the soft tissue and periorbital fat pad. Even when it seems that the same volume as that of the other eye has been achieved during CT inspections, re-modelling of soft tissue or fat pad atrophy may result in enophthalmos. The enophthalmos in two of our patients was defined as a soft tissue response. It is well known that the aesthetic and functional result can be obtained when the earlier significant orbital volume or muscle derangement can be corrected in significant orbital fractures [8]. The symptoms seen in the preoperative period in order of frequency were: ocular movement limitation (in 28 patients), diplopia (in 13 patients), infraorbital paraesthesia (in 10 patients), and enophthalmos (in nine patients). In the literature, the most frequently seen symptom is reported as diplopia in the presence of blow out fractures [6]. It is associated with progression of a fracture to the orbital floor in blowout fractures. According to Shah et al. [15], diplopia is associated with the amount of soft tissue that is incarcerated. In our study, it is considered that diplopia may be a component of orbital volume changes, and was seen in 13 patients (5%). The important issue for surgeons is to differentiate fractures in which diplopia is caused by bone fracture from those cases caused by muscle contusion, which heals spontaneously [12]. Ocular movement limitations were a more frequently seen result than diplopia. In accordance with the literature, we are of the opinion that not only muscle entrapment causes this, but also muscle contusion, oedema, and haematoma can cause the ocular movement limitations in diplopia [6,16]. OML requires an orbital volume check and, if the orbital volume is normal and orbital rims are nondisplaced, the patients are observed. In the literature double vision or diplopia caused by muscle or fine ligament system and suggested by CT examination is an indication of surgical treatment [8]. Exophthalmos was detected in only one patient. This was linked to an error made when shaping the mesh plate. Shaping the titanium mesh plate is very important when fixing an orbital floor fracture, because any bending that is done incorrectly or without adequate diligence will lead to exophthalmos in the postoperative period. The shape of the defect and different geometrical forms of the orbit play important roles in shaping the titanium mesh plate during a surgery. There are no reports stating that the thickness of a titanium mesh plate causes a change in the orbital volume, but, if any difference in the level between the orbital rim and orbital floor is not taken into consideration for a particular case, and the titanium mesh plate is not placed to align with the bone surfaces, then the orbital volume may contract and exophthalmos may occur. Dystopia requires surgery both preoperatively and as a complication in the postoperative period. In our series, there was one patient with vertical dystopia who was operated on immediately. We also encountered dystopia in one patient postoperatively due to an error made when re-positioning the zygoma. The patient was re-operated on: the bones were ruptured again, the masseter muscle was released, and the zygoma was re-positioned and fixed with plates and screws.
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6 M. Karamese et al. The patients were annoyed mostly by ectropion in the postoperative period. Ectropion occurred in 72% of the patients due to the subciliary incision; however, we knew that this condition was temporary. We did not recommend any treatment to our patients other than intensive massage therapy. Ectropion remained fixed in two patients in the late period. We suggested treatment for these patients, but they did not agree to be operated on again. Infraorbital anaesthesia/paraesthesia was seen more frequently in the postoperative period than in the preoperative period (preoperative = 10 patients, 17.2%; postoperative = 18 patients, 31.0%). The width of the dissection, tissue oedema, and excessive handling of the nerve patterns may result in paraesthesia. We did not have any patients who had infraorbital nerve damage in the late period. Conclusion Complex orbital fractures are conditions that need to be treated early. Since preoperative examination findings may often conceal the severity of fractures, it is important to decide on an operation on the basis of a consensus. Orbital volume assessments are valuable but must be associated with the alignment of orbital rims. We offered an algorithm for the management of unilateral orbital fractures based on the clinical examination and CT assessment.
[3] [4] [5] [6] [7] [8] [9] [10]
[11] [12]
Acknowledgement This study was conducted with approval from the Local Ethical Committee.
[13]
Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
[14] [15]
References [1] Clauser L, Galiè M, Pagliaro F, et al. Posttraumatic enophthalmos: etiology, principles of reconstruction, and correction. J Craniofac Surg 2008;19:351–9. [2] Essig H, Dressel L, Rana M, et al. Precision of posttraumatic primary orbital reconstruction using individually bent titanium
[16]
mesh with and without navigation: a retrospective study. Head Face Med 2013;9:18. Wolfe SA. Orbital dystopias. In Wolfe SA, Berkowitz S, editors. Plastic surgery of the facial skeleton. 1st edition. Little, Brown; Boston, MA: 1989. p 507. Yi WS, Xu XL, Ma JR, et al. Reconstruction of complex orbital fracture with titanium implants. Int J Ophthalmol 2012;5: 488–92. Poeschl PW, Baumann A, Dorner G, et al. Functional outcome after surgical treatment of orbital floor fractures. Clin Oral Investig 2012;16:1297–303. Shin JW, Lim JS, Yoo G, Byeon JH. An analysis of pure blowout fractures and associated ocular symptoms. J Craniofac Surg 2013;24:703–7. Strong EB, Fuller SC, Chahal HS. Computer-aided analysis of orbital volume: a novel technique. Ophthal Plast Reconstr Surg 2013;29:1–5. Rodriguez ED, Dorafshar AH, Manson PN. Facial fractures. In Neligan PC, editor. Plastic surgery. 3rd edition. Elsevier Saunders; New York: 2013. p 53–70. Raskin EM, Millman AL, Lubkin V, et al. Prediction of late enophthalmos by volumetric analysis of orbital fractures. Ophthal Plast Reconstr Surg 1998;14:19–26. Millman AL, Della Rocca RC, Spector S, et al. Steroids and orbital blowout fractures–a new systematic concept in medical management and surgical decision-making. Adv Ophthalmic Plast Reconstr Surg 1987;6:291–300. Parsons GS, Mathog RH. Orbital wall and volume relationships. Arch Otolaryngol Head Neck Surg 1988;114:743–7. Manson PN. Facial fractures. In Mathes SJ, editor. Plastic surgery. 2nd edition. Elsevier; Philadelphia, PA: 2006. p 248–344. Alinasab B, Beckman MO, Pansell T, et al. Relative difference in orbital volume as an indication for surgical reconstruction in isolated orbital floor fractures. Craniomaxillofac Trauma Reconstr 2011;4:203–12. Whitehouse RW, Batterbury M, Jackson A, et al. Prediction of enophthalmos by computed tomography after ’blow out’ orbital fracture. Br J Ophthalmol 1994;78:618–20. Shah HA, Shipchandler TZ, Sufyan AS, et al. Use of fracture size and soft tissue herniation on computed tomography to predict diplopia in isolated orbital floor fractures. Am J Otolaryngol 2013;34:695–8. Ansons AM, Davis H. Diagnosis and management of ocular motility disorders. 4th edition. Wiley Blackwell; United Kingdom: 2003. p 543–89.
ORIGINAL ARTICLE
Analysis of unilateral complex orbital fractures with a new treatment algorithm Mehtap Karamese1, Osman Akda g1, Muhammed Nebil Selimoglu1, Tugba Gun Koplay1, Berker Bakbak2, Mustafa Koplay3 & 1 Zekeriya Tosun Department of Plastic Reconstructive and Aesthetic Surgery, Medicine Faculty, Selcuk University, Konya, Turkey, 2Radiology Department, Medicine Faculty, Selcuk University, Konya, Turkey and 3Ophthalmology Department, Medicine Faculty, Selcuk University, Konya, Turkey Journal of Plastic Surgery and Hand Surgery Downloaded from informahealthcare.com by Selcuk Universitesi on 01/20/15 For personal use only.
1
Abstract The aim of this study is to investigate preoperative and postoperative properties, the management of unilateral complex orbital fractures, and to offer an algorithm for orbital fractures. For this research study, 248 patients with orbital trauma were evaluated according to an offered algorithm. Diplopia, enophthalmos, dystopia, infraorbital nerve dysfunction, and ocular movement limitations were documented for clinical assessment. Orbital rim displacement and an orbital volume check with computed tomography (CT) were used for indication of surgery. The injured orbital volume was compared with the healthy orbital volume in the preoperative and postoperative periods. In total, 58 patients required operations among the 248 patients, according to the algorithm. The preoperative mean injured orbital volume measurements of the operated patients were statistically different than the healthy orbital volume measurements (30.13 cm3 ± 2.69 cm3 and 27.15 cm3 ± 1.29 cm3, respectively). In the postoperative period, there was no difference between the injured and healthy orbital volume. In conclusion, an algorithm may facilitate the approach to unilateral complex orbital fractures. Ophthalmic examination, rim displacement, and the measurement of orbital volume using computed tomography are key points of orbital fractures with regard to management. Key Words: Orbital fracture, orbital volume, enophthalmos, algorithm for unilateral orbital fracture, trauma, craniofacial, plastic surgery
Introduction The orbit occupies the middle section of the face, enabling the craniofacial junction, and is, unfortunately, vulnerable to trauma [1]. Orbital bone structures establish a “shock absorbing system” by means of different thicknesses of bone in different areas for the protection of nervous and vascular structures and the globe itself. The floor of the orbit as well as the roof of the maxillary sinus are sites of frequent fractures because they have paper-thin structures. The volume employed by the eye and adnexa may expand or contract secondarily to orbital fractures [2]. Orbital volume changes occur in both blow out fractures and complex orbital fractures, which also involve the rim and the adjacent parts, such as maxillary and zygomatic fractures [3]. Orbital fractures cause functional and aesthetic problems, like visual disturbances, damage to the extraocular muscles, changes in facial appearance, ecchymosis, and lacerations. The symptoms that patients can experience include enophthalmos, exophthalmos, dystopia, diplopia, and infraorbital nerve dysfunction [1]. Orbital fractures are usually evaluated with radiological criteria with respect to fracture size and displacement of bone fragments. In routine clinical practice, fractures are not evaluated with the volume of the orbit because the measurement of the orbital volume is labour intensive, difficult to use in a clinical setting, and time consuming. An algorithm is an effective method expressed a set of rules that precisely defines a sequence of treatments, and management of any medical problems. Since the management of orbital trauma varies widely according to surgeon, an algorithm should be developed. We have developed a treatment algorithm which
includes the analysis of the orbital volume and ophthalmic symptoms; and found it to be useful for unilateral orbital fractures. An algorithm may facilitate the approach in patients who have insignificant symptoms with orbital trauma. Reconstruction of the orbital volume, realignment of the orbital rim, restoration of the continuity of the orbital floor, and isolation of the orbital contents from the paranasal sinus cavities are required in the surgical treatment of orbital fractures [4]. Postoperative complications are associated with the timing of the surgery, meticulous dissection, and the proper alignment of fractures and soft tissue components [5]. The replacement of the orbital volume should not be delayed and the orbital contents must be replaced and supported with special materials in order not to induce late complications such as enopthalmos. This study is aimed to present the treatment algorithm for orbital fractures, the analysis of 248 patients with orbital trauma by algorithm and preoperative examination, and the early and late postoperative symptoms of 58 patients who were operated on due to unilateral complex orbital fractures. Materials and methods This study was designed and approved by the institutional ethical committee, and all patients were provided with informed consent for their management procedure. Between 2009–2013, 248 patients with unilateral orbital trauma had fractures or not and who were suitable for the algorithm were evaluated using the algorithm and treated. Fifty-eight patients required an operation according to the algorithm, in which 248 patients were assessed in terms of
Correspondence: Mehtap Karamese, MD, Assistant Professor, Selcuk Üniversitesi, Tıp Fakültesi Hastanesi, Alaaddin Keykubat Kampüsü, Selçuklu, Konya, Türkiye. Tel: 0090 332 241500. Fax: 0090 332 2416065. E-mail: [email protected] (Received 11 June 2014; accepted 27 August 2014)
Journal of Plastic Surgery and Hand Surgery Downloaded from informahealthcare.com by Selcuk Universitesi on 01/20/15 For personal use only.
2 M. Karamese et al. preoperative, early postoperative, and postoperative properties. Paediatric patients and bilateral orbital fractures were excluded from this study.
preoperative period. The patients were re-assessed after a mean follow-up period of 12 months (8–19 months), and their ophthalmologic examinations were carried out.
Clinical examination Preoperative ophthalmologic examinations consisted of inspection with respect to periorbital ecchymosis, oedema, and ocular movement limitation (OML), infraorbital nerve dysfunction (IOND), diplopia, enophthalmos, and dystopia. Enophthalmos was defined as “to be present if the affected side showed more than 2-mm retro-placement of the eye globe compared with the normal side” [6]. Diplopia was considered significant if it did or did not exist in the primary gaze or reading position. OML was considered to be significant as the presence or absence of the disturbance of eyeball motility. Infraorbital nerve dysfunction (paraesthesia or anaesthesia) was noted as present or absent in all patients with unilateral orbital traumas. Orbital traumas were managed by the algorithm (Figure 1), and patients with enophthalmos or diplopia or dystopia alone were sent to surgery; patients with only ocular movement restrictions or infraorbital nerve dysfunction, or no sign of enophthalmos, diplopia, or ocular movement restrictions, were evaluated with CT for orbital rim assessments. If there was displacement of the orbital rims, the patients were sent to surgery. In patients with non-displaced rims, the radiologist was asked to measure the orbital volumes. If the orbital volume was calculated to be not equal to the healthy orbit, these patients were sent to surgery. If the orbital volume was normal, the patients were observed. Postoperative orbital volume values of the patients were compared with their healthy orbits, and the ocular complaints were also compared to those in the
CT evaluation and measurement of orbital volume Computed tomography (CT) was used to detect the transverse fracture size, presence of significant soft tissue herniation, and to calculate the orbital volume. CT scans were performed with a 4-detector multislice CT scanner (Toshiba Aquilion, Tokyo, Japan), and the images were obtained using continuous 3-mm-thick axial slices in a high resolution osseous window level setting. These images were then transferred to a processing workstation for further analysis with specialised software (Syngo.via, Breemen Mittle, Germany). In addition to the traditional axial images, multiplanar reconstructions (MPR) and three-dimensional volumerendering (3D VR) images were used to assess in detail the transverse fracture and orbital volume, when necessary, in patients who had non-displaced rims. Coronal images were drawn on each section of the orbital borders, and the orbital volumes were calculated automatically using a special software program [7]. Surgical procedure Patients were operated on after the resolution of swelling (mean 5th day; 2–7 days) [8]. The surgeries were performed by the same surgical team, and the subciliary approach was used routinely to gain space for the insertion of larger mesh plates and to repair the inferior orbital wall [8]. Periorbital bone fractures were re-aligned, and 1.3 mm or 1.5 mm titanium plates and screws (Synthes, Balsthal, Switzerland) were placed
Unilateral orbital trauma
Clinical examination IOND (+) OML (+) No clinical sign (only ecchymose/lid edema)
Diplopia (+) Enophthalmos (+) Distopia (+)
(CT evaluation for operation plan)
Chceck orbital rims
Normal orbital rims
Displaced orbital rims
Check orbital volume Increased/ decreased orbital volume Surgery
Normal orbital volume Observation
Figure 1. Algorithm for unilateral orbital fracture.
Algorithm for unilateral orbital fractures
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across the fractured segments. For reconstruction of orbital floor defects, appropriately sized and shaped titanium mesh plates and 1.0 or 1.3 titanium micro screws (Synthes) were used. Release of the soft tissue contents from their displaced positions or adherent structures was the most important issue in our treatment. Restriction or tethering of the globe was confirmed by “forced duction testing”. The skin was closed with 6/0 absorbable suture subcutaneously, and the frost traction [1] suture was removed at 48 hours. After 5 days, massage was recommended. Statistical analysis Statistical analyses were performed using SPSS 15.0 for Windows (SPSS Inc., Chicago, IL). Data are shown as the mean ± standard deviation, range, and percentages (%). The Mann Whitney U-test was used for comparing two groups and the paired t-test was used for preoperative and postoperative results. The results were considered to be statistically significant when the p-value was less than 0.05. Results We evaluated 248 patients with orbital trauma according to our algorithm (Figure 2). Diplopia was seen in 13 patients (5.2%), enophthalmos was seen in nine patients (3.6%), and dystopia was seen in one patient (0.4%) and they were examined in detail in order to send to surgery. The patients with ocular
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movement limitations (28 patients; 11.2%) and infraorbital nerve dysfunction (10 patients; 4.0%) were evaluated with CT for the orbital rims. Among the patients with ocular movement limitations: only five patients had infraorbital rim displacement by infraorbital rim fractures and impure blow-out fractures and they were sent to surgery; 23 patients with ocular movement limitations had normal orbital rims, but increased orbital volume was found in three of them by blow-out fracture, and they were also operated on; six of 10 patients with infraorbital nerve dysfunction had displacements of the infraorbital rim and they went to surgery; and four of the patients with infraorbital nerve dysfunction had normal orbital rims and normal orbital volumes, and they were observed. Of the patients, 187 (75.4%) had ocular trauma but had no sign of diplopia, enophthalmos, or ocular movement limitations, and were also evaluated with CT: three of the 187 patients had displacement of the orbital rims and were operated on; 18 patients had normal orbital rims but abnormal orbital volumes (increased orbital volume by blow-out fracture). In total, 58 patients of 248 evaluated patients (23.3%) (33 men and 25 women) were sent to surgery, and the mean age was 33.1 years (ranging from 19–67 years). All patients had full visual functions in their postoperative ophthalmic examinations. While diplopia was seen in six of the
Orbital trauma (248 patients)
Clinical examination
IOND (10 patients) OML (28 patients) No sign (187 patients)
Diplopia (13 patients) Enophthalmos (9 patients) Distopia (1 patients)
Check rim
Displaced rims (surgery) 5 patients (among OML) 6 patients (among IOND) 3 patients (among no sign)
Non displaced orbital rims 23 patients (with OML) 4 patients (with IOND) 184 patients (with no sign)
Check orbital volume Surgery 23 patients Abnormal Surgery 18 (among no sign) 3 (OML)
Normal
Observation (190 patients)
Figure 2. Patients on algorithm.
4 M. Karamese et al.
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Table I. Preoperative and postoperative symptoms of 58 patients.
Diplopia Ocular movement limitations (OML) Enophthalmos Exophthalmos Ectropion Dystopia Infection Infraorbital nerve dysfunction (IOND) Mesh plate extrusion/displacement Orbital adherence syndrome
patients in the early period, no diplopia was seen in their late period examinations. None of the patients had ocular movement limitations either in the early period or late period. Infraorbital nerve dysfunction was seen in 18 patients in the early period, but it was resolved during the late follow-up. One patient had an infection in the wound site and it was treated with oral antibiotics (Table I). The mean preoperative volume of the injured orbits was 30.1 cm3 (± 2.6 cm3), and the measurement of the postoperative injured volume was (mean) 27.1 cm3 (± 1.2 cm3). There was a statistically significant difference between the preoperative and postoperative orbital volumes (p = 0.0001). The mean volume of the healthy orbits was 27.9 cm3 (± 1.8 cm3), and there was no statistically significant difference between the postoperative injured and non-injured orbital volumes (Figures 3 and 4). In the first postoperative 4-weeks period, 68.9% of the patients had ectropion, and massage was recommended during this period. With the exception of two patients, the ectropion healed over time. These two patients did not agree to undergo an additional operation for the treatment of ectropion. Enophthalmos was found in two patients during the late period examinations. In the orbital CT scans of these patients, their orbital volumes were found to be similar to that of the other eye. Exophthalmos was found in four patients during their early period examinations. In their orbital volume measurements with CT, three of these had congruent orbital volumes with their other eye, but one had a contracted orbital volume. While three patients gained a normal appearance over time, one of the patients with a narrowed orbital volume was administered another operation to reposition the titanium mesh plate. Dystopia developed in one patient in the early postoperative period. Through re-operation, the zygoma was re-positioned.
a
Early postoperative (24 hours–4 weeks) 6 — — 4 40 1 1 18 — —
Preoperative 13 28 9 — — 1 — 10 — —
b
Figure 3. CT imaging of a 24-year-old man with unilateral maxillofacial trauma.
Late postoperative (8–12 months) — — 2 1 2 1 — — — —
Neither titanium mesh plate extrusion or displacement, nor any orbital adherence syndrome was seen in any patient. Patients (190 patients; 79%) who were not operated on according to the algorithm were observed and evaluated with inspection and ophthalmic examination for 8–12 months and no complications such as diplopia, enophthalmos, or dystopia were seen. Discussion This study showed that the proposed algorithm can be used appropriately in orbital traumas, and may provide a treatment opportunity for the patients that are passed over without a volume check. Due to the changeability inside an orbital fracture, with regard to fracture type, fracture site, and concomitant soft tissue injuries, there exists some controversy in management. The management of orbital fractures varies widely and is related to the surgeon’s decision more than any accepted consensus, due to different clinical symptoms. Additionally, evaluating diplopia and enophthalmos is difficult in the early posttraumatic period. Although the surgical approach and materials used for floor reconstruction have often been presented in the literature, management accuracy has rarely been reported. An algorithm
a
b
c
d
Figure 4. Postoperative images and orbital volume measurement of the same patient.
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Algorithm for unilateral orbital fractures for the management of orbital traumas has been used for many years in our clinic. In the literature, many algorithms were reported to be associated with blow out fractures [9]. Millman et al. [10] presented an algorithm related to orbital prolapse, responding to systemic steroids. Our algorithm includes clinical examination, rim fractures, and volume measurements in unilateral orbital fractures. In our study, we encountered enophthalmos, diplopia, and dystopia in 23 patients who were operated on among 58 patients with clinical examinations, and they were sent to operation based on the algorithm. Issues that must be kept in mind are that surgical plans for the patients were created with CT examinations. Of the patients, 187 had no symptoms like enophthalmos, diplopia, OML, or ION dysfunction; however, 21 patients detected by CT evaluation were operated on due to both orbital volume changes and orbital rim displacement. The rim examination of patients with facial fractures may be the first step in the evaluation of the position and the width of the fracture; however, the orbital rim may be non-displaced, and the orbital floor may be fractured due to a special organisation of the orbit [11]. The algorithm stands out in checking the orbital volume with any signs of enophthalmos, diplopia, or OML. In our study, through checking the orbital volume, we had an opportunity for surgical intervention preventing 21 patients from late complications, such as enophthalmos and dystopia. An increase in the orbital volume is more frequent than a decrease in the orbital volume in facial traumas. Fractures in the orbital floor or lateral portion of the orbit may cause an increase in the orbital volume [12]. In cases reported in the literature, such as orbital volume increases, the cause is usually blow out fractures [13]. Although the most obvious symptom of orbital volume increase is expected to be enophthalmos, enophthalmos cannot be identified immediately after a trauma. However, retrobulbar and infraorbital tissue oedemas and haematomas may conceal the emergence of this symptom during the early examination of the patient. Enophthalmos requires surgery, and it is known that early surgical intervention can improve the outcomes [1]. Therefore, CT images should be taken as the basis for surgical indication in orbital fractures, even if there is a normal appearance during inspection [14]. In our study we evaluated all patients with CT so as not to neglect any patient that requires surgical procedures. Surgeons evaluate orbital fractures with radiological criteria such as fracture size, displacement of the bone fragments, and comminution [7]. The measurement of the orbital volume is labour intensive, difficult to use in a clinical setting, and time consuming. The orbital volume must be assessed and compared both preoperatively and postoperatively. In our study, we used CT to measure the orbital volume and reached orbital volumes that are congruent with the other eye in the postoperative period. Achieving the integrity and volume of the orbital bone is the primary objective of the surgery. The aim of the postoperative CT examinations is to check whether or not the same volume as that of the other eye could be achieved. Enophthalmos was seen to continue clinically in two of our patients. The postoperative inspection findings of the patients in the late period are also important in that they show the response of periorbital soft tissue to the treatment. Since the
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integrity of the bone structure supporting the soft tissue was impaired at the time of trauma, re-modelling is done according to the periorbital ligament structures. Proper bone fixations that are made without losing time ensure the protection of the soft tissue and periorbital fat pad. Even when it seems that the same volume as that of the other eye has been achieved during CT inspections, re-modelling of soft tissue or fat pad atrophy may result in enophthalmos. The enophthalmos in two of our patients was defined as a soft tissue response. It is well known that the aesthetic and functional result can be obtained when the earlier significant orbital volume or muscle derangement can be corrected in significant orbital fractures [8]. The symptoms seen in the preoperative period in order of frequency were: ocular movement limitation (in 28 patients), diplopia (in 13 patients), infraorbital paraesthesia (in 10 patients), and enophthalmos (in nine patients). In the literature, the most frequently seen symptom is reported as diplopia in the presence of blow out fractures [6]. It is associated with progression of a fracture to the orbital floor in blowout fractures. According to Shah et al. [15], diplopia is associated with the amount of soft tissue that is incarcerated. In our study, it is considered that diplopia may be a component of orbital volume changes, and was seen in 13 patients (5%). The important issue for surgeons is to differentiate fractures in which diplopia is caused by bone fracture from those cases caused by muscle contusion, which heals spontaneously [12]. Ocular movement limitations were a more frequently seen result than diplopia. In accordance with the literature, we are of the opinion that not only muscle entrapment causes this, but also muscle contusion, oedema, and haematoma can cause the ocular movement limitations in diplopia [6,16]. OML requires an orbital volume check and, if the orbital volume is normal and orbital rims are nondisplaced, the patients are observed. In the literature double vision or diplopia caused by muscle or fine ligament system and suggested by CT examination is an indication of surgical treatment [8]. Exophthalmos was detected in only one patient. This was linked to an error made when shaping the mesh plate. Shaping the titanium mesh plate is very important when fixing an orbital floor fracture, because any bending that is done incorrectly or without adequate diligence will lead to exophthalmos in the postoperative period. The shape of the defect and different geometrical forms of the orbit play important roles in shaping the titanium mesh plate during a surgery. There are no reports stating that the thickness of a titanium mesh plate causes a change in the orbital volume, but, if any difference in the level between the orbital rim and orbital floor is not taken into consideration for a particular case, and the titanium mesh plate is not placed to align with the bone surfaces, then the orbital volume may contract and exophthalmos may occur. Dystopia requires surgery both preoperatively and as a complication in the postoperative period. In our series, there was one patient with vertical dystopia who was operated on immediately. We also encountered dystopia in one patient postoperatively due to an error made when re-positioning the zygoma. The patient was re-operated on: the bones were ruptured again, the masseter muscle was released, and the zygoma was re-positioned and fixed with plates and screws.
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6 M. Karamese et al. The patients were annoyed mostly by ectropion in the postoperative period. Ectropion occurred in 72% of the patients due to the subciliary incision; however, we knew that this condition was temporary. We did not recommend any treatment to our patients other than intensive massage therapy. Ectropion remained fixed in two patients in the late period. We suggested treatment for these patients, but they did not agree to be operated on again. Infraorbital anaesthesia/paraesthesia was seen more frequently in the postoperative period than in the preoperative period (preoperative = 10 patients, 17.2%; postoperative = 18 patients, 31.0%). The width of the dissection, tissue oedema, and excessive handling of the nerve patterns may result in paraesthesia. We did not have any patients who had infraorbital nerve damage in the late period. Conclusion Complex orbital fractures are conditions that need to be treated early. Since preoperative examination findings may often conceal the severity of fractures, it is important to decide on an operation on the basis of a consensus. Orbital volume assessments are valuable but must be associated with the alignment of orbital rims. We offered an algorithm for the management of unilateral orbital fractures based on the clinical examination and CT assessment.
[3] [4] [5] [6] [7] [8] [9] [10]
[11] [12]
Acknowledgement This study was conducted with approval from the Local Ethical Committee.
[13]
Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
[14] [15]
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