ORIGINAL ARTICLE
Analysis of Symptoms According to Areas of Orbital Floor in Orbital Inferior Wall Fractures Taekyung Eom, MD, and Younghwan Kim, PhD, MD Objectives: A considerable number of patients experiencing facial trauma are diagnosed with blowout fracture. Preoperative computed tomographic scan is often different from the actual surgical area. This study is restricted to orbital floor fracture. This study is expected to help speculating fracture site and making surgical plans according to symptoms of periorbital trauma. Methods: From March 2005 to September 2013, a total of 150 cases of orbital floor fracture surgeries have been analyzed. This study analyzed the preoperative symptoms at the certain fractured area of orbital floor, at the aspects of sagittal view of computed tomography, which is sectioned into anterior one-third, middle onethird, posterior one-third, and mixed types. Symptoms for analysis are diplopia, extraocular movement limitation, enophthalmos and other combined facial bone fractures, and the like. Results: Fracture areas of orbital floor are 21 cases (14%) of anterior one-third, 47 cases (31%) of middle one-third, 7 cases (5%) of posterior one-third, and 75 cases (50%) of the mixed. Frequency of diplopia was 0 case, 24 cases (42.1%), 4 cases (7.0%), and 29 cases (50.9%), respectively. In the case of extraocular movement limitation, 0 case, 15 cases (39.5%), 2 cases (5.3%), and 21 cases (55.2%) were found, respectively. In the case of enophthalmos, 0 case, 5 cases (16.7%), 7 cases (23.3%), and 18 cases (60.0%) were found, respectively. The most commonly associated other facial bone fractures were nasal bone fractures. Conclusions: In the case of blowout fracture, diplopia, extraocular movement limitation, enophthalmos, and other symptoms are checked through physical examination. This study would help speculating fracture site and making surgical plans according to symptoms of periorbital trauma. Key Words: Orbital fracture, diplopia, enophthalmos (J Craniofac Surg 2015;26: 647–649)
B
lowout fracture is known to be caused by 2 mechanisms, that is, the hydraulic theory and the buckling theory. The hydraulic theory is that external force on eye causes increased intraorbital pressure and the pressure is transmitted to the orbital wall to cause the fracture. The buckling theory is that external force is applied From the Department of Plastic and Reconstructive Surgery, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea. Received May 30, 2014. Accepted for publication October 28, 2014. Address correspondence and reprint requests to Dr. Younghwan Kim, Department of Plastic and Reconstructive Surgery, Busan Baik Hospital, Inje University College of Medicine, 75 Bokji-ro, Busan Jin-gu, Busan 614-735, South Korea; E-mail: [email protected] The authors report no conflict of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001418
The Journal of Craniofacial Surgery
directly to the inferior orbital rim and to the orbital wall to cause the fracture.1,2 Blowout fracture can be accompanied with symptoms such as diplopia, extraocular movement limitation, enopthalmos, hyphema, retrobulbar hematoma, globe rupture, other facial bone fracutures, and the like.3– 6 This study divided the orbit into anterior one-third, middle one-third, and posterior one-third on the anterior-posterior side of the sagittal plane of computed tomographic (CT) scan. In addition, this compares varying symptoms or signs on each part of blowout fracture.
MATERIALS AND METHODS One hundred fifty patients who were surgically treated on orbital inferior wall fracture during the period from March 2005 to September 2013 were examined. Inferior wall fracture sites were divided into anterior one-third, middle one-third, and posterior one-third sections on the anterior-posterior side of the sagittal plane of CT scan. Moreover, cases where fracture occurred more than 1 section are named mixed fracture. (Figs. 1–4) This article studies symptoms, signs, and combined fracture on each section of CT scan.
RESULTS Age and Sex One hundred fifty patients who were surgically treated on orbital inferior wall fracture during the period from March 2005 to September 2013 were examined. Age spans between 8 and 74 years, with an average of 36.7 years. Of those 150 patients, 119 patients (79%) were males and 31 patients (21%) were females. People in their 30 s showed the highest rate (Table 1).
Etiology Violence is the most prominent cause of trauma (92 patients, 61%), followed by slipping down (30 patients, 20%), traffic accident (15 patients, 10%), and others (13 patients, 9%).
Location of Fractures Twenty-one cases (14%) were found in the anterior one-third section; 47 cases (31%), in the middle one-third, 7 cases (5%), in the posterior one-third, and 75 cases (50%), for mixed fracture. The anterior one-third recorded the highest rate, except the mixed fracture.
Symptoms Swelling and ecchymosis were found in most cases. The number of diplopia cases was 0 in the anterior one-third section, 24 cases in the middle one-third, 4 cases in the posterior one-third, and 29 cases for mixed fracture. The number of extraocular movement limitation cases was 0 in the anterior one-third section, 15 cases in the middle one-third, 2 cases in the posterior one-third, and 21 cases for mixed fracture. Enophthalmos was found in 0 case in the anterior
Volume 26, Number 3, May 2015
647
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Eom et al
The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
TABLE 1. Age and Sex Distribution of Orbital Inferior Wall Fracture
FIGURE 1. Schematic representation of fracture site in the inferior orbital wall.
Age, y
Male
Female
10 11–20 21–30 31–40 41–50 51–60 61–70 71– Total
2 17 28 39 19 11 2 1 119 (79%)
0 4 8 11 6 2 0 0 31 (21%)
Total 2 21 36 50 25 13 2 1 150
(1%) (14%) (24%) (33%) (17%) (9%) (1%) (1%) (100%)
posterior one-third, and 23 cases (52.3%) for mixed fracture. The anterior one-third recorded the highest rate, except the mixed fracture (Table 3).
DISCUSSION FIGURE 2. Example of orbital floor anterior one-third fracture, sagittal view of CT scan. The patient was a 28-year-old male patient, injured by violence.
one-third, 5 cases in the middle one-third, 7 cases in the posterior one-third, and 28 cases for mixed fracture (Table 2).
Associated Facial Bone Fracture The total number of patients with associated facial bone fracture was 44 patients (29.3%). Of those 44 patients, nasal bone fracture was found in 20 patients (45.5%), zygomatic arch fracture in 10 (22.7%), maxilla fracture in 8 (18.2%), mandible fracture with 1 (2.3%), and frontal bone fracture with 7 (11.3%). Nasal bone fracture recorded the highest rate. According to orbital inferior wall fracture, 7 cases (15.9%) were found in the anterior one-third, 12 cases (27.3%) in the middle one-third, and 2 cases (4.5%) in the
FIGURE 3. Example of orbital floor medial one-third fracture sagittal view of CT scan. The patient was a 24-year-old male patient, injured by violence.
Orbital fractures can happen in any sort of incidents that could cause facial trauma including assault, falling down, car accident, sports, occupational accidents, and the like. Such an accident can happen to anyone regardless of age and sex.3,4,7 In this article, a frequency of male (79%) patients showed to be significantly higher than that of female, especially at ages 20 to 50 years. This is thought to be associated with higher outdoor activities in males. Blowout fracture is usually explained with 2 mechanisms: increased intraorbital hydraulic pressure and buckling force to the orbital floor. These forces are thought to be operated respectively or somewhat simultaneously in part. The hydraulic mechanism applies greater force on medial wall and causes fracture where greater threshold stress is exerted. On the other hand, the buckling mechanism applies greater force on the inferior wall.1,2 Thinnest areas of the bony orbit are a lamina papyracea of the ethmoid and the floor of the infraorbital groove. Lamina papyracea is the largest area in the medial orbital wall. However, infraorbital groove is a narrow section supported by the orbital floor.1 This article shows that 50% was mixed fracture, that 31% was the middle one-third, and that 14% was the anterior one-third. The middle one-third section shows the highest frequency, except mixed fracture. This suggests that the threshold of trauma in the orbital floor is relatively lower. Symptoms and signs associated with orbital fracture are diplopia, extraocular movement limitation, enopthalmos, combined other facial bone fracture, hyphema, retrobulbar hematoma, globe rupture, exophthalmos, subconjunctival hemorrhage, periorbital ecchymosis, swelling, infraorbital nerve paralysis, and the like.6,8–11 Diplopia and extraocular movement limitation can be caused by edema, hemorrhage, paralysis of the inferior rectus muscle, incarceration, or damage to the muscle or nerves within the orbit.3,5,8,10 This article shows that frequency of diplopia was found in the order TABLE 2. Symptoms Associated With Orbital Inferior Wall Fracture Site Ant. 1/3 Mid. 1/3 Post. 1/3 Mixed Total
FIGURE 4. Example of orbital floor posterior one-third fracture, sagittal view of CT scan. The patient was a 14-year-old male patient, injured by slipping down.
648
Diplopia 0 24 4 29 57
(0%) (42.1%) (7.0%) (50.9%) (100%)
EOM Limitation 0 15 2 21 38
(0%) (39.5%) (5.3%) (55.2%) (100%)
Enophthalmos 0 5 7 18 30
(0%) (16.7%) (23.3%) (60.0%) (100%)
Ant., anterior; EOM, extraocular movement; Mid., middle; Post., posterior.
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
TABLE 3. Associated Facial Bone Fracture Site
Nasal
Zygoma
Maxilla
Ant. 1/3 3 2 2 Mid. 1/3 7 2 1 Post. 1/3 1 0 1 Mixed 9 6 4 Total 20 (45.5%) 10 (22.7%) 8 (18.2%)
Mandible 0 0 0 1 1 (2.3%)
Frontal
Total
0 7 (15.9%) 2 12 (27.3%) 0 2 (4.5%) 3 23 (52.3%) 5 (11.3%)
Ant., anterior; EOM, extraocular movement; Mid., middle; Post., posterior.
of mixed fracture, the middle one-third, the posterior one-third, and the anterior one-third. This is presumed to be caused by swelling of the orbital soft tissue, extraocular movement limitation, and changes in the visual axis. Anterior fracture tends to cause less changes in the visual axis. The reason why the middle one-third fracture shows higher frequency than the posterior one-third is that fat or muscle of orbital soft tissue can be infiltrated into fracture site to increase orbital volume to cause changes in the position of globe. Extraocular movement limitation is caused by incarceration of muscle, muscle traction and direct muscle injury of the connective tissue septa, and the like.4,6,7 Shin et al5 reported that extraocular movement limitation (12.8%) is the second most frequent orbital fracture symptoms following diplopia (27.6%). They observed 24.2% of extraocular movement limitation in orbital medial wall fracture, 50% in orbital inferior wall fracture, and 49.5% in inferomedial wall fracture. Therefore, they concluded that extraocular movement limitation is more closely related to orbital inferior wall fracture. This article found that the middle one-third has the highest rate, except mixed fracture, followed by the posterior one-third and the anterior one-third. Enophthalmos is usually caused by orbital fracture due to trauma. Associated functional consequences are diplopia and eyelid retraction. The main focus is aesthetic recovery in shape or size through surgical method.4,11,12 Shin et al5 reported that enophthalmos was observed in 8.8% of blowout fracture, 7.7% of orbital inferior wall fracture, and 15.2% of inferomedial wall fracture. In this article, increase in orbital volume in the case of the posterior one-third is presumed to be the cause. The highest rate is in the middle one-third, followed by the posterior one-third and the anterior one-third. Other associated fractures are nasoethmoidal fracture, supraorbital fracture, tripod fracture, midfacial fracture, and the like. Symptoms including flattened nasal bridge, dislocation of the teeth from the skull, and craniodysjunction can be found, and additional treatment is required according to fracture.9 In this article, nasal bone fracture is the most prominent, where combined fracture and middle one-third are the highest frequency. Fracture in the anterior
#
2015 Mutaz B. Habal, MD
Orbital Inferior Wall Fracture Symptoms
one-third is especially related with other facial fractures. This could be accompanied with orbital rim fracture because the anterior onethird is the connecting point of the orbital rim.
CONCLUSIONS In case of blowout fracture, diplopia, extraocular limitation, enophthalmos, and other symptoms must be checked preoperatively. This study divided the orbit into the anterior one-third, the middle one-third, and the posterior one-third on the anteriorposterior side of the sagittal plane of CT scan. Symptoms are analyzed depending on sections of fractures. In the anterior onethird section, no other symptoms were found, except combined facial bone fracture (tripod fracture, maxilla fracture, etc). In the middle one-third section, diplopia and extraocular movement limitation are the most prominent symptoms. Enophthalmos in the posterior one-third section and extraocular movement limitation in combined fracture observed recorded the highest frequency. This study would help speculating fracture site and making surgery plans in blowout inferior wall fracture.
REFERENCES 1. Warwar RE, Bullock JD, Ballal DR, et al. Mechanisms of orbital floor fractures: a clinical, experimental, and theoretical study. Ophthal Plast Reconstr Surg 2000;16:188–200 2. Nagasao T, Miyamoto J, Jiang H, et al. Interaction of hydraulic and buckling mechanisms in blowout fractures. Ann Plast Surg 2010;64:471–476 3. Burm JS, Chung CH, Oh SJ. Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture. Plast Reconstr Surg 1999;103:1839–1849 4. Chi MJ, Ku M, Shin KH, et al. An analysis of 733 surgically treated blowout fractures. Ophthalmologica 2010;224:167–175 5. Shin JW, Lim JS, Yoo G, et al. An analysis of pure blowout fractures and associated ocular symptoms. J Craniofac Surg 2013;24:703–707 6. Yano H, Suzuki Y, Yoshimoto H, et al. Linear-type orbital floor fracture with or without muscle involvement. J Craniofac Surg 2010;21:1072–1078 7. Yano H, Nakano M, Anraku K, et al. A consecutive case review of orbital blowout fractures and recommendations for comprehensive management. Plast Reconstr Surg 2009;124:602–611 8. Tahiri Y, Lee J, Tahiri M, et al. Preoperative diplopia: the most important prognostic factor for diplopia after surgical repair of pure orbital blowout fracture. J Craniofac Surg 2010;21:1038–1041 9. Burnstine MA. Clinical recommendations for repair of orbital facial fractures. Curr Opin Ophthalmol 2003;14:236–240 10. Park MS, Kim YJ, Kim H, et al. Prevalence of diplopia and extraocular movement limitation according to the location of isolated pure blowout fractures. Arch Plast Surg 2012;39:204–208 11. Hazani R, Yaremchuk MJ. Correction of posttraumatic enophthalmos. Arch Plast Surg 2012;39:11–17 12. He Y, Zhang Y, An JG. Correlation of types of orbital fracture and occurrence of enophthalmos. J Craniofac Surg 2012;23:1050–1053
649
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Analysis of Symptoms According to Areas of Orbital Floor in Orbital Inferior Wall Fractures Taekyung Eom, MD, and Younghwan Kim, PhD, MD Objectives: A considerable number of patients experiencing facial trauma are diagnosed with blowout fracture. Preoperative computed tomographic scan is often different from the actual surgical area. This study is restricted to orbital floor fracture. This study is expected to help speculating fracture site and making surgical plans according to symptoms of periorbital trauma. Methods: From March 2005 to September 2013, a total of 150 cases of orbital floor fracture surgeries have been analyzed. This study analyzed the preoperative symptoms at the certain fractured area of orbital floor, at the aspects of sagittal view of computed tomography, which is sectioned into anterior one-third, middle onethird, posterior one-third, and mixed types. Symptoms for analysis are diplopia, extraocular movement limitation, enophthalmos and other combined facial bone fractures, and the like. Results: Fracture areas of orbital floor are 21 cases (14%) of anterior one-third, 47 cases (31%) of middle one-third, 7 cases (5%) of posterior one-third, and 75 cases (50%) of the mixed. Frequency of diplopia was 0 case, 24 cases (42.1%), 4 cases (7.0%), and 29 cases (50.9%), respectively. In the case of extraocular movement limitation, 0 case, 15 cases (39.5%), 2 cases (5.3%), and 21 cases (55.2%) were found, respectively. In the case of enophthalmos, 0 case, 5 cases (16.7%), 7 cases (23.3%), and 18 cases (60.0%) were found, respectively. The most commonly associated other facial bone fractures were nasal bone fractures. Conclusions: In the case of blowout fracture, diplopia, extraocular movement limitation, enophthalmos, and other symptoms are checked through physical examination. This study would help speculating fracture site and making surgical plans according to symptoms of periorbital trauma. Key Words: Orbital fracture, diplopia, enophthalmos (J Craniofac Surg 2015;26: 647–649)
B
lowout fracture is known to be caused by 2 mechanisms, that is, the hydraulic theory and the buckling theory. The hydraulic theory is that external force on eye causes increased intraorbital pressure and the pressure is transmitted to the orbital wall to cause the fracture. The buckling theory is that external force is applied From the Department of Plastic and Reconstructive Surgery, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea. Received May 30, 2014. Accepted for publication October 28, 2014. Address correspondence and reprint requests to Dr. Younghwan Kim, Department of Plastic and Reconstructive Surgery, Busan Baik Hospital, Inje University College of Medicine, 75 Bokji-ro, Busan Jin-gu, Busan 614-735, South Korea; E-mail: [email protected] The authors report no conflict of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001418
The Journal of Craniofacial Surgery
directly to the inferior orbital rim and to the orbital wall to cause the fracture.1,2 Blowout fracture can be accompanied with symptoms such as diplopia, extraocular movement limitation, enopthalmos, hyphema, retrobulbar hematoma, globe rupture, other facial bone fracutures, and the like.3– 6 This study divided the orbit into anterior one-third, middle one-third, and posterior one-third on the anterior-posterior side of the sagittal plane of computed tomographic (CT) scan. In addition, this compares varying symptoms or signs on each part of blowout fracture.
MATERIALS AND METHODS One hundred fifty patients who were surgically treated on orbital inferior wall fracture during the period from March 2005 to September 2013 were examined. Inferior wall fracture sites were divided into anterior one-third, middle one-third, and posterior one-third sections on the anterior-posterior side of the sagittal plane of CT scan. Moreover, cases where fracture occurred more than 1 section are named mixed fracture. (Figs. 1–4) This article studies symptoms, signs, and combined fracture on each section of CT scan.
RESULTS Age and Sex One hundred fifty patients who were surgically treated on orbital inferior wall fracture during the period from March 2005 to September 2013 were examined. Age spans between 8 and 74 years, with an average of 36.7 years. Of those 150 patients, 119 patients (79%) were males and 31 patients (21%) were females. People in their 30 s showed the highest rate (Table 1).
Etiology Violence is the most prominent cause of trauma (92 patients, 61%), followed by slipping down (30 patients, 20%), traffic accident (15 patients, 10%), and others (13 patients, 9%).
Location of Fractures Twenty-one cases (14%) were found in the anterior one-third section; 47 cases (31%), in the middle one-third, 7 cases (5%), in the posterior one-third, and 75 cases (50%), for mixed fracture. The anterior one-third recorded the highest rate, except the mixed fracture.
Symptoms Swelling and ecchymosis were found in most cases. The number of diplopia cases was 0 in the anterior one-third section, 24 cases in the middle one-third, 4 cases in the posterior one-third, and 29 cases for mixed fracture. The number of extraocular movement limitation cases was 0 in the anterior one-third section, 15 cases in the middle one-third, 2 cases in the posterior one-third, and 21 cases for mixed fracture. Enophthalmos was found in 0 case in the anterior
Volume 26, Number 3, May 2015
647
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Eom et al
The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
TABLE 1. Age and Sex Distribution of Orbital Inferior Wall Fracture
FIGURE 1. Schematic representation of fracture site in the inferior orbital wall.
Age, y
Male
Female
10 11–20 21–30 31–40 41–50 51–60 61–70 71– Total
2 17 28 39 19 11 2 1 119 (79%)
0 4 8 11 6 2 0 0 31 (21%)
Total 2 21 36 50 25 13 2 1 150
(1%) (14%) (24%) (33%) (17%) (9%) (1%) (1%) (100%)
posterior one-third, and 23 cases (52.3%) for mixed fracture. The anterior one-third recorded the highest rate, except the mixed fracture (Table 3).
DISCUSSION FIGURE 2. Example of orbital floor anterior one-third fracture, sagittal view of CT scan. The patient was a 28-year-old male patient, injured by violence.
one-third, 5 cases in the middle one-third, 7 cases in the posterior one-third, and 28 cases for mixed fracture (Table 2).
Associated Facial Bone Fracture The total number of patients with associated facial bone fracture was 44 patients (29.3%). Of those 44 patients, nasal bone fracture was found in 20 patients (45.5%), zygomatic arch fracture in 10 (22.7%), maxilla fracture in 8 (18.2%), mandible fracture with 1 (2.3%), and frontal bone fracture with 7 (11.3%). Nasal bone fracture recorded the highest rate. According to orbital inferior wall fracture, 7 cases (15.9%) were found in the anterior one-third, 12 cases (27.3%) in the middle one-third, and 2 cases (4.5%) in the
FIGURE 3. Example of orbital floor medial one-third fracture sagittal view of CT scan. The patient was a 24-year-old male patient, injured by violence.
Orbital fractures can happen in any sort of incidents that could cause facial trauma including assault, falling down, car accident, sports, occupational accidents, and the like. Such an accident can happen to anyone regardless of age and sex.3,4,7 In this article, a frequency of male (79%) patients showed to be significantly higher than that of female, especially at ages 20 to 50 years. This is thought to be associated with higher outdoor activities in males. Blowout fracture is usually explained with 2 mechanisms: increased intraorbital hydraulic pressure and buckling force to the orbital floor. These forces are thought to be operated respectively or somewhat simultaneously in part. The hydraulic mechanism applies greater force on medial wall and causes fracture where greater threshold stress is exerted. On the other hand, the buckling mechanism applies greater force on the inferior wall.1,2 Thinnest areas of the bony orbit are a lamina papyracea of the ethmoid and the floor of the infraorbital groove. Lamina papyracea is the largest area in the medial orbital wall. However, infraorbital groove is a narrow section supported by the orbital floor.1 This article shows that 50% was mixed fracture, that 31% was the middle one-third, and that 14% was the anterior one-third. The middle one-third section shows the highest frequency, except mixed fracture. This suggests that the threshold of trauma in the orbital floor is relatively lower. Symptoms and signs associated with orbital fracture are diplopia, extraocular movement limitation, enopthalmos, combined other facial bone fracture, hyphema, retrobulbar hematoma, globe rupture, exophthalmos, subconjunctival hemorrhage, periorbital ecchymosis, swelling, infraorbital nerve paralysis, and the like.6,8–11 Diplopia and extraocular movement limitation can be caused by edema, hemorrhage, paralysis of the inferior rectus muscle, incarceration, or damage to the muscle or nerves within the orbit.3,5,8,10 This article shows that frequency of diplopia was found in the order TABLE 2. Symptoms Associated With Orbital Inferior Wall Fracture Site Ant. 1/3 Mid. 1/3 Post. 1/3 Mixed Total
FIGURE 4. Example of orbital floor posterior one-third fracture, sagittal view of CT scan. The patient was a 14-year-old male patient, injured by slipping down.
648
Diplopia 0 24 4 29 57
(0%) (42.1%) (7.0%) (50.9%) (100%)
EOM Limitation 0 15 2 21 38
(0%) (39.5%) (5.3%) (55.2%) (100%)
Enophthalmos 0 5 7 18 30
(0%) (16.7%) (23.3%) (60.0%) (100%)
Ant., anterior; EOM, extraocular movement; Mid., middle; Post., posterior.
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 3, May 2015
TABLE 3. Associated Facial Bone Fracture Site
Nasal
Zygoma
Maxilla
Ant. 1/3 3 2 2 Mid. 1/3 7 2 1 Post. 1/3 1 0 1 Mixed 9 6 4 Total 20 (45.5%) 10 (22.7%) 8 (18.2%)
Mandible 0 0 0 1 1 (2.3%)
Frontal
Total
0 7 (15.9%) 2 12 (27.3%) 0 2 (4.5%) 3 23 (52.3%) 5 (11.3%)
Ant., anterior; EOM, extraocular movement; Mid., middle; Post., posterior.
of mixed fracture, the middle one-third, the posterior one-third, and the anterior one-third. This is presumed to be caused by swelling of the orbital soft tissue, extraocular movement limitation, and changes in the visual axis. Anterior fracture tends to cause less changes in the visual axis. The reason why the middle one-third fracture shows higher frequency than the posterior one-third is that fat or muscle of orbital soft tissue can be infiltrated into fracture site to increase orbital volume to cause changes in the position of globe. Extraocular movement limitation is caused by incarceration of muscle, muscle traction and direct muscle injury of the connective tissue septa, and the like.4,6,7 Shin et al5 reported that extraocular movement limitation (12.8%) is the second most frequent orbital fracture symptoms following diplopia (27.6%). They observed 24.2% of extraocular movement limitation in orbital medial wall fracture, 50% in orbital inferior wall fracture, and 49.5% in inferomedial wall fracture. Therefore, they concluded that extraocular movement limitation is more closely related to orbital inferior wall fracture. This article found that the middle one-third has the highest rate, except mixed fracture, followed by the posterior one-third and the anterior one-third. Enophthalmos is usually caused by orbital fracture due to trauma. Associated functional consequences are diplopia and eyelid retraction. The main focus is aesthetic recovery in shape or size through surgical method.4,11,12 Shin et al5 reported that enophthalmos was observed in 8.8% of blowout fracture, 7.7% of orbital inferior wall fracture, and 15.2% of inferomedial wall fracture. In this article, increase in orbital volume in the case of the posterior one-third is presumed to be the cause. The highest rate is in the middle one-third, followed by the posterior one-third and the anterior one-third. Other associated fractures are nasoethmoidal fracture, supraorbital fracture, tripod fracture, midfacial fracture, and the like. Symptoms including flattened nasal bridge, dislocation of the teeth from the skull, and craniodysjunction can be found, and additional treatment is required according to fracture.9 In this article, nasal bone fracture is the most prominent, where combined fracture and middle one-third are the highest frequency. Fracture in the anterior
#
2015 Mutaz B. Habal, MD
Orbital Inferior Wall Fracture Symptoms
one-third is especially related with other facial fractures. This could be accompanied with orbital rim fracture because the anterior onethird is the connecting point of the orbital rim.
CONCLUSIONS In case of blowout fracture, diplopia, extraocular limitation, enophthalmos, and other symptoms must be checked preoperatively. This study divided the orbit into the anterior one-third, the middle one-third, and the posterior one-third on the anteriorposterior side of the sagittal plane of CT scan. Symptoms are analyzed depending on sections of fractures. In the anterior onethird section, no other symptoms were found, except combined facial bone fracture (tripod fracture, maxilla fracture, etc). In the middle one-third section, diplopia and extraocular movement limitation are the most prominent symptoms. Enophthalmos in the posterior one-third section and extraocular movement limitation in combined fracture observed recorded the highest frequency. This study would help speculating fracture site and making surgery plans in blowout inferior wall fracture.
REFERENCES 1. Warwar RE, Bullock JD, Ballal DR, et al. Mechanisms of orbital floor fractures: a clinical, experimental, and theoretical study. Ophthal Plast Reconstr Surg 2000;16:188–200 2. Nagasao T, Miyamoto J, Jiang H, et al. Interaction of hydraulic and buckling mechanisms in blowout fractures. Ann Plast Surg 2010;64:471–476 3. Burm JS, Chung CH, Oh SJ. Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture. Plast Reconstr Surg 1999;103:1839–1849 4. Chi MJ, Ku M, Shin KH, et al. An analysis of 733 surgically treated blowout fractures. Ophthalmologica 2010;224:167–175 5. Shin JW, Lim JS, Yoo G, et al. An analysis of pure blowout fractures and associated ocular symptoms. J Craniofac Surg 2013;24:703–707 6. Yano H, Suzuki Y, Yoshimoto H, et al. Linear-type orbital floor fracture with or without muscle involvement. J Craniofac Surg 2010;21:1072–1078 7. Yano H, Nakano M, Anraku K, et al. A consecutive case review of orbital blowout fractures and recommendations for comprehensive management. Plast Reconstr Surg 2009;124:602–611 8. Tahiri Y, Lee J, Tahiri M, et al. Preoperative diplopia: the most important prognostic factor for diplopia after surgical repair of pure orbital blowout fracture. J Craniofac Surg 2010;21:1038–1041 9. Burnstine MA. Clinical recommendations for repair of orbital facial fractures. Curr Opin Ophthalmol 2003;14:236–240 10. Park MS, Kim YJ, Kim H, et al. Prevalence of diplopia and extraocular movement limitation according to the location of isolated pure blowout fractures. Arch Plast Surg 2012;39:204–208 11. Hazani R, Yaremchuk MJ. Correction of posttraumatic enophthalmos. Arch Plast Surg 2012;39:11–17 12. He Y, Zhang Y, An JG. Correlation of types of orbital fracture and occurrence of enophthalmos. J Craniofac Surg 2012;23:1050–1053
649
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
