Fractures of the Orbital Ring The orbital ring occupies a prominent place on the facial skull and is thus a frequent recipient of traumatization.1-3 Concerning the etiology of 264 orbital fractures, automobile accidents dominated. However, the isolated blowout fractures were primarily caused by human fists or falling on the face. Three times as many accidents happened during leisure time compared with working hours. The pathomechanism of the fractures could always be related to inelastic objects or the impact of the maxillofacial region against an inflexible surface.4 Data have been obtained from an eye, ear, nose, and throat analysis at the departments of the University Hospitals in Miinsters 5 years ago. As published previously, we could not include compact with heavy balls, such as hurling balls, baseballs, cricket balls, or hockey pucks, in our collection of fracture-producing objects,5 since the games to which these balls belong are not very popular in our country. On the other hand, clinical findings of 163injuries resulting from air-filled, elastic balls, such as soccer balls, tennis balls, volleyballs, and handballs, could be correlated to typical contusion-suction traumas of the eyeball. However, there was no evidence of orbital fractures in this group.416 In attempting to classify the fractures we followed the localization and frequency of the lesions. The majority of orbital fractures could be separated into lateral and medial central midface traumas with varying degree of injuries,7 with further divisions of isolated fractures in the inferior, medial, and superior section of the ring (Figs. 1, 2).
PREOPERATIVE DIAGNOSIS Physical examination usually begins with the inspection of the periorbital area for ecchymosis of
the skin and subconjunctival hemorrhage (Fig. 3). Visualization is followed by gentle palpation of the positions of the orbital rims to discover irregularities. Extraocular muscle excursion should be evaluated along with the position of the globe, realizing that exophthalmos, enophthalmos, and vertical dystopia may be masked by periorbital swelling. Diplopia in end position of the globe is always suspect of soft tissue herniation. Clinical investigation should be completed by consultation of an ophthalmologist. This advice is based on the experience that in about 30% of our series in which the eyeball was involved, blindness was found in 13%. Besides these findings, infra- and supraorbital dys- or anesthesia of the trigeminal branches may frequently accompany orbital traumas. Although physical examination is indispensable, the exact nature of these fractures can rarely be determined without x-ray or computed tomography (CT scans) examinations. Both axial and coronal CT sections should be obtained. Three-dimensional scans provide an addition perspective, although they are not essential for the treatment of these injuries.
LATERAL FRACTURES O F THE ORBIT Typical zygoma impression fracture lines (Fig. 1) run from the zygomaticofrontal suture over the lateral wall of the orbit along the orbital floor to the inferior rim. This fracture involves the zygomaticomaxillary buttress and the zygomatic arch. Usually, we find a palpebral and subconjunctivalhematoma, displacement of the lateral canthus and globe, hypoesthesia of the infraorbital nerve, asymmetry of the cheek and arch contours, diplopia with or without skin lacerations, etc.
Reprint requests: Dr. Stoll, Sendener Stiege 68, 4400 Miinster, Germany Copyright 01991 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights resewed.
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
W. Stoll, M.D.
Figure 1. Distribution of medial and lateral fractures of the orbital ring.
Figure 3. Presurgical view of patient with left-sided zygoma-impression fracture and enophthalmos.
Figure 2. orbit.
Frequency of selected isolated fractures of the
Figure 4.
Treatment
Closed lateral canthotomy incision.
at the infraorbital rim. In order to avoid second surgery for plate removal, we often use steel wires for Surgical reconstruction can be managed by differ- the infraorbital rim fixation (Figs. 7, 8A, B). The ent approaches. We prefer the transconjunctivalinci- gingivobuccal incision exposes the zygomaticomaxsion in combination with the lateral canthotomy inci- illary buttress as an additional guide to fracture sion (Fig. 4). If necessary we extend the incision alignment. Especially severe comminutions require along the lateral rim (Fig. 5) to explore the lateral full exposure of all the articulations of the zygoma orbit and the orbital fl00r.8.9 and maxilla with adjacent bones. Reposition of the fragments is followed by stabilizDirect wiring or plating of fracture lines that cross ation with plates and steel wires.1,loJ We place buttresses follows. The orbital floor is supported mostly two six-hole plates at the zygomaticofrontal only in cases of complete comminution with expansuture (Fig. 6). Maxillary adaptation is then applied sive inferior prolapse (Fig. 9) or loss of floor frag-
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FACIAL PLASTIC SURGERY Volume 7, Number 3 1990
ORBITAL RING FRACTURES-St011
-1
Prognosis
Figure 5. Suitable approaches to the orbital ring. Additionally, the nonpainted coronal incision is necessary.
Persistent postoperative complaints are closely correlated to the severity of the injuries. Patients with simple zygoma-impression fractures presented postoperative double vision in 13%, but 31% of patients with complex midface injuries presented diplopia 6 to 12 months after surgery. Residual diplopia will be minimal in functional fields of gaze, despite its presence in peripheral fields, thus no treatment will be required. The remaining persistent defects include ectropion, enophthalmos, dysesthesia, ptosis, sinusitis.
MEDIAL FRACTURES O F THE O R B I T The complexity of medial fractures of the orbit originates from the anatomy of the nasoethmoidal region. At least four fractures are necessary to dislocate the medial orbital angle. These occur in the medial orbital wall, the inferior wall, the nose, and the junction of the frontal process of the maxilla with the frontal bone. Force concentration to the midface Figure 6. Fixation of the zygomaticofrontal suture with a may extend uni- or bilaterally as more generalized Le small plate. The approach is via transconjunctival and lateral Fort or panfacial fractures. However, these genercanthotomy incision. alized fracture types are not discussed here. The diagnosis of nasoethmoidal orbital fractures is suggested by the presence of periorbital ecchymosis and swelling. Frequently, the nose will be distorted. ments (Fig. 10A). Properly contoured bone grafts of On direct pressure, a slight movement of the frontal the rib and in mild destruction Gore-Tex (Fig. 10B)or process implies instability of the rim. Axial and corolyophilized dura patches are available to dictate the nal CT scans provide excellent definition of medial structural position of the soft tissue and the b0ne~2.12 wall fractures. Air in the orbit is a common event and and transmaxillary silicon tubes or water-filled bal- may displace the orbital soft tissue. Comminution of loon catheters are emphasized as successful tech- ethmoid cells with impressed areas and opacity of niques with poor risks.4J3~14 the involved sinuses are almost the rule (Fig. 11).
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Figure 7. Stabilization of the fractured inferior rim over a conjunctival access with steel wires.
Figure 8. A: Zygoma impression fracture, gaping inferior rim. B: Postoperative x-ray control of the zygornatic position.
Treatment Reconstructive surgery has to be adapted individually. Mild dislocations of the nasal frame can be treated by intranasal reposition. The endoscopic controlled transnasal ethmoidectomy is emphasized for destruction of the ethmoidal region combined with less external deformation. However, severe destruction, orbital complications, and liquorrhea are best treated through the open approach via Killian's incision. This excellent access is recommended for orbital and optic nerve decompression, too.15 ConFigure 9. Isolated orbital floor fractures with expansive cerning the effect of decompression surgery, we prolapse into the maxillary sinus. achieved the best results by starting the procedure
m
Figure 10. A: Orbital floor defect. B: Supported orbital floor using a Gore-Tex patch with artificial perforations.
162
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ORBITAL RING FRACTURES-St011
within 24 hours after the post-traumatic visual loss. For safe and adequate decompression, we remove the fractured lamina orbitalis piece by piece and drill down the medial wall of the optic channel under microscopic control. Following this procedure, we improved the vision in 58.3% postoperatively16 In
Figure 12. A. Reconstruction of the glabella and nasoethmoidal region using plates and screws. B. The traumatic lacerationwas used as the surgical approach. C. Postsurgical appearance after 10 months.
SELECTED ISOLATED FRACTURES OF THE ORBIT Orbital Floor Fractures
The orbital floor as well as the lamina orbitalis of the medial wall are predisposed to fracture by the thinness of these bones. The source of trauma comprises two components: first, the increased intraorbi-
.-
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Figure 11. CT scan demonstrating symmetrical compression of ethmoidal air cells. The right-sided fracture visualized in the posterior orbit was accompanied by optic nerve compression syndrome. Optic nerve decompression was performed with good results.
contrast to other authors we neglect the reconstruction of the lamina orbitalis ossis ethmoidalis because scars always produce a sufficient boundary of the medial orbit. From an aesthetic point of view, the precise reconstruction of the glabella and medial canthal region is very important. In particular, surgical techniques that avoid iatrogenic detachment of the canthal ligament protect the natural appearance of the medial eye angle. Therefore the most effective transnasal wire should be placed into the lacrimal fossa to connect the medial orbital rim of both sides. Narrowing of the intercanthal distance can be supported by exactly adapted plates fixed at the frontal bone (Fig. 12A, B, C). Overcorrection is recommended .l
FACIAL PLASTIC SURGERY Volume 7, Number 3 1990
Treatment It should be emphasized, however, that only about 15% of the isolated fractures of the floor do not require surgical treatment. We indicate a surgical procedure for these fractures if one or more of the presented symptoms or impressive defects on CT scans are demonstrated. The technique of orbital floor reconstruction has already been described. "Papyraceous Lamina" Fracture The synonym of the lamina orbitalis ossis ethmoidalis is the paryraceous lamina, because it is actually the thinnest wall of the orbit. The fragile construction permits absorption of the impact forces and thus protects the neurovascular structures. Isolated fractures of this area are extremely rare. On examination, mild physical findings are seen. Air in the orbit (Fig. 13) and bleeding from the ethmoid region are common occurrences. Treatment The indication for surgical intervention is dependent on verification of post-traumatic visual loss or other ocular and orbital complications and the degree of ethmoidal cell destruction. The procedures themselves are identical to the treatment of other medial fractures of the orbit. In most cases the endoscopically controlled transnasal ethmoidectomy under protection of antibiotics is accepted as suitable treatment.
Figure 13. Air-filled orbit following isolated lamina papyraceous fracture.
and produces a displacement of the globe in the same direction. This very rarely fractured area is usually slightly displaced and does not require any intervention.
Treatment Surgical procedures are indicated when severe displacement of the globe, soft tissue herniation, or frontobasilar contribution are presented. CT scans are utilized to determine the exact pattern of the fractures. We are more frequently confronted with supraorbital rim fractures accompanied by anterior table fractures of the frontal sinus (Fig. 2). Because the roof of the orbit forms the floor of the frontal sinus in the basence of any supraorbital ethmoid cells, these paSuperior Orbital Rim and Roof Fractures tients are at high risk for an injury to the drainage Isolated fractures of the orbital roof and the supe- system. Uni- and bilateral orifice injuries may be rior rim are not as frequent as orbital floor fractures found, often without serious external deformity be(Fig. 2). When direct force is sustained by the supe- cause edema may mask the impression. The extent rior orbital rim, a small isolated segment of the roof of this damage will be variable and the sinus must be in the middle third of the orbit may be fractured.17 explored and the drainage system visually inspected. Although this results from a typical blowout mecha- High resolution CT scans will demonstrate the table nism, the fragment is often displaced downward fractures as well as associated orbital and nasoeth-
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
tal pressure combined with compression of the ocular globe; second, the bone transmission of the trauma. Experimental studies have demonstrated that each component may be the major factor in the blowout mechanism. We consider the cause of these fractures to be direct bone transmission as a primary vector of the fracturing force, because in our series the trauma was directed mostly to the bony ring of the orbit. Furthermore, the blowout fractures generally were not combined with severe eyeball lesions. Enophthalmos, diplopia, dysesthesia of the infraorbital nerve, and inhibited ocular motility on account of soft tissue prolapse and herniation are the most frequent findings in isolated orbital floor fractures (Fig. 9).
ORBITAL RING FRACTURES-Stoll
moidal traumas. However, it will not reveal the evidence of injury to the frontal sinus drainage system in every case.18 That is why, conclusions of the presence of injuries to the drainage system are often drawn from the patterns of the fractures. Aesthetically, these traumas are best repaired through an coronal incision (Fig. 14), although the access through a gaping wound, a blepharoplasty incision, or Killian's incision are very suitable, too.
CONCLUSION This survey presents selected types of orbital ring fractures. On account of the complexity of the traumatology in this area, each classification has to be
Figure 15. Adequate stabilization of the fractured frontal table with miniplates through a coronal incision.
incomplete. From our point of view, we concentrated on the aspects to the orbital ring and had to neglect extended fractures, especially the frontorhinobasilar fractures, the Le Fort fractures, and the panfacial, socalled dish-faces.19.20 Comminuted fractures of this extension should be reserved for special chapters.18 According to the severity of the damage, highly qualified specialists and interdisciplinary strategies are demanded.2 Concerning the orbital ring fractures, aggressive surgery is not indicated. Verifying the diagnosis, we have to apply gentle treatment, emphasizing the possibilities of the transnasal endoscopic controlled procedures. Principles of functional and aesthetic surgery are the basis of satisfactory results.
REFERENCES
Figure 14. Sufficiently healed coronal incision 3 weeks after the operation. There are no iatrogenic lesions in the midface area.
1. Manson PN, Iliff NT: Orbital fractures. Facial Plast Surg 5:243-259, 1988 2. Converse J, Bonanno PC. In Kazankian VH, Converse JM (eds): Surgical Treatment of Facial Injuries. Baltimore: Williams & Wilkins 1974, p 394 3. Spoor TC, Nesi FA: Management of ocular, orbital and adnexal trauma. New York: Raven Press, 1988, p p 195-362 4. Stoll W, Kroll P: Etiology and pathomechanism of orbital and ocular trauma with special regard to ball injuries. In Ward PH, Berman WE (eds): Plastic and Reconstructive Surgery of the Head and Neck. St. Louis: C.V Mosby, 1984, pp 574-579 5. Smith 8,Regan WF: Blow out fracture of the orbit. Am J Ophthalmol 44:733-739, 1957 6. Kroll P, Stoll W, Kirchhoff E: Contusion-suction trauma caused by solid unelastic balls. Klin Monatsbl Augenheilkd, 182:555-559, 1983 7. Schroeder HG, Glanz H, Kleinsasser D: Classification and grading of facial skull fractures. HNO 30:174-179, 1982 8. Stoll W, Busse H, Kroll P: Conjunctival approach combined with lateral canthotomy incision: A suitable access to orbital and zygomaticomaxillarytraumas. Laryngol Rhiiol Otol63: 45-47, 1984 9. Tessier P: The conjunctival approach to the orbit floor and maxilla in congenital malformation and trauma. J Maxillofac Surg 1:l-6, 1973 10. Richter NC: Die Techniken der Miplatten-Osteosynthesen in der Hals-Nasen-Ohrenchirurgie. Arch Otorhinolaryngol Suppl 2:28, 1983
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
Treatment The anterior table has to be reconstructed in every case. Few miniplates may suffice for adequate stabilization (Fig. 15). Utilizing few and small miniplates has the advantage of possibly removing them later under local anesthesia. If the drainage system is involved, we always try to reconstruct the frontal nasal duct covering the surroundings with mucosal flaps created from the lateral nasal wall.
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1990
11. Weerda H: Die Versorgung von Jochbein- und Orbitringfrakturen mit Miniplattenosteosynthese. Arch Otorhinolaryngo1 217:245-246, 1977 12. Jannetti G, D'Arco F: The use of lyophilized dura in reconstruction of the orbital floor. J Maxillofac Surg 5:58-62, 1977 13. Simon H: New therapeutic concepts in zygoma fractures and in fractures of the orbital floor and rim. Laryngol Rhinol Otol 64:93-97, 1985 14. Jackson VR, Alley A, Glanz S: Balloon technique for treatment of fractures of the zygomatic bone. J Oral Surg 14:1418, 1956 15. Lehnhardt E, Schultz-Coulon HJ: Zur Indikation und Prognose der transethmoidalen Optikusdekompression bei post-
16. 17. 18. 19. 20.
traumatischer Amaurose. Arch Otorhinolaryngol 209:303313, 1975 Stoll W, Busse H, Kroll P: Decompression of the orbit and the optic nerve in different diseases. J CraniomaxillofacSurg 16: 308-311, 1988 Boenninghaus HG: Blow out fracture of the orbital roof. Laryngol Rhinol Otol (Stuttg) 48:396-398, 1969 Stanley RB: Management of frontal sinus fractures. Facial Plast Surg 5:231-235, 1988 Escher F: Clinic classification and treatment of frontobasal fractures. Nobel Symposium 10. Stockholm: Almquist & Wiksell, 1969, p 343 Le Fort R: Etude experimentale sur les fractures de la mlchoire superieuse. Rev Chir (Paris) 23:360-479, 1901
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PAClAL P L A S S
PREOPERATIVE DIAGNOSIS Physical examination usually begins with the inspection of the periorbital area for ecchymosis of
the skin and subconjunctival hemorrhage (Fig. 3). Visualization is followed by gentle palpation of the positions of the orbital rims to discover irregularities. Extraocular muscle excursion should be evaluated along with the position of the globe, realizing that exophthalmos, enophthalmos, and vertical dystopia may be masked by periorbital swelling. Diplopia in end position of the globe is always suspect of soft tissue herniation. Clinical investigation should be completed by consultation of an ophthalmologist. This advice is based on the experience that in about 30% of our series in which the eyeball was involved, blindness was found in 13%. Besides these findings, infra- and supraorbital dys- or anesthesia of the trigeminal branches may frequently accompany orbital traumas. Although physical examination is indispensable, the exact nature of these fractures can rarely be determined without x-ray or computed tomography (CT scans) examinations. Both axial and coronal CT sections should be obtained. Three-dimensional scans provide an addition perspective, although they are not essential for the treatment of these injuries.
LATERAL FRACTURES O F THE ORBIT Typical zygoma impression fracture lines (Fig. 1) run from the zygomaticofrontal suture over the lateral wall of the orbit along the orbital floor to the inferior rim. This fracture involves the zygomaticomaxillary buttress and the zygomatic arch. Usually, we find a palpebral and subconjunctivalhematoma, displacement of the lateral canthus and globe, hypoesthesia of the infraorbital nerve, asymmetry of the cheek and arch contours, diplopia with or without skin lacerations, etc.
Reprint requests: Dr. Stoll, Sendener Stiege 68, 4400 Miinster, Germany Copyright 01991 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights resewed.
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
W. Stoll, M.D.
Figure 1. Distribution of medial and lateral fractures of the orbital ring.
Figure 3. Presurgical view of patient with left-sided zygoma-impression fracture and enophthalmos.
Figure 2. orbit.
Frequency of selected isolated fractures of the
Figure 4.
Treatment
Closed lateral canthotomy incision.
at the infraorbital rim. In order to avoid second surgery for plate removal, we often use steel wires for Surgical reconstruction can be managed by differ- the infraorbital rim fixation (Figs. 7, 8A, B). The ent approaches. We prefer the transconjunctivalinci- gingivobuccal incision exposes the zygomaticomaxsion in combination with the lateral canthotomy inci- illary buttress as an additional guide to fracture sion (Fig. 4). If necessary we extend the incision alignment. Especially severe comminutions require along the lateral rim (Fig. 5) to explore the lateral full exposure of all the articulations of the zygoma orbit and the orbital fl00r.8.9 and maxilla with adjacent bones. Reposition of the fragments is followed by stabilizDirect wiring or plating of fracture lines that cross ation with plates and steel wires.1,loJ We place buttresses follows. The orbital floor is supported mostly two six-hole plates at the zygomaticofrontal only in cases of complete comminution with expansuture (Fig. 6). Maxillary adaptation is then applied sive inferior prolapse (Fig. 9) or loss of floor frag-
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
FACIAL PLASTIC SURGERY Volume 7, Number 3 1990
ORBITAL RING FRACTURES-St011
-1
Prognosis
Figure 5. Suitable approaches to the orbital ring. Additionally, the nonpainted coronal incision is necessary.
Persistent postoperative complaints are closely correlated to the severity of the injuries. Patients with simple zygoma-impression fractures presented postoperative double vision in 13%, but 31% of patients with complex midface injuries presented diplopia 6 to 12 months after surgery. Residual diplopia will be minimal in functional fields of gaze, despite its presence in peripheral fields, thus no treatment will be required. The remaining persistent defects include ectropion, enophthalmos, dysesthesia, ptosis, sinusitis.
MEDIAL FRACTURES O F THE O R B I T The complexity of medial fractures of the orbit originates from the anatomy of the nasoethmoidal region. At least four fractures are necessary to dislocate the medial orbital angle. These occur in the medial orbital wall, the inferior wall, the nose, and the junction of the frontal process of the maxilla with the frontal bone. Force concentration to the midface Figure 6. Fixation of the zygomaticofrontal suture with a may extend uni- or bilaterally as more generalized Le small plate. The approach is via transconjunctival and lateral Fort or panfacial fractures. However, these genercanthotomy incision. alized fracture types are not discussed here. The diagnosis of nasoethmoidal orbital fractures is suggested by the presence of periorbital ecchymosis and swelling. Frequently, the nose will be distorted. ments (Fig. 10A). Properly contoured bone grafts of On direct pressure, a slight movement of the frontal the rib and in mild destruction Gore-Tex (Fig. 10B)or process implies instability of the rim. Axial and corolyophilized dura patches are available to dictate the nal CT scans provide excellent definition of medial structural position of the soft tissue and the b0ne~2.12 wall fractures. Air in the orbit is a common event and and transmaxillary silicon tubes or water-filled bal- may displace the orbital soft tissue. Comminution of loon catheters are emphasized as successful tech- ethmoid cells with impressed areas and opacity of niques with poor risks.4J3~14 the involved sinuses are almost the rule (Fig. 11).
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
Figure 7. Stabilization of the fractured inferior rim over a conjunctival access with steel wires.
Figure 8. A: Zygoma impression fracture, gaping inferior rim. B: Postoperative x-ray control of the zygornatic position.
Treatment Reconstructive surgery has to be adapted individually. Mild dislocations of the nasal frame can be treated by intranasal reposition. The endoscopic controlled transnasal ethmoidectomy is emphasized for destruction of the ethmoidal region combined with less external deformation. However, severe destruction, orbital complications, and liquorrhea are best treated through the open approach via Killian's incision. This excellent access is recommended for orbital and optic nerve decompression, too.15 ConFigure 9. Isolated orbital floor fractures with expansive cerning the effect of decompression surgery, we prolapse into the maxillary sinus. achieved the best results by starting the procedure
m
Figure 10. A: Orbital floor defect. B: Supported orbital floor using a Gore-Tex patch with artificial perforations.
162
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FACIAL PLASTIC SURGERY Volume 7, Number 3 199C
ORBITAL RING FRACTURES-St011
within 24 hours after the post-traumatic visual loss. For safe and adequate decompression, we remove the fractured lamina orbitalis piece by piece and drill down the medial wall of the optic channel under microscopic control. Following this procedure, we improved the vision in 58.3% postoperatively16 In
Figure 12. A. Reconstruction of the glabella and nasoethmoidal region using plates and screws. B. The traumatic lacerationwas used as the surgical approach. C. Postsurgical appearance after 10 months.
SELECTED ISOLATED FRACTURES OF THE ORBIT Orbital Floor Fractures
The orbital floor as well as the lamina orbitalis of the medial wall are predisposed to fracture by the thinness of these bones. The source of trauma comprises two components: first, the increased intraorbi-
.-
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
Figure 11. CT scan demonstrating symmetrical compression of ethmoidal air cells. The right-sided fracture visualized in the posterior orbit was accompanied by optic nerve compression syndrome. Optic nerve decompression was performed with good results.
contrast to other authors we neglect the reconstruction of the lamina orbitalis ossis ethmoidalis because scars always produce a sufficient boundary of the medial orbit. From an aesthetic point of view, the precise reconstruction of the glabella and medial canthal region is very important. In particular, surgical techniques that avoid iatrogenic detachment of the canthal ligament protect the natural appearance of the medial eye angle. Therefore the most effective transnasal wire should be placed into the lacrimal fossa to connect the medial orbital rim of both sides. Narrowing of the intercanthal distance can be supported by exactly adapted plates fixed at the frontal bone (Fig. 12A, B, C). Overcorrection is recommended .l
FACIAL PLASTIC SURGERY Volume 7, Number 3 1990
Treatment It should be emphasized, however, that only about 15% of the isolated fractures of the floor do not require surgical treatment. We indicate a surgical procedure for these fractures if one or more of the presented symptoms or impressive defects on CT scans are demonstrated. The technique of orbital floor reconstruction has already been described. "Papyraceous Lamina" Fracture The synonym of the lamina orbitalis ossis ethmoidalis is the paryraceous lamina, because it is actually the thinnest wall of the orbit. The fragile construction permits absorption of the impact forces and thus protects the neurovascular structures. Isolated fractures of this area are extremely rare. On examination, mild physical findings are seen. Air in the orbit (Fig. 13) and bleeding from the ethmoid region are common occurrences. Treatment The indication for surgical intervention is dependent on verification of post-traumatic visual loss or other ocular and orbital complications and the degree of ethmoidal cell destruction. The procedures themselves are identical to the treatment of other medial fractures of the orbit. In most cases the endoscopically controlled transnasal ethmoidectomy under protection of antibiotics is accepted as suitable treatment.
Figure 13. Air-filled orbit following isolated lamina papyraceous fracture.
and produces a displacement of the globe in the same direction. This very rarely fractured area is usually slightly displaced and does not require any intervention.
Treatment Surgical procedures are indicated when severe displacement of the globe, soft tissue herniation, or frontobasilar contribution are presented. CT scans are utilized to determine the exact pattern of the fractures. We are more frequently confronted with supraorbital rim fractures accompanied by anterior table fractures of the frontal sinus (Fig. 2). Because the roof of the orbit forms the floor of the frontal sinus in the basence of any supraorbital ethmoid cells, these paSuperior Orbital Rim and Roof Fractures tients are at high risk for an injury to the drainage Isolated fractures of the orbital roof and the supe- system. Uni- and bilateral orifice injuries may be rior rim are not as frequent as orbital floor fractures found, often without serious external deformity be(Fig. 2). When direct force is sustained by the supe- cause edema may mask the impression. The extent rior orbital rim, a small isolated segment of the roof of this damage will be variable and the sinus must be in the middle third of the orbit may be fractured.17 explored and the drainage system visually inspected. Although this results from a typical blowout mecha- High resolution CT scans will demonstrate the table nism, the fragment is often displaced downward fractures as well as associated orbital and nasoeth-
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
tal pressure combined with compression of the ocular globe; second, the bone transmission of the trauma. Experimental studies have demonstrated that each component may be the major factor in the blowout mechanism. We consider the cause of these fractures to be direct bone transmission as a primary vector of the fracturing force, because in our series the trauma was directed mostly to the bony ring of the orbit. Furthermore, the blowout fractures generally were not combined with severe eyeball lesions. Enophthalmos, diplopia, dysesthesia of the infraorbital nerve, and inhibited ocular motility on account of soft tissue prolapse and herniation are the most frequent findings in isolated orbital floor fractures (Fig. 9).
ORBITAL RING FRACTURES-Stoll
moidal traumas. However, it will not reveal the evidence of injury to the frontal sinus drainage system in every case.18 That is why, conclusions of the presence of injuries to the drainage system are often drawn from the patterns of the fractures. Aesthetically, these traumas are best repaired through an coronal incision (Fig. 14), although the access through a gaping wound, a blepharoplasty incision, or Killian's incision are very suitable, too.
CONCLUSION This survey presents selected types of orbital ring fractures. On account of the complexity of the traumatology in this area, each classification has to be
Figure 15. Adequate stabilization of the fractured frontal table with miniplates through a coronal incision.
incomplete. From our point of view, we concentrated on the aspects to the orbital ring and had to neglect extended fractures, especially the frontorhinobasilar fractures, the Le Fort fractures, and the panfacial, socalled dish-faces.19.20 Comminuted fractures of this extension should be reserved for special chapters.18 According to the severity of the damage, highly qualified specialists and interdisciplinary strategies are demanded.2 Concerning the orbital ring fractures, aggressive surgery is not indicated. Verifying the diagnosis, we have to apply gentle treatment, emphasizing the possibilities of the transnasal endoscopic controlled procedures. Principles of functional and aesthetic surgery are the basis of satisfactory results.
REFERENCES
Figure 14. Sufficiently healed coronal incision 3 weeks after the operation. There are no iatrogenic lesions in the midface area.
1. Manson PN, Iliff NT: Orbital fractures. Facial Plast Surg 5:243-259, 1988 2. Converse J, Bonanno PC. In Kazankian VH, Converse JM (eds): Surgical Treatment of Facial Injuries. Baltimore: Williams & Wilkins 1974, p 394 3. Spoor TC, Nesi FA: Management of ocular, orbital and adnexal trauma. New York: Raven Press, 1988, p p 195-362 4. Stoll W, Kroll P: Etiology and pathomechanism of orbital and ocular trauma with special regard to ball injuries. In Ward PH, Berman WE (eds): Plastic and Reconstructive Surgery of the Head and Neck. St. Louis: C.V Mosby, 1984, pp 574-579 5. Smith 8,Regan WF: Blow out fracture of the orbit. Am J Ophthalmol 44:733-739, 1957 6. Kroll P, Stoll W, Kirchhoff E: Contusion-suction trauma caused by solid unelastic balls. Klin Monatsbl Augenheilkd, 182:555-559, 1983 7. Schroeder HG, Glanz H, Kleinsasser D: Classification and grading of facial skull fractures. HNO 30:174-179, 1982 8. Stoll W, Busse H, Kroll P: Conjunctival approach combined with lateral canthotomy incision: A suitable access to orbital and zygomaticomaxillarytraumas. Laryngol Rhiiol Otol63: 45-47, 1984 9. Tessier P: The conjunctival approach to the orbit floor and maxilla in congenital malformation and trauma. J Maxillofac Surg 1:l-6, 1973 10. Richter NC: Die Techniken der Miplatten-Osteosynthesen in der Hals-Nasen-Ohrenchirurgie. Arch Otorhinolaryngol Suppl 2:28, 1983
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
Treatment The anterior table has to be reconstructed in every case. Few miniplates may suffice for adequate stabilization (Fig. 15). Utilizing few and small miniplates has the advantage of possibly removing them later under local anesthesia. If the drainage system is involved, we always try to reconstruct the frontal nasal duct covering the surroundings with mucosal flaps created from the lateral nasal wall.
U
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Volume 7, Number 3
1990
11. Weerda H: Die Versorgung von Jochbein- und Orbitringfrakturen mit Miniplattenosteosynthese. Arch Otorhinolaryngo1 217:245-246, 1977 12. Jannetti G, D'Arco F: The use of lyophilized dura in reconstruction of the orbital floor. J Maxillofac Surg 5:58-62, 1977 13. Simon H: New therapeutic concepts in zygoma fractures and in fractures of the orbital floor and rim. Laryngol Rhinol Otol 64:93-97, 1985 14. Jackson VR, Alley A, Glanz S: Balloon technique for treatment of fractures of the zygomatic bone. J Oral Surg 14:1418, 1956 15. Lehnhardt E, Schultz-Coulon HJ: Zur Indikation und Prognose der transethmoidalen Optikusdekompression bei post-
16. 17. 18. 19. 20.
traumatischer Amaurose. Arch Otorhinolaryngol 209:303313, 1975 Stoll W, Busse H, Kroll P: Decompression of the orbit and the optic nerve in different diseases. J CraniomaxillofacSurg 16: 308-311, 1988 Boenninghaus HG: Blow out fracture of the orbital roof. Laryngol Rhinol Otol (Stuttg) 48:396-398, 1969 Stanley RB: Management of frontal sinus fractures. Facial Plast Surg 5:231-235, 1988 Escher F: Clinic classification and treatment of frontobasal fractures. Nobel Symposium 10. Stockholm: Almquist & Wiksell, 1969, p 343 Le Fort R: Etude experimentale sur les fractures de la mlchoire superieuse. Rev Chir (Paris) 23:360-479, 1901
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