Orbit, 2014; 33(5): 336–342 ! Informa Healthcare USA, Inc. ISSN: 0167-6830 print / 1744-5108 online DOI: 10.3109/01676830.2014.902475
ORIGINAL ARTICLE
Management of Pure Orbital Floor Fractures: A Proposed Protocol to Prevent Unnecessary or Early Surgery Bijan Beigi1, Mona Khandwala2, and Deepak Gupta1
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1
Deptarment of Ophthalmology, Norfolk and Norwich University Hospitals NHS Trust, Norwich, United Kingdom and 2Department of Ophthalmology, Maidstone and Tunbridge Wells NHS Trust, Kent, United Kingdom
ABSTRACT Purpose: To present a case series review of management of pure orbital floor fractures and propose a protocol. Methods: A retrospective review of medical records and computed tomography (CT) scan findings was completed. Fractures were classified into either trap-door, floor-fracture with incarcerated tissue, or depressed floor-fragment fractures. Criteria for surgical success were: enophthalmos51mm; no hypoglobus/hyperglobus; extra-ocular muscle restriction 55 in upgaze but normal in all other positions on Hess chart; and no diplopia other than in extreme upgaze (5 ). Results: A total of 79 patients with orbital floor fractures were identified. There were 6 trap-door type fractures, 42 floor fractures with incarcerated tissue, and 31 depressed floor-fragment type fractures. Thirty-six patients were managed conservatively (antibiotics and observation). In nine of these, surgery was avoided by adhering to our protocol of delayed repair. Forty-three had surgical intervention: 6 were trap-door-type, 18 had a floor fracture with incarcerated tissue and 19 were of the depressed floor-fragment variety. All trap-door fractures underwent early repair (6/43, 14%), the rest had delayed repair (37/43, 84%). Four of 6 trap-door fractures had a successful outcome (66.6%). All 18 fractures with incarcerated tissue underwent successful delayed repair. Seventeen of 19 patients with depressed floor-fragment fractures were treated successfully surgically. The follow-up ranged from 12–64 months. The overall success rate was 85.3%. Conclusion: Non-trap-door type of floor fractures can have a successful outcome with delayed repair. This can avoid unnecessary surgery in selected cases. A management protocol is proposed. Keywords: Delayed repair, orbital floor fracture repair, trap-door fracture
INTRODUCTION
recommendations exist for the treatment of these patients. More recent studies2,3 suggest immediate surgical treatment of these fractures. However, surgery is not without risk and selected cases of floor fractures may not warrant surgery at all. We present a retrospective case series review and propose a management protocol.
Pure orbital floor fractures involve the orbital floor and/or the medial wall, secondary to blunt trauma, without involvement of the orbital rim. Long-term sequelae include ophthalmic functional impairment (extra-ocular muscle dysfunction with subsequent diplopia and infra-orbital nerve anaesthesia) and aesthetic deformity (enophthalmos and deep upper lid sulcus). The timing and indication for surgery remains controversial. Burnstine’s1 review article on orbital floor fractures suggests conflicting
MATERIALS AND METHODS We identified 79 patients with orbital floor fractures, who presented to our department between 2001–2009.
Received 27 May 2013; Revised 11 December 2013; Accepted 3 March 2014; Published online 30 June 2014 Correspondence: Mr. Bijan Beigi, Department. of Ophthalmology Norfolk and Norwich University Hospitals NHS Trust, Colney Lane, Norwich NR4 7UY, Tel: 01603 288372, Fax: 01603 288261, E-mail: [email protected]
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Pure Orbital Floor Fracture Protocol We reviewed the medical records and computed tomography (CT) scans of all patients retrospectively. The study adhered to the principles of the Declaration of Helsinki. The age, gender, cause of injury, pre- and postoperative symptoms, including diplopia and infraorbital nerve paraesthesia, were documented. Following full ocular examination, ocular-motility, hyper/hypoglobus, the degree of enophthalmos and proptosis were noted. The patient cohort underwent orthoptic assessment including Hess charting and field of binocular single vision. In all cases, CT scans were evaluated to determine the fracture type, fracture site, and to confirm whether or not muscle and/or soft tissue entrapment was present. We recorded the time interval between trauma and surgery, the surgical approach, and the type of implant used. Radiological classification of floor fractures was based on coronal CT scan findings. Fractures were classified as: (1) Trap-door fracture: linear fracture of orbital floor with bony fragment snapping back entrapping soft tissue in the process (nil final bone displacement) with soft-tissue (connective tissue septae, Tenon’s or muscle) strangulation (Figure 1). (2) Floor fracture: fracture of the orbital floor, not involving orbital rim. Localized soft-tissue displacement through fracture site with potential tissue entrapment, enophthalmos, hypoglobus and functional diplopia, without strangulated muscle (Figure 2). (3) Depressed floor-fragment fracture: ‘punched out’ floor fracture with free segment of floor, not involving the orbital rim. Floor-fragment, periorbita and orbital contents displaced inferiorly into maxillary antrum. Enophthalmos present in all, with restriction of muscle in some (Figure 3). After the clinical diagnosis of an orbital fracture was made, a CT scan with soft-tissue algorithm was requested with 2-mm sections. Patients with a pure fracture without incarcerated muscle or Tenon’s or a displaced floor were managed conservatively. Patients were put on oral antibiotics (Cephadrine
FIGURE 1. Right trap-door fracture showing fractured bony fragment snapped back into place entrapping inferior rectus muscle. !
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250mgs qid unless contraindicated) for one week and asked to refrain from blowing the nose for 2 weeks. Patients with fractures were either treated early or delayed. Trap-door type fractures with strangulation were immediately repaired. Other fracture types and the conservative type were reviewed in six weeks and placed on a selective waiting list, if required, with the aim of being operated on within 2–3 months.
Surgical Approach All patients were operated on by a single surgeon (BB) under general anaesthesia. A forced duction test was performed in all cases. Surgical approach was trans-conjunctival, with lateral canthotomy and inferior cantholysis (McCord Technique4). Dissection was commenced in the preseptal plane until the inferior orbital rim was reached. The periosteum was elevated off the floor until the fracture site was revealed. Entrapped muscle/soft tissue was gently manipulated out of the defect. The infra-orbital nerve was de-roofed if pre-operative infra-orbital nerve anaesthesia was recorded and the patient complained of discomfort. The defect was closed with titanium mesh or a Medpor implant (Porex Surgical Inc.) if volume augmentation was needed. These particular materials were used due to personal surgical preference, as the surgeon had extensive experience with these
FIGURE 2. Left orbital floor fracture with incarcerated soft tissue in the fracture site.
FIGURE 3. Left depressed floor-fragment fracture with involvement of greater than half the orbital floor.
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338 B. Beigi et al. materials. The anterior aspect of the mesh was secured with 0.8 mm titanium screws to the orbital rim. Periosteum, inferior canthal tendon, conjunctiva and skin were closed in layers. Per operatively, the patient was given intravenous dexamethasone (4– 8 mg) and cefuroxime (750 mg). Oral steroids (0.5 mg/kg) were prescribed to patients with extensive orbital inflammation, determined on CT scanning as enlarged extra-ocular muscles and engorgement of orbital vessels. We assessed all patients 4 hours after surgery for signs of orbital haemorrhage and optic nerve dysfunction. Post-operative regime was oral cephradine 250 mg qid, topical chloramphenicol 0.5% and dexamethasone 0.1% qid for 2 weeks. The patient was advised regarding no nose blowing for 2 weeks postoperatively. Follow-up visits with orthoptic review were at 1, 6 and 12 weeks and 1 year. Criteria for success was as follows: enophthalmos 51 mm, no hypoglobus/ hyperglobus, extra ocular muscle restriction 55 as measured on Hess chart in upgaze, but normal in all other positions. Any diplopia other than in extreme upgaze (5 ) was classified as unsuccessful.
RESULTS A total of 79 patients with orbital floor fractures were identified between 2001–2009. The patients had a mean age of 37 years (range 7–91 years). There were 64 male and 15 female patients. Of the 79 patients, 36 patients (46%) were managed conservatively (antibiotics and observation); 43 (54%) had surgical intervention. The follow-up ranged from 12–64 months. Mechanism of trauma was assault in 41 patients (51.9%), fall in 16 patients (20.3%), road traffic accident 12 patients (15.2%) and sportsrelated injury in 10 patients (12.6%). Based on our classification, there were 6 patients with white-eyed trap-door fractures, 42 patients with floor fracture with incarcerated tissue and 31 patients with depressed floor-fragment fractures.
Of the 36 conservatively managed patients, 9 had enophthalmos, 4 had hypoglobus 41 mm and 5 patients had diplopia in primary position. The enophthalmos ranged from 1 mm in 4 patients, 2 mm in 4 patients to 3 mm in 1 patient. Surgery was offered to those with enophthalmos 42 mm, but patients declined as they were satisfied with their cosmesis, and thus were not placed on an elective waiting list. The 4 patients that had hypoglobus of 41 mm were not concerned with their appearance and also declined surgery. Five patients in the conservative group had diplopia in primary position on presentation. Two of these had persistent diplopia secondary to traumatic third nerve palsy, rather than the floor fracture per se. The diplopia in the other three patients had resolved when they were seen in clinic in 6 weeks. They were discharged. A total of 43 patients had surgical intervention, of which 6 had trap-door fractures, 18 had floor fracture with incarcerated tissue, and 19 had depressed floorfragment fractures. All six patients with white-eyed blowout fractures had diplopia in primary position and marked restriction in eye movement on presentation. They were systemically unwell, despite having white, quiet eyes. These patients with trap-door fractures had surgical intervention between 2 and 30 days (mean 12 days). Surgery was successful in 4/6 patients (Figure 4A and B). The 2 failures in this group were delayed referrals to the eye department. The first patient presented 5 days after initial trauma and was operated on the next day, and the second patient was referred 19 days late, so consequently had delayed surgery. Both patients were left with restriction in eye elevation with the second patient having restriction in elevation and depression secondary to inferior rectus muscle necrosis, but their eye discomfort had much improved. Eighteen patients in the surgical group had floor fractures with incarcerated tissue. Indications for surgery in this group were 7 patients with diplopia and 1 patient with enophthalmos/hypoglobus (more than 2 mm) and 10 patients with both diplopia and enophthalmos/hypoglobus. The mean duration
FIGURE 4. (A) White-eye blow-out trapdoor-type fracture, upgaze pre-op. (B) Upgaze post-op. Orbit
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Pure Orbital Floor Fracture Protocol from fracture to date of surgery was 21.3 weeks (range 12–156.5 weeks). All 18 patients (100%) were successfully managed according to our success criteria. There were a total of 19 patients with depressed floor-fragment fractures. Indications for surgery were diplopia (9 patients), hypoglobus (5 patients) and considerable enophthalmos and hypoglobus (5 patients). They were operated on between 12 weeks to 180 weeks following trauma (mean time: 31 weeks). Seventeen of nineteen (89.5%) patients were successfully managed. See Tables 1 and 2. Of the two unsuccessful cases, one patient had a residual 7 of restriction on upgaze (Hess chart), and 1 patient had a residual 2-mm enophthalmos. The first patient had a penetrating eye injury and underwent primary globe repair 2 days after trauma, requiring use of silicone oil. The oil was removed 6 months later. Following this, he was noted to have diplopia with hypoglobus and enophthalmos. A CT scan confirmed an orbital floor fracture, and he underwent repair with release of entrapped soft tissue. Post-operatively, he still had restriction of upgaze and was offered further surgery but declined. The second patient had 6 mm of enophthalmos initially with diplopia (see TABLE 1. Surgical success based on radiologic fracture type. Type of fracture Trap Door Floor Fracture Depressed floor-fragment
Number
Mean time to surgical intervention
Surgical success
Percentage of surgical success
6 18 19
1.7 weeks 21.3 weeks 31 weeks
4/6 18/18 17/19
66.6% 100% 89.5%
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Figure 5A). He achieved 2 mm enophthalmos following surgery and declined further intervention; his diplopia resolved and he was happy with the outcome and the cosmesis (Figure 5B). Due to our stringent criterion of success being defined as enophthalmos of 2 mm or less, he was recorded as an unsuccessful outcome.
DISCUSSION Common aetiology for orbital floor fractures includes assault, road traffic accidents, sporting injuries and falls causing mid-face trauma.5,6 Fractures of the orbital floor may arise due to hydraulic forces causing globe displacement with a decompressing fracture into an adjacent sinus (hydraulic theory); or posterior transmission of direct orbital rim force causing buckling of the orbital wall (buckling theory);7 or a combination of these mechanisms. The orbital floor is thinnest near the infraorbital sulcus (0.5–1-mm thick at this point).8 In classic blow-out floor fractures, the lateral extent is generally limited by the infraorbital neurovascular structures; the medial extent is limited by the maxillo-ethmoidal strut of bone. The floor is least well supported and therefore the most common site to fracture in the bony orbit.9 The strut of bones of the fronto-ethmoidal and maxillo-ethmoidal sutures, combined with intermittent support of the ethmoid air cells, support the medial wall, limiting medial wall fractures. The roof and lateral wall are thicker and are less prone to fracture. Fractures can be classified according to location, rim involvement, or radiological type of fracture. Lauer et al.10 undertook a retrospective review of
TABLE 2. Patient symptoms and success rate based on fracture type.
Type of fracture Fracture with in-carcerated tissue Depressed
No.
Hypoglobus/ Enophthalmos more than 2 mm
Diplopia
Combined (Diplopia + enophthalmos/ hypoglobus)
Mean time trauma- surgery (weeks)
Surgical success
18
1
7
10
21.3
100%
19
5
9
5
31
89.5%
FIGURE 5. (A) A patient with a depressed floor-fragment fracture with severe enophthalmos, hypoglobus and restriction on upgaze left eye. Photo with gaze fixing with left eye showing right superior rectus over-action. (B) Post operatively, no diplopia and hypoglobus but minimal enophthalmos persists (one of two patients classified as failed in the depressed floor group of fractures). !
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340 B. Beigi et al. orbital CT scans to define anatomical location of the fracture. Pure fractures (isolated floor fractures) do not involve the orbital rim, and are generally located medial to the infra orbital nerve canal or extended on both sides of the nerve. Impure fractures on the other hand involve the orbital rim and are associated with zygomatico-temporal fractures or fractures of the naso-ethmoidal complex. We included only pure fractures in this study. It is the agreed policy at our institution that the maxillo-facial department deals with impure fractures and request ophthalmic input if required. Pure fractures are referred directly to the ocular adnexal team in the Ophthalmology department for management. Based on CT scan findings and clinical differences, we classified pure fractures into: trap-door, floor fracture and depressed floor-fragment fractures. Trap-door fractures are usually linear in form, extend antero-posteriorly and are hinged medially. The bony fragment snaps back into the re-aligned position strangulating muscle, connective tissue septae and fat. Muscle involvement can cause an oculo-cardiac reflex resulting in severe pain, malaise, nausea and vomiting. It is important that these patients are not missed as delay in intervention can result in muscle necrosis and subsequent intractable diplopia. These are akin to greenstick fractures seen in young children whose bone has not yet ossified. Trap-door-type fractures are seen in relatively young patients and usually present with white eyes, muscle restriction and no enophthalmos (white-eyed blow-out).11 Intervention within 24 to 48 hours is desirable. Treatment is always surgical and is aimed at preventing permanent damage to the muscle resulting in longstanding restriction.1 Manson and Iliff,12 in the accompanying article on surgical intervention, stress that the syndrome of early muscle infarction produced by tight incarceration of inferior rectus must be corrected urgently. Bansangi and Meyer13, in their retrospective review of 34 patients with trap-door fractures, aged 1–18 years, report that the time to surgical repair was critical with early intervention resulting in better clinical outcome. Similar findings were reported by Jordan et al.14 and Egbert et al.15 In our series, the age range of these patients was 7–15 years (mean 9.6 years). Of the 6 trap-door fractures, 4 patients were operated on within 48 hours. All were successful technically, except two that presented late and therefore operated on late. They had muscle restriction due to muscle fibrosis. Our findings are in keeping with other retrospective series.13–15 Dutton16 emphasized the fact that some fractures require early intervention and some do well with conservative management. Orbital floor fractures with incarcerated tissue usually present with 2 mm or more enophthalmos
with/without restriction in ocular movements. CT scan findings usually show a fracture medial to the canal with incarceration of tissue, either muscle, Tenon’s capsule or orbital fat. Initial management is conservative: if there is improvement in ocular motility and enophthalmos is insignificant. However, if there is persistent extra-ocular muscle restriction in primary or downgaze and/or significant enophthalmos, surgical repair can be undertaken within 6–8 weeks. This category has not been classified as such in previous studies in the literature. However in our series this was the largest fracture group, and hence warrants separate classification. Of the 18 surgically treated patients in our series with this type of fracture, all 18 (100%) were successfully treated. Harris,17 in a retrospective series, classified 30 patients in to a or b fracture types. The former are characterized by disproportionate soft tissue displacement (these ‘‘a’’-type fractures are akin to trap-door fractures in other published studies); the latter ‘‘b’’-type proportionate soft tissue and bony displacement. They report better outcome in the ‘‘a’’-type fractures when intervention is early within 2 days. In our series, 24 patients of the floor fracture with incarcerated tissue were managed conservatively, despite 3 initially presenting with diplopia. Their symptoms settled on review, and these patients were discharged without the need for surgery. Fractures that have a depressed floor fragment with greater than 2 mm enophthalmos (but typically no extra-ocular muscle restriction) may require surgical treatment. These patients are observed for 6–8 weeks and then reviewed in the clinic. On review, if there was a persistent diplopia and/or there was concern about cosmesis, they were offered surgery within 3 months. If they were satisfied with their appearance, they were discharged. We firmly adhere to good clinical practice and believe in patient choice: specifically that orbital surgery is not a low impact operation. In contrast to our study, Hawes et al.18 recommend surgical repair within 2 weeks if greater than one half of the orbital floor is depressed. Earlier fracture repair is generally advocated as late repair can involve difficult dissection due to fibrosis.1 Late repair is also associated with fat atrophy and scarring of orbital fat to the maxillary antrum.13 We propose that a 6–8-week review and re-assessment is more appropriate to allow initial soft tissue inflammation, oedema and haemorrhage to settle, and motility disturbances to resolve. This enables us to accurately decide on the degree of volume augmentation required. The size of fracture did not add to the surgical challenge this group encounters. Of our 19 depressed floor-fragment fractures, 17 (82%) were successfully operated on. The remaining 2 showed improvement but fell into the failed category according to our criteria for success. In our series, 12 patients with depressed floor-fragment Orbit
Pure Orbital Floor Fracture Protocol
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Pure orbital floor fracture
CT scan (Anbiocs 1-week; advise no nose blowing)
Trap-door fracture
Floor fracture
Depressed floor-fragment fracture
so ssue + muscle strangulaon +EOM restricon
Small localized so ssue displacement +/- EOM restricon
Bone + so ssue displacement into maxillary antrum >2mm enophthalmos +/- diplopia
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Review 6-8 weeks
Enophthalmos, hypoglobus >2mm, funconal diplopia
Nil diplopia or cosmesis concerns
Surgery 6-8 weeks
Discharge
Surgery
ORIGINAL ARTICLE
Management of Pure Orbital Floor Fractures: A Proposed Protocol to Prevent Unnecessary or Early Surgery Bijan Beigi1, Mona Khandwala2, and Deepak Gupta1
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1
Deptarment of Ophthalmology, Norfolk and Norwich University Hospitals NHS Trust, Norwich, United Kingdom and 2Department of Ophthalmology, Maidstone and Tunbridge Wells NHS Trust, Kent, United Kingdom
ABSTRACT Purpose: To present a case series review of management of pure orbital floor fractures and propose a protocol. Methods: A retrospective review of medical records and computed tomography (CT) scan findings was completed. Fractures were classified into either trap-door, floor-fracture with incarcerated tissue, or depressed floor-fragment fractures. Criteria for surgical success were: enophthalmos51mm; no hypoglobus/hyperglobus; extra-ocular muscle restriction 55 in upgaze but normal in all other positions on Hess chart; and no diplopia other than in extreme upgaze (5 ). Results: A total of 79 patients with orbital floor fractures were identified. There were 6 trap-door type fractures, 42 floor fractures with incarcerated tissue, and 31 depressed floor-fragment type fractures. Thirty-six patients were managed conservatively (antibiotics and observation). In nine of these, surgery was avoided by adhering to our protocol of delayed repair. Forty-three had surgical intervention: 6 were trap-door-type, 18 had a floor fracture with incarcerated tissue and 19 were of the depressed floor-fragment variety. All trap-door fractures underwent early repair (6/43, 14%), the rest had delayed repair (37/43, 84%). Four of 6 trap-door fractures had a successful outcome (66.6%). All 18 fractures with incarcerated tissue underwent successful delayed repair. Seventeen of 19 patients with depressed floor-fragment fractures were treated successfully surgically. The follow-up ranged from 12–64 months. The overall success rate was 85.3%. Conclusion: Non-trap-door type of floor fractures can have a successful outcome with delayed repair. This can avoid unnecessary surgery in selected cases. A management protocol is proposed. Keywords: Delayed repair, orbital floor fracture repair, trap-door fracture
INTRODUCTION
recommendations exist for the treatment of these patients. More recent studies2,3 suggest immediate surgical treatment of these fractures. However, surgery is not without risk and selected cases of floor fractures may not warrant surgery at all. We present a retrospective case series review and propose a management protocol.
Pure orbital floor fractures involve the orbital floor and/or the medial wall, secondary to blunt trauma, without involvement of the orbital rim. Long-term sequelae include ophthalmic functional impairment (extra-ocular muscle dysfunction with subsequent diplopia and infra-orbital nerve anaesthesia) and aesthetic deformity (enophthalmos and deep upper lid sulcus). The timing and indication for surgery remains controversial. Burnstine’s1 review article on orbital floor fractures suggests conflicting
MATERIALS AND METHODS We identified 79 patients with orbital floor fractures, who presented to our department between 2001–2009.
Received 27 May 2013; Revised 11 December 2013; Accepted 3 March 2014; Published online 30 June 2014 Correspondence: Mr. Bijan Beigi, Department. of Ophthalmology Norfolk and Norwich University Hospitals NHS Trust, Colney Lane, Norwich NR4 7UY, Tel: 01603 288372, Fax: 01603 288261, E-mail: [email protected]
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Pure Orbital Floor Fracture Protocol We reviewed the medical records and computed tomography (CT) scans of all patients retrospectively. The study adhered to the principles of the Declaration of Helsinki. The age, gender, cause of injury, pre- and postoperative symptoms, including diplopia and infraorbital nerve paraesthesia, were documented. Following full ocular examination, ocular-motility, hyper/hypoglobus, the degree of enophthalmos and proptosis were noted. The patient cohort underwent orthoptic assessment including Hess charting and field of binocular single vision. In all cases, CT scans were evaluated to determine the fracture type, fracture site, and to confirm whether or not muscle and/or soft tissue entrapment was present. We recorded the time interval between trauma and surgery, the surgical approach, and the type of implant used. Radiological classification of floor fractures was based on coronal CT scan findings. Fractures were classified as: (1) Trap-door fracture: linear fracture of orbital floor with bony fragment snapping back entrapping soft tissue in the process (nil final bone displacement) with soft-tissue (connective tissue septae, Tenon’s or muscle) strangulation (Figure 1). (2) Floor fracture: fracture of the orbital floor, not involving orbital rim. Localized soft-tissue displacement through fracture site with potential tissue entrapment, enophthalmos, hypoglobus and functional diplopia, without strangulated muscle (Figure 2). (3) Depressed floor-fragment fracture: ‘punched out’ floor fracture with free segment of floor, not involving the orbital rim. Floor-fragment, periorbita and orbital contents displaced inferiorly into maxillary antrum. Enophthalmos present in all, with restriction of muscle in some (Figure 3). After the clinical diagnosis of an orbital fracture was made, a CT scan with soft-tissue algorithm was requested with 2-mm sections. Patients with a pure fracture without incarcerated muscle or Tenon’s or a displaced floor were managed conservatively. Patients were put on oral antibiotics (Cephadrine
FIGURE 1. Right trap-door fracture showing fractured bony fragment snapped back into place entrapping inferior rectus muscle. !
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250mgs qid unless contraindicated) for one week and asked to refrain from blowing the nose for 2 weeks. Patients with fractures were either treated early or delayed. Trap-door type fractures with strangulation were immediately repaired. Other fracture types and the conservative type were reviewed in six weeks and placed on a selective waiting list, if required, with the aim of being operated on within 2–3 months.
Surgical Approach All patients were operated on by a single surgeon (BB) under general anaesthesia. A forced duction test was performed in all cases. Surgical approach was trans-conjunctival, with lateral canthotomy and inferior cantholysis (McCord Technique4). Dissection was commenced in the preseptal plane until the inferior orbital rim was reached. The periosteum was elevated off the floor until the fracture site was revealed. Entrapped muscle/soft tissue was gently manipulated out of the defect. The infra-orbital nerve was de-roofed if pre-operative infra-orbital nerve anaesthesia was recorded and the patient complained of discomfort. The defect was closed with titanium mesh or a Medpor implant (Porex Surgical Inc.) if volume augmentation was needed. These particular materials were used due to personal surgical preference, as the surgeon had extensive experience with these
FIGURE 2. Left orbital floor fracture with incarcerated soft tissue in the fracture site.
FIGURE 3. Left depressed floor-fragment fracture with involvement of greater than half the orbital floor.
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338 B. Beigi et al. materials. The anterior aspect of the mesh was secured with 0.8 mm titanium screws to the orbital rim. Periosteum, inferior canthal tendon, conjunctiva and skin were closed in layers. Per operatively, the patient was given intravenous dexamethasone (4– 8 mg) and cefuroxime (750 mg). Oral steroids (0.5 mg/kg) were prescribed to patients with extensive orbital inflammation, determined on CT scanning as enlarged extra-ocular muscles and engorgement of orbital vessels. We assessed all patients 4 hours after surgery for signs of orbital haemorrhage and optic nerve dysfunction. Post-operative regime was oral cephradine 250 mg qid, topical chloramphenicol 0.5% and dexamethasone 0.1% qid for 2 weeks. The patient was advised regarding no nose blowing for 2 weeks postoperatively. Follow-up visits with orthoptic review were at 1, 6 and 12 weeks and 1 year. Criteria for success was as follows: enophthalmos 51 mm, no hypoglobus/ hyperglobus, extra ocular muscle restriction 55 as measured on Hess chart in upgaze, but normal in all other positions. Any diplopia other than in extreme upgaze (5 ) was classified as unsuccessful.
RESULTS A total of 79 patients with orbital floor fractures were identified between 2001–2009. The patients had a mean age of 37 years (range 7–91 years). There were 64 male and 15 female patients. Of the 79 patients, 36 patients (46%) were managed conservatively (antibiotics and observation); 43 (54%) had surgical intervention. The follow-up ranged from 12–64 months. Mechanism of trauma was assault in 41 patients (51.9%), fall in 16 patients (20.3%), road traffic accident 12 patients (15.2%) and sportsrelated injury in 10 patients (12.6%). Based on our classification, there were 6 patients with white-eyed trap-door fractures, 42 patients with floor fracture with incarcerated tissue and 31 patients with depressed floor-fragment fractures.
Of the 36 conservatively managed patients, 9 had enophthalmos, 4 had hypoglobus 41 mm and 5 patients had diplopia in primary position. The enophthalmos ranged from 1 mm in 4 patients, 2 mm in 4 patients to 3 mm in 1 patient. Surgery was offered to those with enophthalmos 42 mm, but patients declined as they were satisfied with their cosmesis, and thus were not placed on an elective waiting list. The 4 patients that had hypoglobus of 41 mm were not concerned with their appearance and also declined surgery. Five patients in the conservative group had diplopia in primary position on presentation. Two of these had persistent diplopia secondary to traumatic third nerve palsy, rather than the floor fracture per se. The diplopia in the other three patients had resolved when they were seen in clinic in 6 weeks. They were discharged. A total of 43 patients had surgical intervention, of which 6 had trap-door fractures, 18 had floor fracture with incarcerated tissue, and 19 had depressed floorfragment fractures. All six patients with white-eyed blowout fractures had diplopia in primary position and marked restriction in eye movement on presentation. They were systemically unwell, despite having white, quiet eyes. These patients with trap-door fractures had surgical intervention between 2 and 30 days (mean 12 days). Surgery was successful in 4/6 patients (Figure 4A and B). The 2 failures in this group were delayed referrals to the eye department. The first patient presented 5 days after initial trauma and was operated on the next day, and the second patient was referred 19 days late, so consequently had delayed surgery. Both patients were left with restriction in eye elevation with the second patient having restriction in elevation and depression secondary to inferior rectus muscle necrosis, but their eye discomfort had much improved. Eighteen patients in the surgical group had floor fractures with incarcerated tissue. Indications for surgery in this group were 7 patients with diplopia and 1 patient with enophthalmos/hypoglobus (more than 2 mm) and 10 patients with both diplopia and enophthalmos/hypoglobus. The mean duration
FIGURE 4. (A) White-eye blow-out trapdoor-type fracture, upgaze pre-op. (B) Upgaze post-op. Orbit
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Pure Orbital Floor Fracture Protocol from fracture to date of surgery was 21.3 weeks (range 12–156.5 weeks). All 18 patients (100%) were successfully managed according to our success criteria. There were a total of 19 patients with depressed floor-fragment fractures. Indications for surgery were diplopia (9 patients), hypoglobus (5 patients) and considerable enophthalmos and hypoglobus (5 patients). They were operated on between 12 weeks to 180 weeks following trauma (mean time: 31 weeks). Seventeen of nineteen (89.5%) patients were successfully managed. See Tables 1 and 2. Of the two unsuccessful cases, one patient had a residual 7 of restriction on upgaze (Hess chart), and 1 patient had a residual 2-mm enophthalmos. The first patient had a penetrating eye injury and underwent primary globe repair 2 days after trauma, requiring use of silicone oil. The oil was removed 6 months later. Following this, he was noted to have diplopia with hypoglobus and enophthalmos. A CT scan confirmed an orbital floor fracture, and he underwent repair with release of entrapped soft tissue. Post-operatively, he still had restriction of upgaze and was offered further surgery but declined. The second patient had 6 mm of enophthalmos initially with diplopia (see TABLE 1. Surgical success based on radiologic fracture type. Type of fracture Trap Door Floor Fracture Depressed floor-fragment
Number
Mean time to surgical intervention
Surgical success
Percentage of surgical success
6 18 19
1.7 weeks 21.3 weeks 31 weeks
4/6 18/18 17/19
66.6% 100% 89.5%
339
Figure 5A). He achieved 2 mm enophthalmos following surgery and declined further intervention; his diplopia resolved and he was happy with the outcome and the cosmesis (Figure 5B). Due to our stringent criterion of success being defined as enophthalmos of 2 mm or less, he was recorded as an unsuccessful outcome.
DISCUSSION Common aetiology for orbital floor fractures includes assault, road traffic accidents, sporting injuries and falls causing mid-face trauma.5,6 Fractures of the orbital floor may arise due to hydraulic forces causing globe displacement with a decompressing fracture into an adjacent sinus (hydraulic theory); or posterior transmission of direct orbital rim force causing buckling of the orbital wall (buckling theory);7 or a combination of these mechanisms. The orbital floor is thinnest near the infraorbital sulcus (0.5–1-mm thick at this point).8 In classic blow-out floor fractures, the lateral extent is generally limited by the infraorbital neurovascular structures; the medial extent is limited by the maxillo-ethmoidal strut of bone. The floor is least well supported and therefore the most common site to fracture in the bony orbit.9 The strut of bones of the fronto-ethmoidal and maxillo-ethmoidal sutures, combined with intermittent support of the ethmoid air cells, support the medial wall, limiting medial wall fractures. The roof and lateral wall are thicker and are less prone to fracture. Fractures can be classified according to location, rim involvement, or radiological type of fracture. Lauer et al.10 undertook a retrospective review of
TABLE 2. Patient symptoms and success rate based on fracture type.
Type of fracture Fracture with in-carcerated tissue Depressed
No.
Hypoglobus/ Enophthalmos more than 2 mm
Diplopia
Combined (Diplopia + enophthalmos/ hypoglobus)
Mean time trauma- surgery (weeks)
Surgical success
18
1
7
10
21.3
100%
19
5
9
5
31
89.5%
FIGURE 5. (A) A patient with a depressed floor-fragment fracture with severe enophthalmos, hypoglobus and restriction on upgaze left eye. Photo with gaze fixing with left eye showing right superior rectus over-action. (B) Post operatively, no diplopia and hypoglobus but minimal enophthalmos persists (one of two patients classified as failed in the depressed floor group of fractures). !
2014 Informa Healthcare USA, Inc.
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340 B. Beigi et al. orbital CT scans to define anatomical location of the fracture. Pure fractures (isolated floor fractures) do not involve the orbital rim, and are generally located medial to the infra orbital nerve canal or extended on both sides of the nerve. Impure fractures on the other hand involve the orbital rim and are associated with zygomatico-temporal fractures or fractures of the naso-ethmoidal complex. We included only pure fractures in this study. It is the agreed policy at our institution that the maxillo-facial department deals with impure fractures and request ophthalmic input if required. Pure fractures are referred directly to the ocular adnexal team in the Ophthalmology department for management. Based on CT scan findings and clinical differences, we classified pure fractures into: trap-door, floor fracture and depressed floor-fragment fractures. Trap-door fractures are usually linear in form, extend antero-posteriorly and are hinged medially. The bony fragment snaps back into the re-aligned position strangulating muscle, connective tissue septae and fat. Muscle involvement can cause an oculo-cardiac reflex resulting in severe pain, malaise, nausea and vomiting. It is important that these patients are not missed as delay in intervention can result in muscle necrosis and subsequent intractable diplopia. These are akin to greenstick fractures seen in young children whose bone has not yet ossified. Trap-door-type fractures are seen in relatively young patients and usually present with white eyes, muscle restriction and no enophthalmos (white-eyed blow-out).11 Intervention within 24 to 48 hours is desirable. Treatment is always surgical and is aimed at preventing permanent damage to the muscle resulting in longstanding restriction.1 Manson and Iliff,12 in the accompanying article on surgical intervention, stress that the syndrome of early muscle infarction produced by tight incarceration of inferior rectus must be corrected urgently. Bansangi and Meyer13, in their retrospective review of 34 patients with trap-door fractures, aged 1–18 years, report that the time to surgical repair was critical with early intervention resulting in better clinical outcome. Similar findings were reported by Jordan et al.14 and Egbert et al.15 In our series, the age range of these patients was 7–15 years (mean 9.6 years). Of the 6 trap-door fractures, 4 patients were operated on within 48 hours. All were successful technically, except two that presented late and therefore operated on late. They had muscle restriction due to muscle fibrosis. Our findings are in keeping with other retrospective series.13–15 Dutton16 emphasized the fact that some fractures require early intervention and some do well with conservative management. Orbital floor fractures with incarcerated tissue usually present with 2 mm or more enophthalmos
with/without restriction in ocular movements. CT scan findings usually show a fracture medial to the canal with incarceration of tissue, either muscle, Tenon’s capsule or orbital fat. Initial management is conservative: if there is improvement in ocular motility and enophthalmos is insignificant. However, if there is persistent extra-ocular muscle restriction in primary or downgaze and/or significant enophthalmos, surgical repair can be undertaken within 6–8 weeks. This category has not been classified as such in previous studies in the literature. However in our series this was the largest fracture group, and hence warrants separate classification. Of the 18 surgically treated patients in our series with this type of fracture, all 18 (100%) were successfully treated. Harris,17 in a retrospective series, classified 30 patients in to a or b fracture types. The former are characterized by disproportionate soft tissue displacement (these ‘‘a’’-type fractures are akin to trap-door fractures in other published studies); the latter ‘‘b’’-type proportionate soft tissue and bony displacement. They report better outcome in the ‘‘a’’-type fractures when intervention is early within 2 days. In our series, 24 patients of the floor fracture with incarcerated tissue were managed conservatively, despite 3 initially presenting with diplopia. Their symptoms settled on review, and these patients were discharged without the need for surgery. Fractures that have a depressed floor fragment with greater than 2 mm enophthalmos (but typically no extra-ocular muscle restriction) may require surgical treatment. These patients are observed for 6–8 weeks and then reviewed in the clinic. On review, if there was a persistent diplopia and/or there was concern about cosmesis, they were offered surgery within 3 months. If they were satisfied with their appearance, they were discharged. We firmly adhere to good clinical practice and believe in patient choice: specifically that orbital surgery is not a low impact operation. In contrast to our study, Hawes et al.18 recommend surgical repair within 2 weeks if greater than one half of the orbital floor is depressed. Earlier fracture repair is generally advocated as late repair can involve difficult dissection due to fibrosis.1 Late repair is also associated with fat atrophy and scarring of orbital fat to the maxillary antrum.13 We propose that a 6–8-week review and re-assessment is more appropriate to allow initial soft tissue inflammation, oedema and haemorrhage to settle, and motility disturbances to resolve. This enables us to accurately decide on the degree of volume augmentation required. The size of fracture did not add to the surgical challenge this group encounters. Of our 19 depressed floor-fragment fractures, 17 (82%) were successfully operated on. The remaining 2 showed improvement but fell into the failed category according to our criteria for success. In our series, 12 patients with depressed floor-fragment Orbit
Pure Orbital Floor Fracture Protocol
341
Pure orbital floor fracture
CT scan (Anbiocs 1-week; advise no nose blowing)
Trap-door fracture
Floor fracture
Depressed floor-fragment fracture
so ssue + muscle strangulaon +EOM restricon
Small localized so ssue displacement +/- EOM restricon
Bone + so ssue displacement into maxillary antrum >2mm enophthalmos +/- diplopia
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Review 6-8 weeks
Enophthalmos, hypoglobus >2mm, funconal diplopia
Nil diplopia or cosmesis concerns
Surgery 6-8 weeks
Discharge
Surgery
