Imaging urgent repair enophthalmus most do not develop size of fracture does not predict delayed repair equally effective wait until. Endoscopic, endonasal management of fractures of the. Patients with medial bofs usually have nonspecific. Anatomical landmarks to be respected when attempting to repair fractures involving medial wall of orbit. Jan 22, 2016 this study included 348 orbits of 348 patients, 275 men and 73 women, with isolated medial wall fractures. It is well known that fractures of the orbital floor are more frequent than those of the medial wall. They produced an impact on the orbital soft tissues of a cadaver, increasing. The maxillary bone segment includes the inferior 23rds of the medial orbital rim and the lacrimal crests.
Intervention and timing no financial interests to report indications repair. According to the documentation, the ed physician prescribed amoxicillin for 10 days, and ice to keep swelling down. The strong central part of the bone usually remains intact and the force is transmitted to the three. Considerations for the management of medial orbital wall blowout fracture. Review of the literature reveals six previous cases. The condition can result from traffic accidents, sports activities, violence or fall injuries. This video demonstrates repair of a large medial orbital wall and inferior orbital floor fracture. Medial wall and orbital floor blowout fractures current management. These fractures do not require surgical repair and conservative management is adequate. Anatomical reconstruction of medial wall and orbital floor fractures. There are two broad categories of blowout fractures. Frequently overlooked, this injury may be the cause of delayed enopthalmos, meningitis, or blindness. Trapdoor fracture of the orbital floor is well described.
Case discussion this case of right medial orbital wall fracture emphasizes how by detecting gas outside of the paranasal sinuses and hemorrhage within the paranasal sinuses you can often track down even the. The lateral orbital wall is composed of the frontal process of the zygoma, the orbital plate of the greater wing of the sphenoid and the frontal bone. Fractures of the medial orbital wall result from blunt trauma to the periorbital area. Supporting implant technique for repairing large medial orbital wall fractures. The most common presentation of orbital fractures is associated with zygomatic complex fractures i. Then various implants can be used to support the orbital soft tissue and prevent recurrent herniation. In the case of large medial orbital wall fractures, early surgical management is generally indicated to prevent the development of late enophthalmos and to minimize fibrosis and contraction of the prolapsed tissue. Medial orbital wall fracture with rectus entrapment jama. A transcaruncular approach has been reported to allow direct binocular visualization of the medial orbital wall for accurate fracture definition and direct implantation. Anatomical reconstruction of medial wall and orbital floor. A retrospective study of eyeball rupture in patients with or without orbital fracture. This study included 348 orbits of 348 patients, 275 men and 73 women, with isolated medial wall fractures. Medial blowout fractures are the second most common type, occurring through the lamina papyracea.
We suggest that orbital exploration is indicated for painful or limited ocular motility, significant diplopia, severe orbital. Facial fracture management handbook lateral orbital wall. An orbital blowout fracture is a traumatic deformity of the orbital floor or medial wall, typically resulting from impact of a blunt object larger than the orbital aperture, or eye socket. Management of isolated fractures of the medial orbital wall. Pdf management of pure medial orbital wall fracture with. Orbital blowout fractures occur when there is a fracture of one of the walls of orbit but the orbital rim remains intact. Massive orbital emphysema, in one case, was responsible for temporary loss of vision prior to definitive treatment. Lesions of these fasciculi may cause clinical findings similar to those seen in orbital fractures leading to muscle entrapment. Other less common orbital fractures involve medial or lateral wall. Jun 11, 2010 the medial wall can be accessed through transcaruncular approach. The malar complex is also commonly fractured in isolation by a blow to that area. The medial longitudinal fasciculus extending bilaterally through the brainstem establish connections between iii, vi, viii, and xith cranial nerves.
Orbital blowout fracture radiology reference article. The term blowout fracture was coined in 1957, when smith and regan 1 described the mechanism of injury. Retrocaruncular approach for the repair of medial orbital. Combined transconjunctival and transcaruncular approach for. Endoscopic, endonasal management of fractures of the medial. Facial fracture management handbook lefort fractures iowa. In 50% of cases, inferior blowout fractures are associated with fractures of the medial wall 4. This occurs more commonly in the pediatric population, which tends to have more elastic and thicker bones.
Rapid developments in medical imaging technology over recent years have resulted in computed tomography ct becoming a standard tool for the diagnosis of facial trauma, and in the more frequent detection and operation of medial bof 2,3. Implant placement for combined medial wall and orbital. Combined transconjunctival and transcaruncular approach. Defects involving medial wall of orbit can be repaired by using bone grafts or other inert materials. Orbital fat and the medial rectus muscle may prolapse into the ethmoid air cells. The reason is that the most delicate part of the orbit is the lamina papyracea.
Fractures of the medial orbital wall sciencedirect. Many specialists encounter and treat orbital fractures. Reconstruction of severe medial orbital wall fractures using titanium mesh plates placed using transcarunculartransconjunctival approach. Medial orbital wall fractures and the transcaruncular. Both blowin and blowout patterns can result in muscle entrapment. Considerations for the management of medial orbital wall.
Pdf considerations for the management of medial orbital. Orbital reconstruction for orbit, medial orbital wall fracture. Computed tomography of blowout fracture of the medial orbital wall 427 computed tomographic ct findings in four patients with isolated blowout fracture of the medial orbital wall are reported. Pfeiffer proposed the globetowall theory, which is when a force pushes the globe into the orbit and causes the globe to contact the orbital floor, resulting in a floor fracture. Clinically, patients complain of diplopia with lateral gaze and forced duction tests confirm medial rectus entrapment. Medial orbital wall fracture with concomitant medial. We suggest that orbital exploration is indicated for painful or limited ocular motility, significant diplopia, severe orbital emphysema, or. The patient had a previous surgery and the needle tip cautery is used to make a transconjunctival incision along the scar of the previous surgery. Designed from ctscan data, the threedimensional implants closely approximate the topographical anatomy of the human orbital floor and medial wall, to provide accurate reconstruction even after significant two wall fractures. Computed tomography of blowout fracture of the medial. Within the posterior orbit lefort iii fractures may pass through the inferior or superior orbital fissure and in rare situations through the optic canal.
A patient presented with an eye injury from a softball. Medial wall fractures can result from either directly as injuries to the face or indirectly as blowout fractures, 2 theorized to occur from a direct buckling of orbital bones or a hydraulic mechanism involving indirect transmission of forces. This article reports our experience and proposes a clinical classification regarding medial orbital wall fractures. Burm and oh found 40% of medial wall fractures result in enophthalmos. Isolated medial orbital wall fracture is a silent injury, due to the lack of signs and symptoms in the affected patients, it can easily be overlooked. Apr 17, 2003 isolated orbital fractures are rare and may cause entrapment of intraocular muscles. Medial orbital wall fractures have a strong association with diploplia due to loss of the posteriormedial bulge of the orbit or mechanical entrapment of the medial rectus muscle, fig 11. Although various approaches to the medial wall have been described, the isolated transcaruncular approach has continued to gain popularity since its introduction more than 10 years ago. Associated injuries included a 17% incidence of serious globe or optic nerve injuries and % incidence of.
Fischbein fi, lesko ws, blowout fracture of the medial orbital wall. Implant placement for combined medial wall and orbital floor. The physician referred the patient to an eye specialist for followup. The segment articulates with the medial orbital wall and nasal dorsum. The degree of bony disruption may not be the only predictor of developing enophthalmos or persistent diplopia. An noe fracture centers on the frontal process of the maxilla and can also involve the ethmoid bone, lacrimal bone, nasal bone and frontal bone. Pdf recently, diagnoses of and operations for medial orbital blowout fracture have increased because of the development of imaging technology.
Orbital fractures occur when the force generated by blunt trauma exceeds the tolerances of the bony surfaces. Combined orbital fracture especially involving all four orbital walls are the least common orbital fracture 6 patterns whilst the leading functional and esthetic problems of this pattern are much more serious than former fracture types. High resolution ct has helped make this diagnosis more precise and permits us visualize the region surrounding the lamina papyracea with greater detail. Later, we modified this technique by placing the incision. Over a 49month period, 121 orbital wall fractures were treated and 92 were followed for a median of 6. Nowadays, medial orbital blowout fracture bof operations have become more common. A retrospective study of pure medial orbital wall fracture. Combined orbital fracture especially involving all four orbital walls are the least common orbital fracture 6 patterns whilst the leading functional and esthetic problems of this pattern are. Jan 02, 2015 the most common orbital injury is a blowout fracture, usually involving the orbital floor the medial wall. Designed from ctscan data, the threedimensional implants closely approximate the topographical anatomy of the human orbital floor and medial wall, to provide accurate reconstruction even after significant twowall fractures. Careful exploration under the periosteum allows easy visualization of the fracture boundaries as well as correction of the herniated tissue. Routine radiographs failed to disclose the fractures, which were clearly shown by computed tomography. There is right intraorbital gas and a trace of right ethmoid air cell hemorrhage adjacent to a subtle fracture of the medial orbital wall.
Medial wall orbital fractures though commonly accompanying orbital floor fractures can also occur alone. Presence of concurrent ruptured globe is a contraindication for orbital surgery. The most common intraorbital fracture is the medial wall blowout fracture. After a retrospective analysis of 2741 patients with facial fractures, we were able to evaluate 273 patients with 304 medial orbital wall fractures. Management of medial orbital wall fractures has benefited from recent surgical extension of transconjunctival incision medially and technological developments and from technological advances such as navigation. Fractures were divided into types based on location and severity of injury. Orbital fractures symptoms, diagnosis and treatment. Two patients developed severe enophthalmos secondary to the medial wall fractures. Management of pure medial orbital wall fracture with autogenous bone graft.
Type iii fractures involve a complex fracture, with the aforementioned distance being greater than 30 mm or having multiple fracture segments. This is typically caused by a direct blow to the central orbit from a fist or ball. Orbital emphysema was detected in 70 orbits of 70 patients 20. Two cases of medial orbital fracture with medial rectus muscle entrapment are reported, one a bona fide blowout fracture. Isolated orbital fractures are rare and may cause entrapment of intraocular muscles. Orbital fractures symptoms, diagnosis and treatment bmj. The reported incidence for this injury ranges widely, although diagnosis can be made effectively with clinical examination and computed tomography. Medial rectus muscle injuries associated with functional endoscopic sinus surgery. Reconstructive surgery was planned for one patient. However, it is up to the surgeon to gain the best visualization of the defect. Medial orbital wall fractures and the transcaruncular approach. The characteristics of midfacial fractures and the. The fracture is a transverse separation of the nasofrontal suture, medial orbital wall, lateral orbital wall or zygomaticofrontal suture, zygomatic arch and pterygoid plates. Nov 17, 2015 burm and oh found 40% of medial wall fractures result in enophthalmos.
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