Pediatric orbital floor fracture: Direct extraocular muscle involvement
University of Minnesota, Department of Ophthalmology, Minneapolis, Minnesota 55455-0501, USA. Ophthalmology
(Impact Factor: 6.14).
11/2000; 107(10):1875-9. DOI: 10.1016/S0161-6420(00)00334-1
To study the clinical presentation, operative findings, and postoperative results of a surgical series of isolated orbital floor fractures in children.
Noncomparative, retrospective, consecutive case series.
Thirty-four patients (34 orbits) less than 18 years of age with isolated orbital floor fractures. Indications for surgery were severe limitation of extraocular ductions, 22 of 34; enophthalmos, 8 of 34: or both, 4 of 34.
Cause of fracture, symptoms, clinical signs, radiographic data, operative findings, postoperative results, and complications.
Children older than 12 years of age were more likely to sustain an orbital floor fracture as a result of interpersonal violence than were children less than 12 years of age (P: = 0.020). Sixty-two percent of patients (21 of 34) exhibited pain with eye movements and/or nausea and vomiting. Most had a trapdoor type fracture (21 of 34). The inferior rectus muscle was entrapped in the orbital floor fracture in 69% (18 of 26) of patients with a severe limitation of ocular ductions. Preoperative nausea and vomiting were immediately relieved after surgery. The median time for improvement of preoperative duction deficits and diplopia was 4 days for patients receiving surgery within 7 days and 10.5 days for those undergoing surgery after 14 days (P: = 0.030). Resolution of duction deficits or diplopia was not dependent on time of surgery if performed within 1 month of injury. Loss of vision, worsening of motility, or implant complications did not occur.
Pediatric patients with isolated orbital floor fractures who had pain, nausea, vomiting, and severe limitation of extraocular motility often have direct entrapment of the inferior rectus muscle into the fracture site. Surgical repair rapidly relieved preoperative pain, nausea, and vomiting. For patients with severe limitation of ductions, early surgical repair within 7 days of injury resulted in more rapid improvement of ductions and diplopia than surgery performed later.
Available from: PubMed Central
- "Bansagi and Meyer  reported that pediatric cases of orbital fractures in which surgery was performed within 2 weeks of injury, recovered a greater degree of ocular motility. But Egbert et al.  showed no significant difference in the degree of the recovery from ocular motility between patients undergoing surgery after one month of the onset of trauma and those doing within seven days. These authors noted, however, that there was a significant difference in the time to recovery from ocular motility between the two groups (4 days in the group with a time to surgery of <7 days vs. 10.5 days in the group with a time to surgery of >7 days). "
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We conducted this study to identify the correlation between the time to surgery and that to recovery from postoperative diplopia.
In the current single-center, retrospective study, we enrolled a total of 11 patients (n=11) who were diagnosed with white-eyed blowout fracture and underwent surgical operation at our institution between January 2009 and January 2013. To identify the correlation between the time to surgery and that to recovery from postoperative diplopia, we divided our patients into the three groups: the group A (time to surgery, <2 days) (n=4), the group B (time to surgery, 3-7 days) (n=4) and the group C (n=3) (time to surgery, 8-60 days). Then, we compared such variables as sex, age, signs of soft tissue injury, preoperative nausea/vomiting, the degree of preoperative diplopia and the side of the fracture on computed tomography scans between the three groups.
In our series, mean age at the onset of trauma was nine years (range, 5-16 years); the mean time to surgery was 30 days (range, 2-60 days); and the mean follow-up period was one year (range, 6 months-2 years). Our results showed that the time to recovery was shorter in the patients with a shorter time to surgery.
We found that the degree of recovery from impaired ocular motility and diplopia was the highest in the patients undergoing surgical operations within 48 hours of the onset of trauma with the reconstruction of the fracture sites using implant materials.
Archives of Plastic Surgery 09/2014; 41(5):486-492. DOI:10.5999/aps.2014.41.5.486
Available from: Harumasa Yokota
- "This is caused by muscle entrapment or connective tissue septa after the orbital floor fracture,4,5 and without emergent release, the incarcerated muscles may become necrotic because of ischemia.6–8 In the chronic phase, fibrosis may also develop from inflammation, causing permanent ocular movement disorders.4,5,8,9 For this reason, immediate surgery is often recommended for orbital floor fractures with symptomatic persistent diplopia or clinical evidence of entrapment.7,8,10 "
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ABSTRACT: Trapdoor fractures, or blowout fractures, result from muscle entrapment after orbital floor fractures. The incarcerated muscles may become necrotic because of ischemia; immediate surgery is recommended for symptomatic persistent diplopia or clinical evidence of entrapment. We report a case of spontaneous resolution of diplopia in a patient with a high suspicion of a trapdoor fracture. A 15-year-old girl presented with diplopia after being hit in the eye while playing volleyball. Computed tomography did not show a fractured orbital bone, but the forced duction test was positive when the left eye was pulled forward toward the left. Magnetic resonance imaging was negative for edema and inflammation in the extraocular muscles. With observation only, the diplopia resolved 2 weeks after onset. A negative forced duction test confirmed the resolution. Observation only may be appropriate in cases with posttraumatic limited ocular movement, after imaging has excluded an emergent condition.
Clinical ophthalmology (Auckland, N.Z.) 08/2014; 8:1535-8. DOI:10.2147/OPTH.S68430
Available from: Tommaso Agostini
- "The goal of treatment is the restoration of orthoscopic vision and visual acuity. Early fracture repair is associated with improved outcomes compared with a delayed repair approach within 3 weeks.14,15,23–25 Several autologous, alloplastic, and allogenic materials are available for orbital floor fracture repair.25,26 "
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Orbital blowout fractures can be managed by several surgical specialties including plastic and maxillofacial surgery, otolaryngology, and ophthalmology. Recommendations for surgical fracture repair depend on a combination of clinical and imaging studies to evaluate muscle/nerve entrapment and periorbital tissue herniation.
The aim of this study was to verify the applicability of regional anesthesia when repairing orbital floor fractures. A retrospective chart review was performed for isolated orbital floor fractures treated at the Department of Maxillofacial Surgery in Florence between May 2011 and July 2012. The study included 135 patients who met the inclusion criteria: 96 subjects were male (71%) and 39 were female (29%). The mean age was 45.3 years, ranging from 16 to 77 years.
The results revealed that isolated anterior orbital floor fractures can be safely repaired under regional and local anesthesia. Regional and local anesthesia should be combined with intravenous sedation when the fracture involves the posterior floor. The surgical outcome was comparable to the outcome achieved under general anesthesia. There was a lower rate of surgical revisions due to concealed malposition or entrapment of the inferior rectus muscle (19% vs 22%). However, this result was not statistically significant (P > 0.05).
There are several advantages to surgically repairing isolated orbital floor fractures under regional and local anesthesia that include the following: surgeons can check the surgical outcome (enophthalmos and extrinsic ocular muscles function) intraoperatively, thereby reducing the reoperation rate; patient discomfort due to general anesthesia is eliminated; and the hospital stay is reduced, thus decreasing overall healthcare costs.
01/2014; 2(1):e97. DOI:10.1097/GOX.0000000000000039
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