Pediatric orbital floor fracture : direct extraocular muscle involvement.

University of Minnesota, Department of Ophthalmology, Minneapolis, Minnesota 55455-0501, USA.
Ophthalmology (Impact Factor: 6.17). 11/2000; 107(10):1875-9. DOI: 10.1016/S0161-6420(00)00334-1
Source: PubMed

ABSTRACT 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.
Surgical repair.
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.

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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.
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    ABSTRACT: In this study medical history and computed tomography (CT) scans of 12 patients with pure orbital floor trap door fracture were recorded. The age range was 13-30 years. They were all from the out patients of the Research Institute of Ophthalmology, Cairo – Egypt.All patients were investigated and recorded. Among the cases 10 patients were recently truamatized and suffering from soft tissue (inferior rectus muscle) entrapment and only 2 patients were delayed and suffering from fibrous tissue ingrowths at the fracture site.Limitation of ocular motility was graded on a numerical scale of 0 to -4, with 0 representing no limitation and -4 representing no movement in the field of gaze. Surgery was determined mainly on the basis of clinical evidence of muscle entrapment and CT confirmation of trapdoor fracture. Surgical repair was performed through transconjunctival incision under general anesthesia.After dissecting in the preseptal plane to the inferior orbital rim and elevating the periosteum off the floor, the entrapped tissue was gently freed from fracture site.In delayed cases with fibrous tissue formation, dissection and removal of the fibrous tissue was done. Forced duction test was repeated at this point to confirm if tissue entrapment was released completely. Demineralized bone sheet was damped in normal saline for ten minutes and formed to be adapted and positioned to the fracture site. Postoperatively the patients were treated with systemic antibiotics and anti-inflammatory drugs for 1 week.Postoperative follow up, with clinical examination, after one and two weeks, then after one, two and three months was done, then CT. Coronal scan three months postoperative. Results: Clinical examination of the patients after one week revealed mild edema and periorbital ecchymosis of the eye lids, slight subconjunctival hemorrhage. Full rang motility with slight restriction in upward gaze of the eye was encountered and slight diplopia remains in all patients. Two weeks later clinical examination revealed resolution of edema,ecchymosis and the subconjunctival hemorrhage.Diplopia was relieved in the first ten patients, who were immediately presented to the hospital and operated as soon as possible, however, it remains only in the two delayed cases.One month later diplopia was relieved in all patients and there was no any other complication throughout the follow up period.Radiographic examination using CT coronal scan revealed intact orbital floor without any herneiation in all cases). Conclusions:-Early surgical repair within 7 days or 14days of injury resulted in more rapid improvement of ocular motility and diplopia. Meticulous freeing of the entrapped tissue,taking care of the infraorbital neurovascular bundle, positioning appropriate implant material as Demineralized human bone sheets and shortening the operation time could prevent any complication and relieves motility restriction and diplopia. This form of the material is very thin to reconstruct the thickness of the orbital floor when enophthalmos exists and weak to support the ocular tissue when the gap exceeds one mm.
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