However, it is up to the surgeon to gain the best visualization of the defect. The malar complex is also commonly fractured in isolation by a blow to that area. Review of the literature reveals six previous cases. 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. Medial orbital wall fractures and the transcaruncular approach. Other less common orbital fractures involve medial or lateral wall. The physician referred the patient to an eye specialist for followup. Medial orbital wall fracture with rectus entrapment jama. Orbital emphysema was detected in 70 orbits of 70 patients 20. Intervention and timing no financial interests to report indications repair. Two cases of medial orbital fracture with medial rectus muscle entrapment are reported, one a bona fide blowout fracture. Considerations for the management of medial orbital wall blowout fracture. Lesions of these fasciculi may cause clinical findings similar to those seen in orbital fractures leading to muscle entrapment.
Presence of concurrent ruptured globe is a contraindication for orbital surgery. A retrospective study of eyeball rupture in patients with or without orbital fracture. Considerations for the management of medial orbital wall. Computed tomography of blowout fracture of the medial. 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. A transcaruncular approach has been reported to allow direct binocular visualization of the medial orbital wall for accurate fracture definition and direct implantation.
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. There are two broad categories of blowout fractures. The most common presentation of orbital fractures is associated with zygomatic complex fractures i. We suggest that orbital exploration is indicated for painful or limited ocular motility, significant diplopia, severe orbital emphysema, or. Anatomical reconstruction of medial wall and orbital floor. High resolution ct has helped make this diagnosis more precise and permits us visualize the region surrounding the lamina papyracea with greater detail. 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. Orbital reconstruction for orbit, medial orbital wall fracture. Associated injuries included a 17% incidence of serious globe or optic nerve injuries and % incidence of.
The reported incidence for this injury ranges widely, although diagnosis can be made effectively with clinical examination and computed tomography. The condition can result from traffic accidents, sports activities, violence or fall injuries. Nowadays, medial orbital blowout fracture bof operations have become more common. The segment articulates with the medial orbital wall and nasal dorsum. 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. The most common intraorbital fracture is the medial wall blowout fracture. Reconstruction of severe medial orbital wall fractures using titanium mesh plates placed using transcarunculartransconjunctival approach. 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. Jan 02, 2015 the most common orbital injury is a blowout fracture, usually involving the orbital floor the medial wall. 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. Implant placement for combined medial wall and orbital floor. Supporting implant technique for repairing large medial orbital wall fractures. 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.
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. It is well known that fractures of the orbital floor are more frequent than those of the medial wall. Pdf management of pure medial orbital wall fracture with. According to the documentation, the ed physician prescribed amoxicillin for 10 days, and ice to keep swelling down. Medial blowout fractures are the second most common type, occurring through the lamina papyracea. 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. Combined transconjunctival and transcaruncular approach. Many specialists encounter and treat orbital fractures. Management of pure medial orbital wall fracture with autogenous bone graft.
This is typically caused by a direct blow to the central orbit from a fist or ball. Within the posterior orbit lefort iii fractures may pass through the inferior or superior orbital fissure and in rare situations through the optic canal. Apr 17, 2003 isolated orbital fractures are rare and may cause entrapment of intraocular muscles. Orbital fractures symptoms, diagnosis and treatment bmj. Jun 11, 2010 the medial wall can be accessed through transcaruncular approach. These fractures do not require surgical repair and conservative management is adequate. Retrocaruncular approach for the repair of medial orbital. Medial wall and orbital floor blowout fractures current management. The characteristics of midfacial fractures and the. Orbital blowout fracture radiology reference article. 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. Management of isolated fractures of the medial orbital wall. Isolated orbital fractures are rare and may cause entrapment of intraocular muscles.
Medial wall orbital fractures though commonly accompanying orbital floor fractures can also occur alone. Fractures of the medial orbital wall result from blunt trauma to the periorbital area. Massive orbital emphysema, in one case, was responsible for temporary loss of vision prior to definitive treatment. Routine radiographs failed to disclose the fractures, which were clearly shown by computed tomography. Pdf recently, diagnoses of and operations for medial orbital blowout fracture have increased because of the development of imaging technology. Reconstructive surgery was planned for one patient.
Careful exploration under the periosteum allows easy visualization of the fracture boundaries as well as correction of the herniated tissue. Patients with medial bofs usually have nonspecific. 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. Morphological characteristics and clinical manifestations. The maxillary bone segment includes the inferior 23rds of the medial orbital rim and the lacrimal crests. A patient presented with an eye injury from a softball. Then various implants can be used to support the orbital soft tissue and prevent recurrent herniation. This occurs more commonly in the pediatric population, which tends to have more elastic and thicker bones. Fractures of the medial orbital wall sciencedirect. Imaging urgent repair enophthalmus most do not develop size of fracture does not predict delayed repair equally effective wait until. Over a 49month period, 121 orbital wall fractures were treated and 92 were followed for a median of 6. Medial rectus muscle injuries associated with functional endoscopic sinus surgery.
Facial fracture management handbook lefort fractures iowa. The strong central part of the bone usually remains intact and the force is transmitted to the three. Fractures were divided into types based on location and severity of injury. We suggest that orbital exploration is indicated for painful or limited ocular motility, significant diplopia, severe orbital. A retrospective study of pure medial orbital wall fracture. 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. The reason is that the most delicate part of the orbit is the lamina papyracea. 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. Pdf considerations for the management of medial orbital. The medial longitudinal fasciculus extending bilaterally through the brainstem establish connections between iii, vi, viii, and xith cranial nerves.
Endoscopic, endonasal management of fractures of the medial. 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. Orbital fractures occur when the force generated by blunt trauma exceeds the tolerances of the bony surfaces. There is right intraorbital gas and a trace of right ethmoid air cell hemorrhage adjacent to a subtle fracture of the medial orbital wall. Type iii fractures involve a complex fracture, with the aforementioned distance being greater than 30 mm or having multiple fracture segments. Orbital fat and the medial rectus muscle may prolapse into the ethmoid air cells. Morphological characteristics and clinical manifestations of. Fischbein fi, lesko ws, blowout fracture of the medial orbital wall. Orbital blowout fractures occur when there is a fracture of one of the walls of orbit but the orbital rim remains intact. 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.
Clinically, patients complain of diplopia with lateral gaze and forced duction tests confirm medial rectus entrapment. 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. Later, we modified this technique by placing the incision. Jan 22, 2016 this study included 348 orbits of 348 patients, 275 men and 73 women, with isolated medial wall fractures. Orbital fractures symptoms, diagnosis and treatment. Medial orbital wall fracture with concomitant medial. Anatomical reconstruction of medial wall and orbital floor fractures.
Defects involving medial wall of orbit can be repaired by using bone grafts or other inert materials. Frequently overlooked, this injury may be the cause of delayed enopthalmos, meningitis, or blindness. Facial fracture management handbook lateral orbital wall. 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. Ct delineated the fracture site and its extent in each case, and clearly demonstrated medial rectus muscle entrapement in two. Both blowin and blowout patterns can result in muscle entrapment.
This video demonstrates repair of a large medial orbital wall and inferior orbital floor fracture. This study included 348 orbits of 348 patients, 275 men and 73 women, with isolated medial wall fractures. The term blowout fracture was coined in 1957, when smith and regan 1 described the mechanism of injury. Combined transconjunctival and transcaruncular approach for. The fracture is a transverse separation of the nasofrontal suture, medial orbital wall, lateral orbital wall or zygomaticofrontal suture, zygomatic arch and pterygoid plates. They produced an impact on the orbital soft tissues of a cadaver, increasing. Medial orbital wall fractures and the transcaruncular. Medial wall fractures are less common in isolation and more often with a floor fracture or as part of a complex fracture.
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