Retrospective analysis of 314 orbital fractures

Rare consequences of a single fist punch to the orbital region - a description of two cases

A direct punch with a clenched fist to the face most often results in soft tissue damage, which is usually not serious enough to be considered a severe health impairment. This article presents two cases in which a single punch to the orbital region led to a blowout fracture. The first case resulted in additional displacement of the right lens into the vitreous body, secondary glaucoma and retinal detachment. In the second case, the victim sustained retinal concussion and subretinal haemorrhage due to choroidal rupture at the level of the macula resulting in temporary, almost complete loss of vision. Such injuries, although possible, are not typical of the mechanism described. In both cases, the effects meet the legal definition of impairment of the functioning of a bodily organ or disturbance of health lasting longer than 7 days within the meaning of the relevant article of the Polish Penal Code. Additionally, in the second case, we deal with exposure to direct danger - loss of vision in one eye (another severe disability) within the meaning of the relevant articles of the Polish Penal Code.

Risk factors for inpatient hospital admission following isolated orbital floor fractures

Orbital floor fractures are common injuries seen in the emergency department (ED). In this study, the National Trauma Data Bank (NTDB, 2016-2017) was used to identify patients presenting with isolated orbital floor trauma. Patient-specific factors were analyzed to determine associations with management. The sample comprised 912 patients; 285 (31.3%) of these patients were discharged from the ED, 541 (59.3%) were admitted to the hospital but did not undergo an operation, and 86 (9.4%) underwent operative treatment. Pediatric patients and older patients (<18 years and>55 years) were more likely to be admitted than those aged 18-55 years, and pediatric patients were more likely to undergo an urgent operative intervention than those in the other age groups (all P < 0.001). Patients with alcohol use disorder (P = 0.002) and hypertension (P = 0.004) had increased odds of admission. Private and Medicare insurance patients were more likely to be admitted, and self-pay patients less likely (P < 0.001). Older age and Medicaid payor status showed increased odds of a greater hospital length of stay. Biological sex, race/ethnicity, functionally dependent health status, myocardial infarction, steroid use, and substance use disorder were not associated with discharge disposition. There are non-injury related, patient-specific factors that may influence the management of orbital floor fractures.

Assessment of quality of life in patients treated for orbital fractures

PURPOSE

This study aimed to assess the quality of life (QOL), before and after surgery, of patients who underwent open reduction and internal fixation for orbital fractures.

STUDY DESIGN

A prospective study.

PARTICIPANTS AND SETTING

The self-report outcome measures of 50 patients treated at the Department of Oral and Maxillofacial Surgery of the Second Affiliated Hospital of Jiamusi University from January 2016 to June 2019 were prospectively collected.

MAIN MEASURES

The quality of life was assessed using four patient-reported outcome measures (PROMs): the 15D questionnaire, Oral Health Impact Profile-14 (OHIP-14), Hospital Anxiety and Depression Scale (HADS), and 36-item Short Form Survey (SF-36). Both descriptive and comparative data analyses were calculated.

RESULTS

Zygomaticomaxillary complex fractures were the most encountered (40.3%). The total OHIP-14 scores before and after treatment were 1.72 and 1.68, respectively. Vision, breathing, sleeping, eating, usual activities, discomfort and symptoms, and vitality showed minimal changes in the 15D questionnaire. The HADS scores were ranged from 0 to 7, indicating no anxiety or depression. The comparison of SF-36 scores after 3 months and after ≥6 months of treatment revealed no significant difference.

CONCLUSIONS

Patients' QOL was minimally impacted by orbital fractures and their treatments. The severity of the negative impact can be minimized if appropriate management strategies are taken.

Orbital floor fractures: epidemiology and outcomes of 1594 reconstructions

Objective

The aim of this study was to retrospectively review the midface and orbital floor fractures treated at our institution with regard to epidemiological aspects, surgical treatment options and postoperative complications and discuss this data with the current literature.

Study design

One thousand five hundred and ninety-four patients with midface and orbital fractures treated at the Department of Oral, Cranio-Maxillofacial and Facial Plastic Surgery of the Goethe University Hospital in Frankfurt (Germany) between 2007 and 2017 were retrospectively reviewed. The patients were evaluated by age, gender, etiology, fracture pattern, defect size, surgical treatment and complications.

Results

The average patient age was 46.2 (± 20.8). Most fractures (37.5%) occurred in the age between 16 and 35. Seventy-two percent of patients were male while 28% were female. The most common cause of injury was physical assault (32.0%) followed by falls (30.8%) and traffic accidents (17.0%). The average orbital wall defect size was 297.9 mm² (± 190.8 mm2). For orbital floor reconstruction polydioxanone sheets (0.15 mm 38.3%, 0.25 mm 36.2%, 0.5 mm 2.8%) were mainly used, followed by titanium meshes (11.5%). Reconstructions with the 0.15 mm polydioxanone sheets showed the least complications (p < 0.01, r = 0.15). Eighteen percent of patients who showed persistent symptoms and post-operative complications: 12.9% suffered from persistent hypoesthesia, 4.4% suffered from post-operative diplopia and 3.9% showed intra-orbital hematoma.

Conclusion

Results of the clinical outcome in our patients show that 0.15 mm resorbable polydioxanone sheets leads to significantly less post-operative complications for orbital floor defects even for defects beyond the recommended 200 mm².

Repair of unilateral combined orbital floor and medial wall fracture using two titanium mesh plates: a modified technique

Background

Compared to isolated orbital wall fracture, combined orbital floor and medial wall fractures are more likely to be required surgical correction due to a higher possibility of complications. However, it remains a challenge to repair concomitant orbital fracture using a one-piece implant due to the complex anatomic structures of the orbit. Aiming to reduce surgical difficulties and enhance therapeutic effects, we repaired unilateral combined orbital floor and medial wall fractures using two separated modified titanium mesh plates in this study.

Methods

A retrospective study was conducted on 21 consecutive patients who presented with unilateral combined orbital floor and medial wall fractures in Tianjin Medical University General Hospital between November 2010 and January 2016. The orbital fractures were repaired with two separated titanium mesh plates. The corner at the transition zone area between the orbital floor and the medial wall was reconstructed simultaneously through a combined transcaruncular and inferior subciliary approach with lateral canthotomy. The pre- and post-operative functions and aesthetic results were evaluated.

Results

Preoperatively, all patients presented with 3.5-6.5 mm enophthalmos, five patients presented with diplopia with ocular motility limitation in injured eyes, and six patients presented with hypoglobus ranging from 1.5 to 3.5 mm. Orbital floor and medial wall fractures of all patients were successfully repaired with two separated titanium mesh plates. Postoperatively, enophthalmos was improved in all patients, which was less than 2 mm on the last follow-up day. Hypoglobus was disappeared in all six patients postoperatively. Diplopia was resolved in five patients within 3 months post operation, and was reduced in one patient.

Conclusions

In cases of unilateral concomitant orbital floor and medial wall fractures, two titanium mesh plates implantation is a safe and effective procedure. It is worthwhile to take the technique into account when the key points to consider when applying this method include reconstruction of the special orbital shape and the complete return reposition of prolapsed intraorbital soft tissues were intended.

Review of Orbital Fractures in an Urban Level I Trauma Center

Objective

To perform a comprehensive review and analysis of surgically treated orbital fractures.

Study Design

Retrospective cohort chart review study for surgically treated orbital fractures during 5 years.

Results

A total of 173 patients (average age 41.6 years) were diagnosed with orbital fractures. Most were male with a ratio of 3.3:1. Most fractures were caused by assault (39.3%); 22.5% of the cases were bilateral. The left orbit (40.5%) was fractured more than the right. The orbital floor (97.1%) was the most common anatomic location and the maxilla (65.3%) was the most commonly involved bone. The average time from trauma to surgical intervention was 8.7 ± 14.6 days and the average time from surgical intervention to discharge was 5.1 ± 9.0 days. The transconjunctival incision (63%) was the most commonly used incision, and nonresorbable implant (92.7%) was the most commonly used implant. Finally, the length of stay for the repair of a simple orbital fracture was less than for complex orbital fracture (1.5 days and 5.9 days, respectively).

Conclusion

Understanding the patterns and mechanisms of injury associated with orbital fractures can assist in developing standardized treatment protocols across all surgical specialties. This would ultimately allow for a uniform high quality of surgical care for patients with maxillofacial fractures.

A Rare Complication of Infraorbital Nerve Hyperesthesia in Surgically Repaired Orbital Fracture Patients

Injury to the peripheral sensory branches of the trigeminal nerve can follow a wide variety of craniofacial injuries. Many patients with facial fractures complain about the symptom of numbness to the distribution of injured nerve, which is indicative of hypoesthesia. Hyperesthesia involving the infraorbital nerve is rare in comparison to hypoesthesia secondary to facial trauma. The authors report on 2 patients with infraorbital nerve hyperesthesia in surgically repaired orbital fracture patients. Surgical decompression of the infraorbital nerve led to rapid resolution of hyperesthesia. To the best of our knowledge, these were rare cases of patients who presented with persistent hyperesthesia. Clinician should perform early surgical decompression of the infraorbital nerve in patient with persistent hyperesthesia of the infraorbital nerve.

Epidemiology and Predictors of Orbital Fractures in Children

OBJECTIVES

Data regarding clinical predictors of orbital fractures in children are limited. We sought to describe the epidemiology of pediatric orbital fractures and identify the signs and symptoms of orbital fractures in children.

METHODS

We performed a retrospective cohort study of children younger than 22 years who underwent a facial or orbital computed tomography (CT) scan to evaluate for orbital fracture. We included patients presenting to an emergency department of a tertiary care children's hospital between January 2009 and May 2013. The presence of an orbital fracture was assessed using the final interpretation of the CT by an attending radiologist in the electronic medical record.

RESULTS

Among 326 children who underwent facial or orbital CT during the study period, 133 (41%) had an orbital fracture. The presence of nausea or vomiting, orbital tenderness, swelling, or ecchymosis and limitation of extraocular movement were each associated with the presence of an orbital fracture (P < 0.05 for each). Twenty-two children (6.7% of cohort and 16.5% of children with orbital fractures) underwent surgical repair for an orbital fracture. In the absence of orbital tenderness, swelling, or ecchymosis, there was 1 child with an orbital fracture who underwent operative intervention.

CONCLUSIONS

Fewer than half of children undergoing CT have an orbital fracture identified, and fewer than 7% have a fracture that requires operative intervention. In the absence of orbital tenderness, swelling, or ecchymosis, only 1 child had an orbital fracture requiring surgical repair.

Outcomes of Orbital Blow-Out Fracture Repair Performed Beyond 6 Weeks After Injury

PURPOSE

Blow-out fractures cause expansion of the bony orbital walls and prolapse of orbital contents in the sinuses. This can result in diplopia, enophthalmos, and hypoglobus. Early surgical repair has been previously recommended, however, recent reports show that delayed surgery can also be effective. In this study, the clinical and functional outcome of patients with delayed presentation and blow-out fracture repair beyond 6 weeks after injury are described.

METHODS

This is a noncomparative retrospective study. Medical records of adult patients with late orbital floor fracture repair performed by 4 surgeons from April 2008 to January 2014 at 3 tertiary referral centers were reviewed. All repairs were performed more than 6 weeks from the time of injury. Patients with prior orbital fracture repair surgery were excluded.

RESULTS

Twenty patients were included in the study. The duration from time of injury to surgery ranged from 7 weeks to 21 years with a mean of 19 months. Follow up ranged from 6 weeks to 56 months (mean 8 months). Mean age was 48 years (range, 25-80). Male to female ratio was 11:9. Surgery was performed on 10 right eyes and 10 left eyes. CT imaging demonstrated 10 patients had isolated floor fractures, while the remaining 10 patients had combined floor and medial wall fractures. Four patients also had associated facial fractures that did not require surgery. Indications for surgery included enophthalmos of 2 mm or more (18 of 20) and/or significant diplopia within 30° of primary gaze (6 of 20). Mean pre- and postoperative enophthalmos was 2.4 ± 0.9 mm and 0.3 ± 0.2 mm, respectively, corresponding to a mean reduction in enophthalmos of 2.1 ± 1.2 mm (range, 1-5 mm). Four of 7 patients with hypoglobus ranging from 1.5 mm to 8 mm preoperatively had complete resolution postoperatively, the remaining 3 patients showed reduced hypoglobus. Of the 12 patients that had diplopia preoperatively in any position of gaze, 6 patients had complete resolution of diplopia postoperatively, 4 patients had reduced but residual diplopia in extreme gaze, and 2 patients had persistent diplopia, in primary position and down gaze, respectively. Two patients had poor vision that precluded the manifestation of diplopia. None of the 6 patients without preoperative diplopia developed symptoms post operatively.

CONCLUSION

Surgical repair of blow-out fractures of the orbit occurring more than 6 weeks or more from injury can achieve marked improvement in both the functional and cosmetic aspects. The likelihood of induced diplopia is low. Orbital floor fracture repair should be considered to successfully treat enophthalmos or diplopia in patients with delayed clinical presentation, even decades postinjury.

Orbital reconstruction with a partially absorbable mesh (monofilament polypropylene fibre and monofilament poliglecaprone-25): Our experience with 34 patients

Purpose

To evaluate the effectiveness and complications related to the use of a partially absorbable mesh for the reconstruction of orbital floor fractures.

This is a retrospective review of 34 consecutive patients who suffered orbital trauma from August 2007 to March 2013 treated with a partially absorbable mesh for orbital reconstruction. Data collected included gender, age, nationality, cause of injury, date of admission, date of surgery, date of discharge, type of fracture, signs and symptoms such as diplopia, enophthalmos, and sensory disturbance related to the infraorbital nerve, complications before and after surgery, and follow-ups at 1 week, 1 month, 6 months, and after 1 year.

Results

Since January 2007, 34 patients were treated in our department with orbital fractures: 28 males (82.4%) and 6 females (17.6%). The mean age was 31 years (minimum 14, maximum 45). The main causes of trauma were road traffic accidents (20 patients, 58.8%), followed by work-related accidents (9 patients, 26.5%), aggressions (3 patients, 8.8%), and sports (2 patients, 6%). Posttraumatic Diplopia was present in 20 patients (58.8%), and enophthalmos was in 9 (26.5%). The incidence of postoperative diplopia was present in 8 patients (23.5%), which decreased to 1 (2.9%) after one year. Paresthesia due to trauma was first noticed in 8 patients (20.6%) and completely disappeared after 12 months. Post surgical enophthalmos was noticed in 3 patients (7.5%). There was one case of migration of the mesh and one case of adherence in the lower lid. Both required surgery and resolved completely. Time from trauma to surgery was on average 5.5 days (min 0, max 27, SD 5.15), and the number of days before discharge was 3.5 days (min 1, max 16, SD 2.61).

Conclusions

This study describes the results of the first series of orbital floor reconstructions with a partially absorbable mesh (Monofilament polypropylene fibre and monofilament poliglecaprone-25) to date. Although there are a wide variety of materials for treatment, we believe it is a suitable option with an acceptable rate of complications.

Etiology of orbital fractures at a level I trauma center in a large metropolitan city

Background/Purpose:

Orbital fractures are a common facial fracture managed by multiple surgical specialties. Methods: A retrospective review of the electronic medical records of patients (age, 18–85 years) presenting to Northwestern Memorial Hospital and Northwestern Medical Faculty Foundation in Chicago, IL, USA with International Classification of Diseases, Ninth Revision codes for facial fractures or CPT (Current Procedural Terminology) codes for orbital fracture repair.

Results:

A review of the electronic medical records identified 504 individual incidents of orbital fractures with available imaging for review. The most common location for an orbital fracture was a floor fracture (48.0%) followed by a medial wall fracture (25.2%). Left-sided orbital fractures were statistically significantly more common than right-sided orbital fractures (99% confidence interval). Orbital fractures were more prevalent in younger age groups. The mean patient age was 39.3 years. The most common cause of all orbital fractures was assault followed by falls. However, falls were the most common cause of orbital fractures in women and in patients aged 50 years and older. Evaluation by an ophthalmologist occurred in 62.8% of orbital fracture patients, and evaluation by a team comprising the facial trauma service (Otolaryngology, Plastic Surgery, and Oral and Maxillofacial Surgery) occurred in 81.9% of orbital fracture patients.

Conclusion:

Assault was the largest cause of all orbital fractures, and occurred most commonly in young males. Assaulted patients were more likely to have left-sided fractures compared to nonassaulted patients. In patients aged 50 years and older, falls were the most common cause of orbital fractures.

Orbital floor fractures--short- and intermediate-term complications depending on treatment procedures

Background

Many reconstruction materials for orbital floor fractures have been described in the past including autologous bone transplants, resorbable polymers and titan meshes. So far evidence is missing which material is used successfully regarding indication and particular size of defect. Therefore the aim of this study was to evaluate which reconstruction technique produces best clinical outcome and least complications associated with indication.

Methods

Retrospectively, surgical and ophthalmological data plus CT scans from a collective of 775 patients between 2005 and 2012 were analyzed. Furthermore included patients were sounded on satisfaction and potential problems postoperatively.

Results

Overall 593 patients offered full pre- and postoperative short-time data appropriate to inclusion criteria – of these 507 (85,5 %) underwent primary surgical treatment. Smallest average defect size was found in cases with no indication for surgical treatment (81 mm²), largest in cases indicating titanium mesh reconstruction (601.5 mm²). In 15 cases exact fragment reposition was possible without insertion of alloplastic material. Best clinical results obtained reconstruction using polydioxanone foil (PDS). 0.15 mm PDS-foil: 444 patients, reduced diplopia pre to postoperative 16 to 6 % (p < 0.01), ex- and enophthalmus < 2 % after surgery. 0.25 mm PDS-foil: 26 patients, reduced diplopia from pre- to postoperative 34,6 to 3,8 % (p < 0.01), postoperative exophthalmus rate was higher than preoperative (3,8 to 7,7 %). In comparison to reconstruction with PDS-foil a higher percentage of patients reconstructed with titanium meshes (n = 22) revealed no significant reduction of diplopia (45,5 to 31,8 %; p = 0.07). Furthermore 63 of all included patients agreed to complete a questionnaire on intermediate-term postoperative symptoms and surgical contentedness. Remarkably 50 % of the patients reconstructed with titanium meshes indicated foreign body sensations and cold feeling in the long-term.

Conclusions

Short- and intermediate-term results of clinical outcome in our patients with surgical treated orbital floor fractures (i.e. diplopia, en- or exophthalmus) reveal that thin resorbable foils, particularly 0.15 mm diameter PDS-foil seem to generate best results referring to orbital floor defects with a size of 250 to 300 mm².

Trial registration

Study number 4222, year 2013, ethics committee of the medical faculty of the Heinrich Heine university of Duesseldorf.

Orbit fractures: Identifying patient factors indicating high risk for ocular and periocular injury

OBJECTIVES/HYPOTHESIS

Maxillofacial trauma frequently involves the bony orbit that surrounds the ocular globe. Concomitant globe injury is a concern whenever orbit trauma occurs and in severe cases can occasionally result in vision loss. The mechanism of injury, physical exam findings, and radiographic imaging can provide useful information concerning the severity of the injury and concerns for vision loss. Using these three tools, it is hypothesized that the patient's history, physical exam, and radiographic findings can identify high-risk maxillofacial trauma patients with concomitant ocular injury. Identification of high risk patients who require comprehensive ophthalmologic evaluation may alter management and possibly preserve or restore vision.

STUDY DESIGN

A retrospective clinical chart review was performed at a tertiary academic medical center.

METHODS

Subjects were identified using the institutional trauma registry. Data collected included subject demographics, patient medical records and notes, ophthalmologic testing, and radiographic imaging. The incidence of orbit fracture and concomitant ocular injury associated with the mechanism of injury, physical exam findings, and radiographic imaging was determined. Statistical analysis was performed using a chi-square and Fisher exact test.

RESULTS

In this study, 279 subjects with orbit fractures were identified and the incidence of concomitant ocular injury was 27.6% (77 of 279). Mechanism of injury was statistically associated with an increased risk of ocular injury (P = 0.0340), with penetrating trauma being the most likely etiology. The physical exam findings of visual acuity and an afferent pupillary defect were statistically associated with ocular injury (P = 0.0029 and 0.0001, respectively). Depth of orbit fracture on radiographic imaging was statistically associated with ocular injury (P = 0.0024), with fractures extending to the posterior third of the orbit being most likely to have associated ocular injury.

CONCLUSION

Maxillofacial trauma patients with orbit fractures and concomitant ocular injury occur in more than one in four patients. Comprehensive ophthalmologic evaluation is recommended for all patients who sustain an orbit fracture. Subjects with a penetrating trauma mechanism of injury, physical exam findings of visual acuity deficits and an afferent pupillary defect, and radiographic imaging demonstrating fracture depth involvement of the posterior orbit are at highest risk for vision loss and warrant specific concern for ocular injury assessment.

LEVEL OF EVIDENCE

IV.

Trend and Characteristics of 2,636 Maxillofacial Fracture Cases over 32 Years in Suburban City of Japan

Trend and characteristics of maxillofacial fractures in 2,636 patients over 32 years were analyzed retrospectively. Patients comprised 1,764 males and 872 females with ages ranging from 0 to 99 years. Patients younger than 30 years consisted of 60% maxillofacial fractures in the early period but decreased to 40% in the late period. In contrast, patients older than 60 years gradually increased to 30%. In terms of cause, traffic accidents consisted of more than 50%, predominantly motorcycle accidents, but gradually decreased to 40%. In contrast, falls markedly increased from less than 10 to 30%. Fractures occurred in the midface in 938 patients, in the mandible in 1,490, and in both in 208. In the midface, zygoma fractures consisted of 50% throughout the period. In the mandible, condyle fractures were observed in 40%, followed by fractures of the symphysis and angle. The ratio of condylar fractures slightly increased. Open reduction and internal fixation (ORIF) were performed in 782 patients, followed by observation in 716, maxillomandibular fixation (MMF) in 605, intramaxillary splinting (IMS) in 294, transcutaneous reduction (TCR) in 126, and others in 113. MMF markedly decreased from more than 30 to less than 5% and observation increased from 20 to 40%.

Patient specific implants (PSI) in reconstruction of orbital floor and wall fractures

Fractures of the orbital wall and floor can be challenging due to the demanding three-dimensional anatomy and limited intraoperative overview. Misfitting implants and inaccurate surgical technique may lead to visual disturbance and unaesthetic results. A new approach using individually manufactured titanium implants (KLS Martin, Group, Germany) for daily routine is presented in the current paper. Preoperative CT-scan data were processed in iPlan 3.0.5 (Brainlab, Feldkirchen, Germany) to generate a 3D-reconstruction of the affected orbit using the mirrored non-affected orbit as template and the extent of the patient specific implant (PSI) was outlined and three landmarks were positioned on the planned implant in order to allow easy control of the implant's position by intraoperative navigation. Superimposition allows the comparison of the postoperative result with the preoperative planning. Neither reoperation was indicated due to malposition of the implant and the ocular bulb nor visual impairments could be assessed. PSI allows precise reconstruction of orbital fractures by using a complete digital workflow and should be considered superior to manually bent titanium mesh implants.

Clinical analysis of midfacial fractures

Purpose:

To analyze the features of midfacial fractures.

Methods:

Data of 320 patients treated for midfacial fractures during the past 10 years were retrospectively analyzed.

Results:

Patients were 192 male and 128 female. Their age ranged from 1 to 96 years old with the average of 42.1. Injury most frequently occurred by traffic accidents in 168 patients, followed by falls in 78, assaults in 31 and sports in 25. Pattern of the fractures was classified into zygoma in 159 patients, alveolus in 60, multiple sites in 54, maxilla in 45 and nasal bone in 2. Facial injury severity scale ranged from 1 to 12 with the average of 1.52. Injuries to other sites of the body were found in 90 patients. Fractures of multiple sites showed higher facial injury severity scale and were associated with injuries to other sites of the body at a higher rate. Observation was most frequently chosen in 153 patients, followed by open reduction and internal fixation in 72, intramaxillary fixation in 43 and transcutaneous reduction in 26.

Conclusions:

Midfacial fractures showed a variety of features in terms of the site and severity and associated injuries. Understanding these features is important to manage these patients properly.