Ophthalmic involvement in cranio-facial trauma

Clinical Significance of Diplopia and the Orthoptic Examination in Zygomatic Maxillary Complex Fractures

Literature describes variable rates of diplopia of associated with zygomatic maxillary complex (ZMC) fractures (6% to 40%). The aim of this study was to retrospectively assess the prevalence of diplopia in ZMC fracture patients, the usefulness of the orthoptic evaluation compared with the clinical finger-tracking examination, and to seek possible relations of this symptom with clinical parameters. Data of patients attending the Maxillofacial Surgery Units of the University of Messina and University of Naples "Federico II", between January 2012 and December 2022 were retrieved. Statistical analysis of positive versus negative diplopia at both the clinical examination and the orthoptic evaluation and subgroup analysis were performed. 320 patients were included in the analysis. 50 (15.6%) patients reported diplopia at the clinical examination, whereas 70 (21.9%) resulted positive at the orthoptic evaluation. Statistical analysis for every determinant and subgroup did not show statistical significance (P>0.05). Performing routine preoperative orthoptic evaluation allowed an increase of 6.3% in positive reports. Although it seems that no basic clinical parameter can predict diplopia, results suggest that the orthoptic evaluation is superior in the assessment of this symptom. Clinical analysis was shown to be a moderate/low efficient test and should not be used as a decisional standard.

Factors Associated With Head and Neck Polytrauma Presentation and Admissions at Emergency Departments of Varying Sizes

Timely diagnosis of acute head and neck polytrauma presenting to emergency departments (EDs) optimizes outcomes. Since ED capacity influences triage and admission, the authors utilized the National Electronic Injury Surveillance System database to understand how ED size and trauma characteristics affect head and neck polytrauma presentation and admissions. Demographics and injury characteristics from the National Electronic Injury Surveillance System database from 2018 to 2021 were analyzed to delineate factors contributing to polytrauma presence and admission through multivariable logistic regressions. The authors' 207,951-patient cohort was primarily females (48.6%), non-Hispanic (62.4%), and white (51.4%) people who averaged 57.2 years old. Nonspecific head injuries were predominant (59.7%), followed by facial trauma (22.6%) with rare substance involvement (alcohol, 6.3%; drugs, 4.1%) presenting to high-volume EDs (48.5%). Of the patients, 20% were admitted, whereas 31.1% sustained polytrauma. Substance use [alcohol, odds ratio (OR) = 4.44; drugs, OR = 2.90] increased polytrauma likelihood; neck (OR = 1.35), face (OR = 1.14), and eye (OR = 1.26) associated with polytrauma more than head injuries. Burns (OR = 1.38) increased polytrauma likelihood more than internal organ injuries. Black patients sustained higher polytrauma when presented to non-small EDs (OR = 1.41-1.90) than white patients showed to small EDs. Admissions were higher for males (OR = 1.51). Relative to small EDs, large EDs demonstrated a higher increase in admissions (OR = 2.42). Neck traumas were more likely admitted than head traumas (OR = 1.71). Fractures (OR = 2.21) and burns (OR = 2.71) demonstrated an increased admission likelihood than internal organ injuries. Polytrauma presence and admissions likelihood are site, injury, and substance dependent. Understanding the impact of factors influencing polytrauma presence or admission will enhance triage to optimize outcomes.

Incidence of ophthalmologic pathology and associated risk factors in orbital fractures at a level I trauma centre

OBJECTIVE

To estimate the incidence of ophthalmologic pathology at presentation of patients with orbital fracture to a level I trauma centre and the most significant associated risk factors.

METHODS

A total of 244 patients with 278 fractured orbits over a 2-year period at a level I trauma centre were reviewed. The primary outcome was the incidence of urgent ophthalmologic pathology, defined as requiring attention without delay. Patient demographics, history, findings on radiographic imaging, and physical examination findings at initial and follow-up examinations were recorded. Odds ratios with 95% confidence intervals were calculated.

RESULTS

On initial examination and follow-up, 9.7% of orbits had ophthalmologic pathology. Only 3 patients (1.1%) had urgent pathology, including orbital compartment syndrome and globe rupture, whereas 22 patients (7.9%) had semiurgent pathology and 4 patients (1.4%) had nonurgent pathology. Subjective decreased vision (odds ratio [OR] = 3.5; p = 0.021), assault-related injuries (OR = 2.4; p = 0.036), work-related injuries (OR = 7.7; p = 0.004), afferent pupillary defect (OR = 19.2; p = 0.017), anisocoria (OR = 7.8; p = 0.001), and symmetrical extraocular movement limitation (OR = 5.2; p = 0.003) and fixed pupil (OR = 16.9; p < 0.001) had statistically significant odds ratios associated with pathology. Patient sex, eye involved, intoxication, anticoagulation, and antiplatelets, as well as previous ocular surgery, were not associated with pathology.

CONCLUSIONS

Most orbital fractures do not present with ophthalmologic pathology. Subjective vision loss, history of assault or work trauma, and pupil abnormalities on examination were the greatest risk factors for pathology. Our results highlight the most important factors on patient presentation that should prompt first responders to seek urgent ophthalmologic consultation.

The Association Between Craniofacial Fracture Patterns and Traumatic Optic Neuropathy

Traumatic optic neuropathy (TON) is a rare but potentially devastating complication of craniofacial trauma. Approximately half of patients with TON sustain permanent vision loss. In this study, we sought to identify the most common fracture patterns associated with TON. We performed a retrospective review of craniomaxillofacial CT scans of trauma patients who presented to the R Adams Cowley Shock Trauma Center from 2015 to 2017. Included were adult patients who had orbital fractures with or without other facial fractures. Patients diagnosed with TON by a formal ophthalmologic examination were analyzed. Craniofacial fracture patterns were identified. Bivariate analysis and multivariate logistic regression were performed to identify craniofacial fracture patterns most commonly associated with TON. A total of 574 patients with orbital fractures who met inclusion criteria [15 (2.6%)] were diagnosed with TON. The median [interquartile range (IQR)] age was 44 (28-59) years. Patients with optic canal fractures and sphenoid sinus fractures had greater odds of TON compared with patients who did not have these fracture types [adjusted odds ratio (aOR) 95% confidence interval (CI) 31.8 (2.6->100), 8.1 (2.7-24.4), respectively]. Patients who sustain optic canal and sphenoid sinus fractures in the setting of blunt facial trauma are at increased odds of having a TON. Surgeons and other physicians involved in the care of these patients should be aware of this association.

Frequency of Diplopia in Zygomatic Complex Fractures-A Cross-Sectional Descriptive Study

Background

The zygomatic complex is the second most common fracture of the facial bones after the nasal bone. The prominent convex shape of the zygoma makes it vulnerable to traumatic injury. Diplopia is one of the serious complications of zygomatic complex fracture and is a common subjective complaint.

Objective

To determine the frequency of diplopia in zygomatic complex fractures. Methodology. A cross-sectional descriptive study was conducted at the Oral and Maxillofacial Surgery Ward, Civil Hospital, Karachi, Pakistan. The duration of the study was 1 year (March 1, 2021 to February 28, 2022). A total of 126 patients having zygomatic complex fractures were included in this study. After recording the patient's complete history, like demographic details and cause for fracture, diplopia was examined clinically. If, during the examination, the patient complained of double vision, this was labeled as diplopia positive (Yes) and negative (No) if the patient did not have any such complain. Data were statistically analyzed.

Results

The mean (±SD) age of patients was 33.42 (±9.27), with 91 (72.2%) male patients and 35 (27.8%) female patients. The frequency of diplopia in zygomatic complex fractures was observed in 52 (41.3%) patients. The rate of diplopia was significantly high in patients aged between 31 and 40 years (P-value=0.0005).

Conclusion

The frequency of diplopia among patients having zygomatic complex fractures was high in this study. Thus, forming a strategy to properly diagnose and treat it and to prevent persistent morbidity to improve patient's quality of life is recommended.

The Pattern of Midface Fractures in Jordan: A Retrospective Review of Medical Records

Introduction

Midface fracture incidence and trauma patterns vary across countries, due to socioeconomic, environmental, and cultural factors. The aim of this retrospective study was to assess the etiology, pattern, and treatment of midface fractures in North of Jordan during 2018-2021.

Methods

This single-center retrospective study was based on the review of the medical records of patients who had suffered midface fractures and were treated at the Department of Oral and Maxillofacial Surgery at the King Abdullah University Hospital. The dataset for this investigation spanned the 4-year period from January 2018 to December 2021.

Results

During the 4-year period, 267 patients presented with 376 different maxillofacial fractures. Of those, 140 patients had 250 midface fractures, with a mean of 1.79 per patient. Their age ranged from 2 to 68 years (mean [standard deviation] = 25.8 [12.0] years). The most frequent injury cause was road traffic accidents (RTA) (n = 72, 51.3%), followed by falls (n = 27, 19.3%). Among midface fractures, the most frequent were orbit fractures (42.4%), followed by zygomatic fractures (31.6%) and maxillary fractures (26%). The majority of fractures (77.9%) were treated through open reduction and internal fixation (ORIF), while the remaining (15.7%) required closed reduction and conservative treatment was sufficient in 6.43% of fractures.

Conclusions

Midface fractures were more common among males, and primarily occurred in the orbital floor due to the high incidence of RTAs. Maxillary fractures were mostly of the LeFort I Type and ORIF was the most common treatment modality.

Risk Factors for Acute Postoperative Complications Following Operative Management of Le Fort Fractures-A NSQIP Study

INTRODUCTION

Le Fort fractures comprise a pattern of complex midfacial fractures that arise secondarily to craniofacial trauma. Although management of these fractures has been detailed within the literature, there is a paucity of research examining postoperative outcomes after surgical repair. The primary aim of this study is to assess patient outcomes after operative management of Le Fort fractures, and examine factors influencing the risk for developing postoperative complications, through utilization of the ACS-NSQIP database.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for cases recorded between 2012 and 2019 with International Classification of Disease (ICD)-9 and ICD-10 codes corresponding to Le Fort fractures. Patient demographics, clinical variables, and postoperative variables were recorded. Logistic regression analysis was conducted to identify independent risk factors for postoperative complications.

RESULTS

Identification of cases with appropriate ICD codes, and exclusion of those with missing data, yielded 562 patients for analysis. There were no cases of minor complications and 14 cases of severe complications (3 cases of wound dehiscence, 3 cases of transfusion requirement, 1 case of failure to wean from the ventilator for more than 48 h, 1 pulmonary embolism, and 8 cases of reoperation), corresponding to an overall complication rate of 2.49%. Logistic regression analysis revealed steroid use as an independent predictor of severe postoperative complications (OR =13.73, 95% CI: 1.08-128.02, P =0.02).

CONCLUSION

The present study is the first to conduct a risk factor analysis of patients with Le Fort fractures using the ACS-NSQIP national database. The overall postoperative complication rate was 2.49%, with 14 cases of complications recorded in 8 years. Although this may suggest that surgical management of Le Fort fractures is generally well-tolerated, it should be noted that this problem is frequently associated with other severe injuries of the head and neck that may influence patient prognosis. Given this, further analysis would benefit from a larger patient cohort and longer postoperative data as the ACS-NSQIP database only records outcomes within 30 days.

Ophthalmic Complications in Maxillofacial Trauma: A Prospective Study

Objectives: To determine the incidence and types of ophthalmic complications associated with maxillofacial trauma over a period of 24 months.

Methods: An institutional prospective study was conducted on 62 patients presenting with maxillofacial trauma to study the correlation between facial trauma and ophthalmic complications.

Results: Road traffic accidents were reported to be the primary etiologic factor for most trauma cases studied. Zygomaticomaxillary complex (ZMC) fracture was associated with more ophthalmic complications while fractures involving the orbital rims and walls were associated with severe complications.

Conclusions: Maxillofacial trauma, particularly those associated with midface, including ZMC fracture, Le Fort II, Le Fort III, and naso-orbito-ethmoidal fractures, can commonly cause ophthalmic complications and blindness in rare cases. Hence, every patient with maxillofacial trauma should undergo an ophthalmic examination and should be placed under close observation for necessary treatment when required.

Ocular Outcomes of Maxillofacial Trauma - A Decennary Descriptive Study

Maxillofacial trauma is amongst the most frequently encountered trauma seen in the hospital emergency setting. It may be life-threatening on rare occasions, and with concomitant injuries, it is often severely debilitating.

OBJECTIVE

The present study was conducted to determine the occurrence of concomitant orbital and ocular injuries amongst patients with maxillofacial trauma, and also helps in deriving a correlation between different patterns of maxillofacial fractures.

METHODS

All the records of the patients with maxillofacial trauma who were admitted to our institution over a 10-year period were analyzed. The files were screened to isolate the patients with concomitant ocular and orbital injuries.

RESULTS

Out of a total of 686 patients, 370 had associated ocular injuries. A total of 566 (82.5%) patients were males and 120 (17.5%) females. A total of 236 patients (34.4%) were in the 3rd decade. A total of 351 cases of orbital fracture (isolated + concomitant) were reported. About 44 (12.5%) cases of isolated orbital floor fractures were seen.Subconjunctival hemorrhage accounted for the maximum number of cases amounting to 59.19%. The least associated ocular injuries seen were of traumatic mydriasis (0.28%). Out of 370 cases of ocular injuries, 249 (67.3%) were associated with fractures of the zygomaticomaxillary complex.

CONCLUSIONS

The present study draws attention to the concomitant orbital and ocular injuries in maxillofacial trauma patients. This study is strongly suggestive of a very high probability of concomitant ocular injury in maxillofacial trauma patients which necessitates strong interdepartmental coordination for holistic management of the maxillofacial trauma patients.

Use of custom fabricated surgical jig to improve surgical outcomes in open reduction internal fixation of unilateral orbital fractures: A prospective clinical study

PURPOSE

The aim of the study was to assess the efficacy of virtual planning and surgical guide jig to improve surgical outcomes of open reduction and internal fixation with restoration and correction of orbital volume (OV) in unilateral orbital wall fractures.

METHODS

Fifteen patients with unilateral orbital fractures were assessed with ophthalmologic and radiographic parameters. The orbit was divided into three zones on computed tomography to localize defects. Fractures were coded into Fx Mx Rx Lx (F = Orbital Floor, M = Medial Wall, L = Lateral wall, R = Orbital Roof) based on pattern and specific wall involved. 1-mm sections were used to make stereolithographic models, design the custom fabricated surgical jig for intraoperative use as a guide.

RESULTS

Pre- and postoperative ophthalmological parameters, OV, were compared with the contralateral normal orbit serving as the reference. Postoperative ophthalmological parameters showed significant improvement in terms of visual acuity, enophthalmos, dystopia, and traumatic optic neuropathy. OV changes were concentrated in Zones 2 and 3. OV showed adequate restoration postoperatively.

CONCLUSION

The surgical jig served as an efficient guide to improve surgical outcomes of open reduction internal fixation. Preplanned intraoperative positioning helped achieve adequate anatomical reduction and fixation with an adequate reconstruction of OV aiding the effective transfer of virtual surgical plan on the table with improved surgical outcomes in clinical performance and functional restitution.Clinical trial registration: The Clinical Trials Registry of India (CTRI) Registration No.: CTRI/2019/11/021929.

Pattern of Ocular Involvement in Midface Injuries Seen at a Tertiary Care Hospital in Northern Nigeria

Aim:

The aim of the study was to report the etiology, pattern, and spectrum of ocular injuries in patients with maxillofacial injuries seen at a tertiary care hospital in northern Nigeria.

Patients and Methods:

This is a retrospective evaluation of the etiology, spectrum, and treatment of ocular injures seen in patients with midfacial fractures, who presented at Ahmadu Bello University Teaching Hospital, Shika-Zaria, Nigeria, a tertiary care hospital in northern Nigeria. Cases were seen at the oral and maxillofacial clinic for those presenting with midfacial fractures, whereas those presenting with ocular injuries due to midfacial injuries were referred from the ophthalmology department. Data were collected on their demographics, etiology of injuries, body part(s) involved, and treatment.

Results:

A total of 256 patients had midfacial injuries during the period, of which 219 patients had 357 associated ocular injuries. The age range was between 3 and 76 years. There were more males (83.8%) than females (16.2%), giving a male-to-female ratio of 5.2:1; the 21–30 years' age bracket was most frequently affected (38.4%). The predominant etiology of injuries was road traffic accidents (RTAs) (90.1%), followed by assault (4.9%). Zygomatic complex fractures (38.6%) and orbital wall fractures (24.7%) were the common midfacial injuries. There were 357 ocular injuries, giving a patient: injury ratio of 1:1.6, with subconjunctival hemorrhage (32.5%) and ruptured globe (20.0%) being common. Treatments performed were reduction and immobilization of midfacial fractures plus evisceration (32.0%), followed by reduction and immobilization of fractures alone (23.9%) and reduction and immobilization plus grafting of soft tissues (21.2%).

Conclusion:

Ocular injuries are quite common in patients with midfacial injuries, with a ratio of 1.6:1. RTA was the most common etiology, with zygomatic complex fractures as the most common midfacial injury. Subconjunctival hemorrhage was the most common ocular injury manifestation, with young adults (21–30 years of age) being most affected. Treatment often involved reduction and immobilization of midface fractures with evisceration and grafting of ocular tissues.

Review of Ocular Injuries in Patients with Orbital Wall Fractures: A 5-Year Retrospective Analysis

Purpose

The purpose of this study was to determine the incidence of minor and major ocular injuries in patients with orbital wall fractures at Loma Linda University Health, a level-one trauma center, to help determine the most appropriate setting for the initial dilated fundus examination by ophthalmologists.

Methods

A retrospective study was performed from January 2008 to January 2013 of patients diagnosed with orbital wall fracture secondary to trauma. Exclusion criteria included unknown mechanism of injury, the absence of ophthalmology consultation, or absence of imaging. Data collected included age, gender, mechanism of injury, visual acuity, and anterior/posterior segment findings. Ocular injuries were categorized as either minor or major.

Results

Of 567 charts reviewed, 460 met criteria and were included for analysis. In the analysis, 86.5% of patients were male, and 81.3% were Caucasian. The most common mechanism of orbital fracture was blunt injury. Visual acuity was better than 20/100 in 82.4% of patients. On chart review, 81.1% of patients were found to have either a minor injury, a major injury, or both. The most common injury was subconjunctival hemorrhage (53.5%). Globe rupture (2.9%) and vision-threatening posterior segment findings such as retinal tear and choroidal rupture (1.3%) were relatively rare. Only one retinal detachment (0.2%) was found, specifically in the setting of severe injury with concomitant globe rupture.

Conclusion

Knowledge of the common ocular injuries associated with orbital fractures will help emergency department (ED) physicians and ophthalmologists provide the dilated fundus exam in the most appropriate setting. The most frequent injuries identified were non-vision threatening, and visually significant posterior segment findings were relatively rare (1.3%). Thus, for the majority of patients presenting to the ED with orbital fracture, a dilated fundus exam can be performed at a later date in the outpatient clinic setting, unless urgent orbital fracture surgery is planned.

A Clinical Study of the Evaluation and Assessment of the Etiology and Patterns of Ocular Injuries in Midfacial Trauma in a Tertiary Care Hospital

Aims

The aim is to study the pattern of ocular injuries in midfacial trauma and to evaluate the overall incidence of ophthalmic injury of any severity following maxillofacial trauma.

Methods and Materials

The maxillofacial surgeon conducted routine facial examination of patients with midfacial fractures, which also included a detailed ophthalmologic examination of patients, at the time of initial presentation. These patients were then further evaluated by an ophthalmologist for thorough examination of the eye.

Results

The total number of recorded midface maxillofacial trauma cases was 181. Out of 181 patients, 161 had ocular injuries. Among 181 cases, 161 (88.95%) cases were due to road traffic accidents, which was the prime etiologic factor. Out of total 181 patients, 172 (95.03%) were males and 9 (4.97%) were females. The maximum number of cases were of zygomaticomaxillary complex fractures (44.75%) followed by nasal bone fractures (21.5%). Periorbital ecchymosis accounted for the maximum number of cases, amounting to 61.88%. Loss of vision or blindness was seen in eight (4.42%) patients.

Conclusions

The study stresses further on the importance of long-term and continuous data collection and record management of trauma patients, which may help health care providers with necessary information to develop treatment protocols and device measures for the prevention of complications.

Prevalence of Ocular Complications in Patients with Zygomatic Bone Fractures in an Iranian Population

Objectives:

Damages to the middle third of the facial bone generally involve the orbital skeleton and can lead to eye impairment. In this study, it is attempted to determine the incidence of ophthalmic injuries in maxillofacial trauma with zygomatic bone fractures.

Materials and Methods:

One hundred and fifteen cases with ophthalmic (ocular) involvement after maxillofacial trauma were referred to the Shariati Hospital, Tehran, Iran, and were visited at the Ophthalmology Department between 2016 and 2018. Zygomatic fractures and resulting ocular complications were evaluated in 87 males and 28 females with the mean ages of 26 and 32 years, respectively.

Results:

Subconjunctival ecchymosis was detected in 23.07% of men and 21.05% of women. Displacement of the palpebral fissure was detected in 26.5% of men and 27.6% of women. Furthermore, the unequal pupillary level was observed in 18.37% of men and 15.78% of women. Diplopia was detected in 8.9% of men and 10.5% of women. Additionally, enophthalmos was observed in 23.1% of men and 25% of women.

Conclusion:

The most common ocular presentations in midfacial trauma are diplopia and reduced visual acuity. Even after the operation, a significant number of patients experience poor vision and diplopia. Ophthalmology consultation is essential for these patients.

Associated Ophthalmic Injuries in Patients With Fractures of the Midface

Purpose

Concomitant ophthalmic injuries are common in patients with facial fractures, though frequency varies widely in the literature. Major ophthalmic injuries can have drastic consequences for patients, and permanent visual impairment cannot be prevented in all cases. This study analyzed the frequency and distribution pattern of associated ophthalmic injuries in patients who received operative treatment for fractures of the midface.

Material and Methods

The clinical information system was searched for patients with midface fractures that were treated operatively between December 2014 and November 2017. Demographic, fracture-related, and ophthalmic data were assessed and statistically analyzed.

Results

This study included 282 patients. The most common fracture types were zygomaticomaxillary complex fractures and orbital floor fractures. Falls and violence were the most common causes of fractures (43.3% and 24.5%, respectively). Chemosis and subconjunctival bleeding were the most common associated eye injuries. The most prevalent long-term eye injury was diplopia, which was identified in 18.4% of cases preoperatively. Postoperative diplopia persisted in 36 cases (12.8%) at 3-month follow-up. Optic neuropathy, enophthalmos, exophthalmos, and retrobulbar hematomas were identified infrequently.

Conclusion

Minor ophthalmic injuries, including chemosis and subconjunctival bleeding, are more frequently associated with midface trauma. These minor injuries tend to heal quickly and without sequela. Major ophthalmic injuries, including retinal detachment, optic neuropathy, and retrobulbar hematomas, are identified less frequently. Special attention should be paid to patients with diplopia, as this condition may persist and have long-term occupational consequences. Therefore, close interdisciplinary collaboration is essential when treating patients with fractures of the midface to prevent permanent visual impairment.

Screening Criteria for Detecting Severe Ocular Injuries in the Setting of Orbital Fractures

PURPOSE

Define incidence of severe ocular trauma in orbital fracture patients and determine if ocular signs and symptoms are useful predictors of severe ocular injuries.

METHODS

Retrospective chart review was performed on all patients with orbital fractures between April 1, 2013, and December 31, 2014. Patients were included if they had radiographic evidence of acute fracture of at least one orbital wall and were evaluated by the Ophthalmology service. Demographics, concurrent injury data, and symptoms and signs of ocular trauma were collected. Concurrent ocular injuries were grouped by severity. Predictive signs or symptoms for severe ocular trauma were identified by stepwise logistic regression analysis. The threshold point for predictive signs and symptoms was detected by a receiver operating characteristic (ROC).

RESULTS

Five-hundred-twelve patients were included. The most common mechanisms of injury were assault (39%), fall (25%), and motor vehicle accident (21%). The incidence of any concurrent ocular trauma was 75% (383/512), with 14% (70/512) being severe. Four signs and symptoms were predictors of severity: blurred vision (P < 0.0001), pain with eye movements (P < 0.0001), visual acuity worse than 20/40 in the ipsilateral eye (P < 0.001), and restricted motility (P < 0.001). The presence of 2 or more of these signs or symptoms was predictive of severe ocular trauma with high sensitivity (91%) and specificity (86%).

CONCLUSIONS

In cooperative patients with acute orbital wall fractures, the presence of 2 or more signs or symptoms is predictive of severe ocular trauma and necessitates the need for urgent ophthalmic consultation.Severe ocular injury associated with orbital wall fracture is more likely in patients with 2 or more ophthalmic signs or symptoms.

Anatomic Factors Predicting Postoperative Strabismus in Orbital Wall Fracture Repair

This study is aimed to determine the relationship between orbital fracture sites in each CT scan view and postoperative diplopia. Data for 141 patients of orbital wall fracture were analyzed retrospectively. One group of examiners reviewed sagittal, coronal and axial CT scans. Descriptive statistical analysis was used to assess each fracture area and its potential relationship with the occurrence of postoperative diplopia. Among the three anatomical views, sagittal sections were significantly associated with post-operative diplopia (PD) (p = 0.044). For orbital wall fractures in a single location, C1 (p = 0.015), A1 (p = 0.004) and S3 (p = 0.006) fractures were significantly related to PD. Orbital wall fractures found in more than one location resulted in a higher probability of PD in all sections:, C1 + C2 group (p = 0.010), C1 + C2 + C3 group (p = 0.005), A1 + A2 group (p = 0.034), A3 + A1 group (p = 0.005), S1 + S2 group (p < 0.001), S2 + S3 group (p = 0.006) and S1 + S2 + S3 group (p < 0.001). For combinations of two or three sections, we found that only fractures involving both coronal and sagittal sections led to a significantly increased risk of PD (p = 0.031). PD is the main posttreatment complication of orbital bone fracture reduction. In addition to the known myogenic cause (failure to relieve entrapment) of diplopia, both trauma and surgical manipulation can compromise ocular motor nerve function and possibly result in the development of neurogenic causes of diplopia. Careful assessment of patient symptoms (whether preoperative diplopia is present), and the location of orbital fractures (and the influence of related musculature, fat, and nerves) on CT scans are strongly related to surgical success.

Is specialized ophthalmologic evaluation necessary after orbital fractures? A prospective 64-case study

INTRODUCTION AND OBJECTIVE

The objective of this study was to determine whether there is a need for ophthalmologists to perform a specialized assessment after the occurrence of orbital fractures.

MATERIALS AND METHODS

Sixty-three patients (64 orbits) diagnosed with orbital fractures were evaluated preoperatively (up to 24 h after the trauma) and in 90-day postoperative period.

RESULTS

Eight injuries required either specialized clinical or surgical ophthalmologic intervention. Of these patients, four required emergency eye surgery: two patients with corneal lacerations had lesions larger than 2 mm. Two patients had extensive ocular lesions after multiple traumas with uveal exposure and without light perception. Another four patients (iridodialysis associated with lens subluxation, anterior uveitis, direct lesion on the optic nerve, and chorioretinitis sclopetaria) received conservative management.

CONCLUSION

This study concluded that a specialized ophthalmologic examination as soon as possible is important, particularly in cases in which the signs and symptoms of severity are associated. The non-ophthalmologist surgeon must have the basic medical knowledge required to provide basic primary ophthalmologic care and to discern the severity of the injury.

Facial Fracture Patterns Associated with Traumatic Optic Neuropathy

Traumatic optic neuropathy (TON) is rare. The heterogeneity of injury patterns and patient condition on presentation makes diagnosis difficult. Fracture patterns associated with TON have never been evaluated. Retrospective review of 42 patients diagnosed with TON at the R. Adams Cowley Shock Trauma Center from May 1998 to August 2010 was performed. Thirty-three patients met criteria for study inclusion of fracture patterns. Additional variables measured included patient demographics and mechanism. Cluster analysis was used to form homogenous groups of patients based on different fracture patterns. Fracture frequency was analyzed by group and study population. Visual depiction of fracture patterns was created for each group. Cluster analysis of fracture patterns yielded five common "groups" or fracture patterns among the study population. Group 1 ( n  = 3, 9%) revealed contralateral lateral orbital wall (100%), zygoma (67%), and nasal bone (67%) fractures. Group 2 ( n  = 7, 21%) demonstrated fractures of the frontal bone (86%), nasal bones (71%), and ipsilateral orbital roof (57%). Group 3 ( n  = 14, 43%) involved fractures of the ipsilateral zygoma (100%), lateral orbital wall (29%), as well as frontal and nasal bones (21% each). Group 4 ( n  = 5, 15%) consisted of mid- and upper-face fractures; 100% fractured the ipsilateral orbital floor, medial and lateral walls, maxilla, and zygoma; 80% fractured the orbital roof and bilateral zygoma. Group 5 ( n  = 4, 12%) was characterized by fractures of the ipsilateral orbital floor, medial and lateral orbital walls (75% each), and orbital roof (50%). A notably high 15 of 33 patients (45%) sustained penetrating trauma. Our study demonstrates five fracture pattern groups associated with TON. Zygomatic, frontal, nasal, and orbital fractures were the most common. Fractures with a combination of frontal, nasal, and orbital fractures are particularly concerning and warrant close attention to the eye.

Single-stage soft tissue reconstruction and orbital fracture repair for complex facial injuries

BACKGROUND

Orbital fractures with open periorbital wounds cause significant morbidity. Timing of debridement with fracture repair and soft tissue reconstruction is controversial. This study focuses on the efficacy of early single-stage repair in combined bony and soft tissue injuries.

METHODS

Retrospective review. Twenty-three patients with combined open soft tissue wounds and orbital fractures were studied for single-stage orbital reconstruction and periorbital soft tissue repair. Inclusion criteria were open soft tissue wounds with clinical and radiographic evidence of orbital fractures and repair performed within 48 h after injury. Surgical complications and reconstructive outcomes were assessed over 6 months.

RESULTS

The main outcome measures were enophthalmos, pre- and post-CT imaging of orbits, scar evaluation, presence of diplopia, and eyelid position. Enophthalmos was corrected in 16/19 cases and improved in 3/19 cases. 3D reconstruction of CT images showed markedly improved orbital alignment with objective measurements of the optic foramen to cornea distance (mm) in reconstructed orbits relative to intact orbits of 0.66, 95% confidence interval [CI] (lower 0.33, upper 0.99) mm. The mean baseline of Stony Brook Scar Evaluation Scale was 0.6, 95%CI (0.30-0.92), and for 6 months, the mean score was 3.4, 95%CI (3.05-3.73). Residual diplopia in secondary gazes was present in two patients; one patient had ectropion. Complications included one case of local wound infection.

CONCLUSIONS

An early single-stage repair of combined soft tissue and orbital fractures yields satisfactory functional and aesthetic outcomes. Complications are low and likely related to trauma severity.

Treatment Outcomes following Traumatic Optic Neuropathy

BACKGROUND

Traumatic optic neuropathy is characterized by sudden loss of vision following facial trauma leading to variable visual deficits. The purpose of this study was to evaluate recent institutional trends in the treatment of traumatic optic neuropathy, evaluate the outcomes of different treatment strategies, and identify factors associated with improved vision.

METHODS

Institutional review board approval was obtained to retrospectively review patients diagnosed with traumatic optic neuropathy at a high-volume trauma center from 2004 to 2012. Pretreatment and posttreatment visual acuity was compared using quantitative analysis of standard ophthalmologic conversion.

RESULTS

A total of 109 patients met inclusion criteria (74.3 percent male patients), with a mean age of 38.0 ± 17.5 years (range, 8 to 82 years). Management of traumatic optic neuropathy involved intravenous corticosteroids alone in 8.3 percent of patients (n = 9), 56.9 percent (n = 62) underwent observation, 28.4 percent (n = 31) had surgical intervention, and 6.4 percent (n = 7) underwent surgery and corticosteroid administration. Only 19.3 percent of patients returned for follow-up. Vision improved in 47.6 percent of patients, with a mean follow-up of 12.9 weeks. Patients younger than 50 years had a trend toward higher rates of visual improvement, 60 percent versus 16.7 percent (p = 0.15).

CONCLUSIONS

The majority of traumatic optic neuropathy patients are unlikely to return for a follow-up examination. Optic nerve decompression has fallen out of favor in the authors' institution, and observation is the most common management strategy. Outcomes following corticosteroid administration and observation are comparable.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Ocular Injuries in Patients of Zygomatico-Complex (ZMC) Fractures

PURPOSE

Mid face injuries commonly destroy the integrity of the orbital skeleton, and are frequently complicated by injury to the eye, ranging between 2.7 and 90.6 % as reported in literature. The eye injuries range from simple subconjunctival haemorrhage to globe rupture. The paper aims to study the types of ocular injuries in patients with ZMC fractures.

PATIENTS AND METHODS

A study of 67 patients, who had sustained facial trauma sufficient to lead to a facial bone fracture, was undertaken in the department of Oral and Maxillofacial Surgery, Govt Dental College, Srinagar from 2008 to 2014 and the patients received a comprehensive examination by an ophthalmologist within 1 week of injury. All the patients sustaining confirmed ZMC fracture were examined by an ophthalmologist for any associated ocular injury. A thorough ophthalmologic examination included assessment of visual acuity, pupillary reactivity, anterior and posterior segment examination and extraocular motility. The variables reviewed included patient's gender, mechanism of injury, visual acuity, pupillary reactivity, extra ocular motility, presence or absence of diplopia, ocular and orbital findings, and intraorbital hypoesthesia.

RESULTS

The most common etiology of trauma was RTA (64.1 %), followed by falls (14.9 %) in our study. In our study 83.5 % of the patients were males. Minor ocular injuries such as subconjunctival haemorrhage and corneal injury accounted for most of the cases. Subconjunctival haemorrhage was the most common injury, present in 86.5 % of the cases. Hyphema was present 13.4 %, vitreous haemorrhage 2.98 %, retinal haemorrhage 1.49 %, corneal abrasion 4.47 %, mydriasis 1.49 %, choroidal rupture 5.97 %, retinal detachment 2.98 %, decreased visual activity 13.4 %, retinal tear and angle recession was present 7.46 % times.

CONCLUSION

ZMC fractures are associated with higher incidence of ocular injuries. The incidence of traumatic optic neuropathy and other ocular injuries warrants a prompt ophthalmologic examination of all patients with ZMC fractures as quickly as possible to prevent morbidity.

Ocular trauma in patients with maxillofacial fractures

PURPOSE

The purpose of this study was to analyze and evaluate ocular injuries in patients with maxillofacial fractures. Correlation of the ocular injury and patients' age, sex, trauma mechanism, and type of maxillofacial fracture was also investigated.

MATERIALS AND METHODS

From January 2000 to December 2009, a total of 1131 patients with facial fractures were registered. The information and data collected and analyzed included the following: age, sex, mechanism of injury, type of facial fracture, type of ocular injury, and the relationship between ocular injury and facial fracture.

RESULTS

Ocular injury (349 injuries) was sustained by 209 patients (18.5%), with a male/female ratio of 5.33:1 (176 males and 33 females). The age range of the patients associated with ocular trauma was 3 to 68 years (mean [SD], 32.40 [11.27] y). Patients aged 30 to 39 years showed the highest risk for ocular trauma (odds ratio [OR], 1.852; P < 0.001). Children showed the lowest risk for ocular injuries (OR, 0.162; P < 0.001). Motor vehicle accidents were the most common mechanism of injury (97 patients, 46.4%). Motor vehicle accidents also had a 2.243-fold risk for ocular trauma (OR, 2.243; P = 0.021). Ocular traumas were more prone to occur in patients who sustained midfacial fractures (OR, 10.232; P < 0.001), especially the patients with multiple midfacial fractures (OR, 12.389; P < 0.001). Fracture of the mandible had the lowest risk for ocular injuries (multimandibular fractures: OR, 0.035, P < 0.001; single mandibular fracture: OR, 0.151; P < 0.001).

CONCLUSIONS

The occurrence of ocular injuries was significantly related to sex, age, etiology, as well as the pattern and position of the maxillofacial fractures.

A clinical analysis of bilateral orbital fracture

Although bilateral orbital fracture can cause serious eyeball and facial skeletal problems, few reports have been issued on the topic. We analyzed the clinical features of bilateral orbital fracture by reviewing the medical records of 147 patients and compared bilateral and unilateral fractures by reviewing the literature.Bilateral orbital fracture was most common in men aged between 50 and 59 years. A traffic accident was the leading cause of trauma, and average time between trauma and surgery was 12.2 days. Bilateral medial fracture accompanied by nasal fracture accounted for the overwhelming majority, and impure blowout fracture in at least 1 eye occurred in 69.4% of the 147 patients. Associated ocular injuries seemed to be similar for bilateral and unilateral fracture. Thirty-five patients (23.8%) had other multiple traumas affecting other than the eyes, and this significantly increased the need for surgery (P < 0.05). Of the 48 patients who underwent surgery, including 4 cases of bilateral surgery, 21 patients who had ocular motility restriction with central diplopia within 30 degrees almost completely recovered. No significant relation between the timing of surgery and improvement was found. Although unilateral surgery was performed in most cases, facial asymmetry related to enophthalmos was unclear at 6 months postoperatively.In summary, bilateral orbital fracture was found to be clinically distinguishable from unilateral fracture in several aspects. We hope these findings provide a reference guide to the approach and management of bilateral orbital fracture.

Injuries of the globe: what can the radiologist offer?

Traumatic ocular injuries are a significant cause of blindness and visual deficits. In the setting of acute orbital trauma, urgent ophthalmologic evaluation and intervention are critical in preserving vision. However, in the acute trauma setting, clinical evaluation of the globe may be difficult in the presence of surrounding periorbital soft-tissue swelling and other associated injuries, and patient cooperation may be limited because of unresponsiveness, altered mentation, or sedation. Often, rapid access to imaging is part of the initial diagnostic evaluation, and radiologists may be the first to identify traumatic injuries of the globe. Because of this, radiologists should be familiar with normal orbital and globe anatomy at various imaging modalities and have a thorough understanding of the various patterns of ocular injury and their imaging appearances. Radiologists should also be familiar with the various mimics of ocular injury, including congenital and acquired conditions that may alter the shape of the globe, various types of ocular calcifications, and the different types of material used to treat retinal detachment. Such knowledge may help radiologists make accurate diagnoses, which facilitates prompt and appropriate patient care.

Persistent diplopia after fractures involving the orbit related to nerve injury

BACKGROUND

Fractures in the facial skeleton are common and may lead to orbital sequelae caused by the injury and/or the surgery. In this long-term follow-up, we examined the nature of sequelae after facial fractures involving the orbit and whether a higher complexity of the fractures produced more sequelae compared to simpler fracture patterns, and if so, to what extent.

METHODS

Patients surgically treated for facial fractures involving the orbit at the Karolinska University Hospital with a follow-up duration of ≥3 years were included in this retrospective study and were examined by a neuro-ophthalmologist. Based on the location and severity of the fractures, the patients were divided into four groups according to fracture complexity: 1) isolated zygomatic fracture, 2) isolated orbital floor blowout fracture, 3) zygomatic fracture combined with blowout fracture and 4) bilateral or multiple fracture patterns.

RESULTS

Out of 154 patients, 81 patients (53%) attended follow-up examinations, 65 male (80%) and 16 female (20%). The duration of follow-up was 3.0-7.6 years (mean of 4.9 years). The incidence of diplopia was 3.7%, visual loss 2.5%, dystopia 4.9% and visible enophthalmos (>2 mm) 8.6%. Severe diplopia (2.5%) was due to nerve injuries. Visual loss was encountered only in group 4 with complex fractures. Fracture complexity had an effect on the presence of any sequelae, with group 4 presenting a higher percentage of patients with sequelae than the other three groups. However, no statistically significant effect of group could be found on the individual, quantitative output values of dystopia and enophthalmos.

CONCLUSIONS

In this study, severe persistent diplopia in patients was due to nerve injuries, which emphasizes the need for preoperative ophthalmologic examinations, in all patients with fractures involving the orbit. A higher fracture complexity was found to lead to a higher percentage of patients presenting sequelae.

Etiology, incidence and patterns of mid-face fractures and associated ocular injuries

A prospective study on mid-face fractures was carried out in the Department of Oral and Maxillofacial Surgery at College of Dentistry, Indore, from August 2007 to September 2009 to analyze etiology, incidence and patterns of midface fractures and associated ocular injuries. Two hundred patients were included in this study, amongst those who reported to the Department of OMFS, College of Dentistry, Indore. After confirmed diagnosis of mid face fracture all the patients were stratified according to age, sex, cause of the accident, influence of alcohol, location, type of fractures and associated ocular injuries. The study included 200 patients with a mean age of 29.6 years. The most frequently injured patients belonged to the 21-30 year-old age group. The male predilection was 76 %. Road traffic accident was the most common causative factor (64 %), followed by assault (21 %), cases of fall (9.5 %) and other causes (5.5 %). The most common fracture in this study was found to be zygomatic complex fractures (62.5 %) (more in the age group of 21-30 years). This was followed by Lefort II fractures (23 %), multiple fractures (10 %) and Lefort I fractures (6 %), Lefort III fractures (4.5 %) and Naso-ethmoidal fractures (4 %) in descending order. 84.5 % subjects were having ocular involvement. Subconjunctival hemorrhage was present mostly in 83.5 % followed by remaining as corneal injury 15 %, reduced acuity 11.5 %, diplopia 10.5 %, enophthalmos 8.5 %, telecanthus 5 %, hyphema 3.5 %, blindness 3 % and proptosis 0.5 %. Zygomatic complex fractures were the most frequent type of injury that was complicated by blindness or a serious eye injury (61 %). Collection of data regarding the epidemiology of maxillofacial fractures is important because it may assist healthcare providers to provide necessary information for the development and evaluation of preventive measures. Ocular injuries should have an early ophthalmological examination at the time of trauma to detect any kind of ocular dysfunction.

A closer look at orthopedic injuries associated with maxillofacial trauma

Although orthopedic injury has been reported to be the most frequent injury associated with facial trauma, their relationship has not been sufficiently evaluated in the literature. To evaluate this relationship, we compared 263 patients with concomitant facial and orthopedic injuries with 2006 patients with facial injuries alone. The rate of associated orthopedic injuries was 11.5%. Motor vehicle accidents, falls, mandibular fractures, and Le Fort I fractures increased the chance of sustaining orthopedic injuries nearly 17-, 15-, 10-, 4.4-, and 4.5-fold, respectively. Most fractures occurred in large bones with their inherent potential to cause severe, life-threatening complications. The high rates of mortality and morbidities associated with orthopedic injuries and the frequent occurrence of these injuries in patients with facial trauma emphasize upon the fact that maxillofacial surgeons, residents, and trauma nurses need more training in early diagnosis and appropriate management of associated orthopedic injuries.

Ophthalmic Evaluation and Management of Traumatic Accidents Associated with Retinal Breaks and Detachment: A Retrospective Study

Purpose

This retrospective study reviews a group of patients with retinal breaks or retinal detachment following ocular trauma.

Methods

A total of 94 patients were included in the study. They underwent closed globe injuries causing multiple retinal breaks or retinal detachment at time of presentation in the emergency department. Analysis concerned epidemiologic, clinical, and therapeutic aspects, both in short-term (1 and 3 months) and long-term (6-12 months) follow-up.

Results

A total of 85% of patients were male, involved in work-related injuries, and complaining visual function decrease. Retinal breaks were mostly singular, U-shaped, and located in the upper temporal quadrant. At presentation, visual acuity ≥5/10 and Ocular Trauma Score of 4 were the most represented. Fifty-eight patients (61.70%) underwent repair within 48 hours of the trauma, 27 (28.73%) within 7 days, and 9 (9.57%) more than 7 days after trauma. Procedures performed were photocoagulation with argon laser (52%), episcleral buckle (34.45%), or vitrectomy associated with episcleral buckle and intraoperative argon laser (13.55%). A total of 92% of patients treated within 48 hours had better or unchanged visual acuity in 6-12 months of follow-up. All patients treated more than 7 days after trauma had worse visual acuity (p<0.01 with Student t test).

Conclusions

Detailed clinical history, well-done preoperative examination, early diagnosis, and prompt parasurgical or surgical repair are significant prognostic factors for better visual outcome and lower incidence of relapse.

Efficacy of Iliac Crest vs. Medpor in Orbital Floor Reconstruction

AIM

The present study is to compare the effectiveness of iliac crest graft and medpor implant, for repairing traumatic orbital floor defects.

MATERIALS AND METHODS

A total of 20 patients were included in the study. Autogenous iliac crest graft and medpor implant was used in 10 patients of the each group. Patients were evaluated for the presence or absence of diplopia, enophthalmos, infraorbital nerve paresthesia, and ocular motility disorders. Surgical indications for orbital exploration included entrapment of orbital tissues, large orbital defect (greater than 50% of the orbital floor or more than 8 mm), or orbital floor defects with involvement of other zygomaticofrontal complex fractures.

RESULTS

All patients were successfully treated by restoration of the orbital wall continuity. Follow-up was done at 1-12 weeks. One patient had postoperative infection. There was no graft extrusion.

CONCLUSIONS

Both the groups showed satisfactory results, but group II was better than group I, as there was no donor site morbidity. Porous polyethylene (Medpor) is a biocompatible and high-density polyethylene implant. It is well tolerated by surrounding tissue, and its porous structure is rapidly infiltrated by host tissue. It is a highly stable and somewhat flexible porous alloplast that has rapid tissue in growth into its pores.

Orbital Fractures Complicated by Late Enophthalmos: Higher Prevalence in Patients With Multiple Trauma

PURPOSE

To present our experience with orbital fracture treatment outcomes in patients with multiple trauma and those suffering localized orbital trauma.

METHODS

Retrospective data review of all patients examined for ocular motility problems and/or enophthalmos following orbital trauma in a 4-year period.

RESULTS

Forty-three patients were included in the study: 31 (72%) had localized orbital trauma (LOT) and 12 (28%) had concomitant traumatic insults to other organs (MT). More orbital walls were affected in MT patients than in LOT patients, and the incidence of zygomatic fracture was higher in MT patients. Late enopthalmos was much more prevalent in the MT group compared with the LOT group. Differences of outcome of extra ocular motility disturbance between groups in our series did not reach statistical significance.

CONCLUSIONS

The findings of more walls affected and higher incidence of zygomatic fractures in MT patients probably represent a stronger impact of the original insult, causing both more damage to other organs and more severe damage to the orbit. The increased rate of late enophthalmos in MT patients may be associated with their primary presentation to the emergency room with potentially life-threatening injuries. Under such circumstances, thorough ophthalmologic examination is nearly impossible, both because the patient cannot cooperate sufficiently and because medical priorities dictate concentration on taking care of the injuries threatening life. The lack of a thorough ophthalmic examination prevents early comprehensive treatment.

Individual preformed titanium meshes for orbital fractures

OBJECTIVES

The aim of this investigation was to develop and test the accuracy of a procedure for fabricating individual preformed titanium meshes for orbital fractures.

STUDY DESIGN

Preoperative CT datasets from five patients with orbital fractures were used for 3D reconstruction by mirroring the unaffected side onto the defective one, resulting in a new sub-volume. A template for adaptation of the titanium mesh was produced by applying these sub-volumes. Navigation-aided procedures guaranteed the exact placement of the preformed mesh during the operation.

RESULTS

The accuracy of the reconstructed orbital floor was determined to be approximately 1 mm, which lies within the technical limit of detection.

CONCLUSION

These results indicate a further application or navigation-aided reconstruction, which will serve as a pilot project for further investigations. Clustered databases of patients will be used to produce various template sets, reflecting ideal skeletons, according to age, sex, and other patient variables. These could be used for manufacturing preformed osteosynthesis templates.

Complex-type penetrating injuries of craniomaxillofacial region

Craniofacial traumas are one of the most common clinical events of the 21st century. The possibility of associated injuries of the head and neck may also determine functional and cosmetic problems in these patients. The most frequent pathologic conditions observed are contusions, lacerations, abrasions, avulsions, and the inclusion of foreign bodies. In particular, penetrating injuries represent a rare but complex variety of craniofacial trauma. Generally, the penetrating material is stiff enough to cross through different anatomic structures during a particularly violent collision caused by a road or work accident or during an attack. The therapeutic strategy adopted for this type of patient depends mainly on diagnostic procedures such as skull radiograms in different projections, computerized tomography, magnetic resonance imaging, and, occasionally, echotomography. However, on arrival at the emergency department, the clinical conditions of the patient will determine the type of investigation to be carried out. Last, to prevent any postoperative infections, wide spectrum antibiotic therapy is advisable. Ideally, imaging should be repeated postoperatively to confirm resolution of the initial clinical condition. In this article, the authors describe three unusual clinical cases of patients with penetrating injuries of the head and face together with the protocol adopted for treatment of such complex craniofacial injuries. The three cases described demonstrate that, despite the initial appearance of penetrating wounds, a correct diagnostic assessment followed by a suitable therapeutic protocol can reduce cosmetic and functional defects to a minimum.

Severe panfacial fracture with facial explosion: integrated and multistaged reconstructive procedures

Midface fractures, especially if related to traffic accidents, represent a remarkable problem from a surgical, psychological, and social standpoint. In trauma dynamics, the pattern of the fractures can extend to all bony fragments and is often associated with soft tissue injuries and loss of bony structures. This can lead to posttraumatic deformities that greatly influence the patient psychologically and limit his social rehabilitation, sometimes permanently. Panfacial trauma includes midface fractures associated with fractures of other areas (i.e., mandible, frontal bone). Orbits and the nasoethmoidal area are often involved with loss of soft tissue and, in severe cases, loss of orbital contents. We report an unusual complex clinical case representative of this kind of pathological profile in which the guidelines described in the literature were followed in the reconstructive procedure.

Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries

INTRODUCTION

Cranio-maxillofacial trauma management requires pertinent documentation. Using a large computerized database, injury surveillance and research data describe the whole spectrum of injuries. The goal of this study was to assess the effect of the five main causes of accidents resulting in facial injury on the severity of cranio-maxillofacial trauma.

PATIENTS AND METHODS

During a period of 10 years (1991-2000) 9,543 patients were admitted to the Department of Oral and Maxillofacial Surgery, University Hospital of Innsbruck with cranio-maxillofacial trauma. Data of patients were prospectively recorded including cause of injury, age and gender, type of injury, injury mechanisms, location and frequency of soft tissue injuries, dentoalveolar trauma, facial bone fractures and concomitant injuries. Statistical analyses performed included descriptive analysis, chi square test, Fisher's exact test, and Mann-Whitney's U test. This was followed by logistic regression analyses for the three injury types to determine the impact of the five main causes on the type of injury at different ages in facial trauma patients.

RESULTS

Five major categories/mechanisms of injury existed: in 3,613 (38%) cases it was activity of daily life, in 2991 (31%) sports, 1170 (12%) violence, in 1,116 (12%) traffic accidents, in 504 (5%) work accidents and in 149 (2%) other causes. A total of 3,578 patients (37.5%) had 7,061 facial bone fractures, 4,763 patients (49.9%) suffered from 6,237 dentoalveolar, and 5,968 patients (62.5%) from 7,769 soft tissue injuries. Gender distribution showed an overall male-to-female ratio of 2.1 to 1 and the mean age was 25.8+/-19.9 years; but both varied greatly depending on the injury mechanism (facial bone fractures: 35.4+/-19.5 years, higher risk for males; soft tissue injuries: 28.7+/-20.5, no gender preference; dentoalveolar trauma: 18+/-15.6, elevated risk for females). For patients sustaining facial trauma, logistic regression analyses revealed increased risks for facial bone fractures (225%), soft tissue lesions (58%) in patients involved in traffic accidents, and dental trauma (49%) during activities of daily life and play accidents. When compared with other causes, the probability of suffering soft tissue injuries and dental trauma, but not facial bone fractures, is higher in sports-related accidents, 12 and 16%, respectively.

CONCLUSION

This study differentiated between injury mechanisms in cranio-maxillofacial trauma. The specially trained surgeons treating cranio-maxillofacial trauma are the primary source of information for the public and legislators on implementing preventive measures for high-risk activities. In facial trauma, older persons are prone to bone fractures (increase of 4.4%/year of age) and soft tissue injuries (increase of 2%/year of age) while younger persons are more susceptible to dentoalveolar trauma (decrease of 4.5%/year of age).

Ocular and periocular injuries from orbital fractures

BACKGROUND

Orbital fractures are associated with ocular and periocular injuries. The role of the ophthalmologist in the evaluation and management of facial trauma, including orbital fractures, has not been clearly defined. The purpose of this study is to identify and characterize ocular and periocular injuries associated with orbital fractures to define the role of the ophthalmologist in the management of facial trauma.

STUDY DESIGN

Retrospective case review.

RESULTS

Three hundred sixty-five patients with orbital fractures who were evaluated by an ophthalmologist as part of their initial trauma evaluation were studied. The majority of the patients with orbital fractures (74%) did not have associated ocular or periocular injuries. Twenty-three of 104 (22%) ocular injuries in 23 of 95 (24%) patients required immediate intervention by an ophthalmologist.

CONCLUSIONS

Facial trauma and orbital fractures are associated with significant ocular and periocular injuries, the minority of which require immediate evaluation and treatment by an ophthalmologist. These results differ from those previously reported.