Cases reported "Orbital Fractures"

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1/81. Less common orbital fracture patterns: the role of computed tomography in the management of depression of the inferior oblique origin and lateral rectus involvement in blow-in fractures.

    During the past decade, advances in radiographic imaging have made it possible for the surgeon managing orbital fractures to adopt a rational therapeutic strategy based on a knowledge of alterations in surgical anatomy secondary to traumatic injury. To illustrate the value of computed tomography in the surgeon's armamentarium for management of orbital fractures, cases are presented in which imaging proved decisive in planning a course of therapy. Two patients presented with two types of isolated lateral blow-in fracture, an uncommon fracture pattern. The other cases underscore the value of defining involvement of the inferior oblique origin and lateral rectus muscles in imaging complex orbital fractures, issues not emphasized in earlier literature. Although diplopia alone does not always warrant surgical intervention, diplopia in the context of computed tomography-defined muscle entrapment or muscle origin displacement justifies operative therapy. These cases demonstrate the value of computed tomography in directing surgical therapy with resolution of diplopia and prevention and correction of enophthalmos.
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2/81. Repair of orbital floor fractures with hydroxyapatite block scaffolding.

    PURPOSE: To determine the efficacy of using a scaffold of hydroxyapatite blocks within the maxillary sinus to treat patients with large orbital floor fractures and secondary vertical globe dystopia. methods: Case series of five patients. Hydroxyapatite blocks were stacked within the maxillary antrum to support the reconstructed orbital floor. RESULTS: All patients had good results, though mild residual enophthalmos persisted in three patients. The orbital floor implants and globe positions remained stable during follow-up intervals ranging from 46 to 65 months. No adverse postoperative complications, such as sinusitis, developed. CONCLUSIONS: Hydroxyapatite block scaffolding is a useful alternative to metallic floor implants and autologous bone grafts in the reconstruction of large traumatic orbital floor defects associated with vertical globe dystopia.
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keywords = operative
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3/81. Benefits of stereolithography in orbital reconstruction.

    OBJECTIVE: To describe the benefits of the stereolithography (SLA) modeling system in the evaluation and surgical planning of selected bony orbital pathology. DESIGN: Two case reports. PARTICIPANTS: One patient presented with a displaced left orbital roof fracture into his orbit causing globe compression and binocular vertical diplopia. A second patient underwent removal of his right orbital floor, medial wall, and inferior portion of his lateral wall during excision of a cylindrical cell papilloma of the paranasal sinuses. Postoperatively, he suffered from globe ptosis and binocular oblique diplopia. INTERVENTION: Stereolithographic models of the patients' orbits were obtained from computed tomography data to better assess the bony orbital pathology. In the second patient, the model was used as a template to create a temporary custom fit prosthesis to repair the defect of his orbital walls. RESULTS: The SLA models were useful in evaluating the dimensions of the bony defects and in preoperative surgical planning. Intraoperatively, the SLA models facilitated orbital surgical rehabilitation. Postoperatively, both patients noted resolution of their diplopia after reconstruction of more normal bony anatomy. CONCLUSIONS: In selected cases, SLA offers highly accurate models of the bony orbit for preoperative evaluation, surgical planning, and teaching and can act as a template for custom prosthesis manufacturing. This technology increases the orbital surgeon's options in managing complex orbital pathology.
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ranking = 5
keywords = operative
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4/81. Internal orbital fractures in the pediatric age group: characterization and management.

    OBJECTIVE: To evaluate the specific characteristics and management of internal orbital fractures in the pediatric population. DESIGN: Retrospective observational case series. PARTICIPANTS: Thirty-four pediatric patients between the ages of 1 and 18 years with internal orbital ("blowout") fractures. methods: Records of pediatric patients presenting with internal orbital fractures over a 5-year period were reviewed, including detailed preoperative and postoperative evaluations, surgical management, and medical management. MAIN OUTCOME MEASURES: Ocular motility restriction, enophthalmos, nausea and vomiting, and postoperative complications. RESULTS: Floor fractures were by far the most common fracture type (71%). Eleven of 34 patients required surgical intervention for ocular motility restriction. Eight were trapdoor-type fractures with soft-tissue incarceration; five had nausea and vomiting. Early surgical intervention (<2 weeks) resulted in a more complete return of ocular motility compared with the late intervention group. CONCLUSIONS: Trapdoor-type fractures, usually involving the orbital floor, are common in the pediatric age group. These fractures may be small with minimal soft-tissue incarceration, making the findings on computed tomography scans quite subtle at times. Marked motility restriction and nausea/vomiting should alert the physician to the possibility of a trapdoor-type fracture and the need for prompt surgical intervention.
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ranking = 3
keywords = operative
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5/81. Surgical treatment of penetrating orbito-cranial injuries. Case report.

    Penetrating orbital injuries are not frequent but neither are they rare. The various diagnostic and therapeutic problems are related to the nature of the penetrating object, its velocity, shape and size as well as the possibility that it may be partially or wholly retained within the orbit. The authors present another case with unusual characteristics and discuss the strategies available for the best possible treatment of this traumatic pathology in the light of the published data. The patient in this case was a young man involved in a road accident who presented orbito-cerebral penetration caused by a metal rod with a protective plastic cap. Following the accident, the plastic cap (2.5x2 cm) was partially retained in the orbit. At initial clinical examination, damage appeared to be exclusively ophthalmological. Subsequent CT scan demonstrated the degree of intracerebral involvement. The damaged cerebral tissue was removed together with bone fragments via a bifrontal craniotomy, the foreign body was extracted and the dura repaired. Postoperative recovery was normal and there were no neuro-ophthalmological deficits at long-term clinical assessment. Orbito-cranial penetration, which is generally associated with violent injuries caused by high-velocity missiles, may not be suspected in traumas produced by low-velocity objects. Diagnostic orientation largely depends on precise knowledge of the traumatic event and the object responsible. When penetration is suspected and/or the object responsible is inadequately identified, a CT scan is indicated. The type of procedure to adopt for extraction, depends on the size and nature of the retained object. Although the possibility of non-surgical extraction has been described, surgical removal is the safest form of treatment in cases with extensive laceration and brain contusion.
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keywords = operative
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6/81. strabismus due to flap tear of a rectus muscle.

    PURPOSE: To present a previously unreported avulsion-type injury of the rectus muscle, usually the inferior rectus, and detail its diagnosis and operative repair. methods: Thirty-five patients underwent repair of flap tears of 42 rectus muscles. The muscle abnormality was often subtle, with narrowing or thinning of the remaining attached global layer of muscle. The detached flap of external (orbital) muscle was found embedded in surrounding orbital fat and connective tissue. Retrieval and repair were performed in each case. RESULTS: Fourteen patients had orbital fractures, 7 had blunt trauma with no fracture, and 9 had suspected trauma but did not undergo computed tomographic scan. Five patients experienced this phenomenon following retinal detachment repair. Diagnostically, the predominant motility defect in 25 muscles was limitation toward the field of action of the muscle, presumably as a result of a tether created by the torn flap. These tethers simulated muscle palsy. Seventeen muscles were restricted away from their field of action, simulating entrapment. The direction taken by the flap during healing determined the resultant strabismus pattern. All patients presenting with gaze limitation toward an orbital fracture had flap tears. The worst results following flap tear repair were seen in patients who had undergone orbital fracture repair before presentation, patients who had undergone previous attempts at strabismus repair, and patients who experienced the longest intervals between the precipitating event and the repair. The best results were obtained in patients who underwent simultaneous fracture and strabismus repair or early strabismus repair alone. CONCLUSIONS: Avulsion-type flap tears of the extraocular muscles are a common cause of strabismus after trauma, and after repair for retinal detachment. Early repair produces the best results, but improvement is possible despite long delay.
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7/81. Growing fractures of the orbital roof. A report of two cases and a review.

    Growing fractures rarely arise in the skull base. Only six cases of orbital roof growing fractures were found in the relevant literature. We report two such cases. The first case was a 2-year-old girl who had progressive proptosis for 6 months following a mild head injury 1 year previously. The second case was a 9-year-old girl with a history of injury at the age of 3 months. She developed eye deviation and proptosis for 1 year. Computed tomography scan is excellent for demonstrating bony defects in the orbital roof, while magnetic resonance imaging is more sensitive in showing the intraorbital extension of a leptomeningeal cyst. Both patients were operated successfully and proptosis disappeared postoperatively. The exact pathophysiology of growing fractures is still debated in the literature, but a dural laceration along a fracture line is noted in all cases, and frontobasal brain injury seems to play an important role in the pathogenesis of the fracture growth. Growing fractures of the orbital roof should be suspected if ocular symptoms appear in a child who had sustained a head injury several months or years before.
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keywords = operative
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8/81. Traumatic encephalocele related to orbital roof fractures: report of six cases and literature review.

    BACKGROUND: Orbital roof fractures after blunt injury are rare. Traumatic encephaloceles in the orbital cavity are even rarer, with only 15 cases published to date. methods: The clinical, radiological, and surgical findings of 6 cases of traumatic encephalocele treated at our institution from June 1998 to January 2000 are presented. They are also compared with previously published series. RESULTS: In contrast to other published cases, 5 out of 6 patients in our series were adults. The most common cause of trauma was road traffic accident. ecchymosis and preoperative exophthalmos/proptosis were frequent. In all of our patients a coronal CT scan (3 mm increments with bone windows) was obtained. It demonstrated the extension of the orbital roof fractures and a possible encephalocele in 4 cases. Associated frontal brain contusions were seen in 5 cases. An MRI was performed in 3 patients (and only in 2 previously published cases); it showed the extension of the brain herniation into the orbital cavity. Surgical treatment via a fronto-basal approach with evacuation of the contused herniated brain tissue and orbital roof reconstruction was performed.The outcome at 6 months was good recovery in five patients with one patient still in a persistent vegetative state. Postoperatively the ocular disturbances improved in 5 cases. A review of the other published cases confirmed recovery of normal ocular function in the vast majority of the cases. CONCLUSIONS: Whenever orbital roof fractures associated with frontal contusions are identified in an acute brain injured patient, an orbital encephalocele should be suspected. In our opinion MRI is the investigation of choice in such patients. If the encephalocele is confirmed, a surgical approach via the subfrontal route is indicated with resection of herniated contused brain tissue, dural closure, and orbital roof reconstruction. Good results in regard to the orbital symptoms (mainly exophthalmos) can be expected.
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ranking = 2
keywords = operative
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9/81. Orbital deformity after craniofacial fracture repair: avoidance and treatment.

    BACKGROUND AND OBJECTIVES: To achieve the optimal preoperative appearance following craniofacial fracture repair, the surgeon must be facile in the most sophisticated reconstructive techniques and able to determine their application. The purpose of this article is to describe the common deformities following such repairs, outline a strategy to avoid them, and review the surgical techniques to correct them. methods AND MATERIALS: The deformities are categorized by the anatomic zones of the orbit, i.e., zygomatic, frontal, and nasoethmoidal, affected by low-, middle-, and high-energy impact. The common types of deformity and acute and late treatments are discussed for each category. RESULTS AND/OR CONCLUSIONS: The optimal time to correct posttraumatic orbital deformities is during the acute phase. Extended open reduction and rigid fixation techniques have their own morbidity, which must not outweigh the deformity of an untreated or partially treated injury. The results of late reconstruction are always limited by scarring of the overlaying soft tissue envelope.
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keywords = operative
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10/81. Orbitocraniofacial gunshot wounds: craniofacial reconstruction and preparation of the anophthalmic socket.

    This article is a retrospective clinical and radiographic analysis of four patients who survived high caliber orbitocraniofacial gunshot injuries. Early multidisciplinary craniofacial reconstruction included repair of comminuted orbital fractures with multiple autogenous bone grafts and/or porous polyethylene implants, enucleation, and insertion of a hollow silicone sphere as an anophthalmic socket implant. Migration of the silicone implant occurred in one case, requiring replacement with an autogenous dermis fat graft. There were no cases of extrusion or infection. Socket motility remained limited in all cases, despite reapposition of the extraocular muscles. In two cases with autogenous bone grafts along the orbital roof, there was no radiographic evidence of graft resorption after three years. Soft tissue volume deficiency and superior sulcus deformity developed in the three cases which were followed for more than six months. Despite these limitations, all four patients are wearing comfortable ocular prostheses. The postoperative results support immediate preparation of the anophthalmic socket after craniofacial reconstruction of these injuries.
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