Lukens,' reviewing the literature 40 years ago, was able to walls, 3, injury to Mueller's orbital

34 Pages·2005·6.24 MB·English

FRACTURES OF THE ORBITAL FLOOR*t
ARTHUR GERARD DEVOE, M.D.
NewYork, N.Y.
INTRODUCTION
This discussion will describe a not infrequently neglected
deformity, present typical case reports of the condition in its
various degrees of extent, evaluate the various methods of
treatment which have been advocated and describe in detail
the treatment whichhas proved most satisfactory in a group
of 34 patients.
Lukens,' reviewing the literature 40 years ago, was able to
find 78 cases of traumatic enophthalmos and some 19
hypotheses for its mechanism. Among these were: 1, indirect
fracture of the orbital walls, 2, direct fracture of the orbital
walls, 3, injury to Mueller's orbital muscle, 4, injury to the
checkligaments, 5, rupture of Tenon's capsule, 6, atrophy of
orbital tissue due to in:jury of sympathetic and trigeminal
nerves, 7, hemorrhage of the ophthalmic artery behind the
ciliary body, 8, minute hemorrhages in the nerve sheaths,
particularly the sympathetic, 9, cicatricial contraction of
orbitaltissuefollowinginflammation, 10,cicatricialadhesions
of the eyeball, 11, cicatricial contraction of the extra-ocular
muscles, 12, absorption of orbital fat due to the pressure
incident to severe cellulitis, 13, similar pressure atrophy fol-
lowing an orbital hematoma, 14, gross destruction of orbital
content. Dislocation ofthetrochleahas alsobeenpostulated.2
With the passage of time and particularly with improve-
ment in radiographic technique it is now felt by most
*FromtheInstituteofOphthalmologyofthePresbyterianHospital, andthe
DepartmentofOphthalmology, CollegeofPhysiciansandSurgeons, Columbia
University, NewYork. 0
tCandidate's thesisformembership accepted by CommitteeonTheses.
502
DEVOE: Fractures of the Orbital Floor 503
observers that of the factors enumerated above only the
direct and indirect orbital wall fractures are significant, and
that the other hypotheses play little if any role in producing
the condition known as traumatic enophthalmos. Neverthe-
less, depressed fractures of the orbital floor are not infre-
quently overlooked, evenwhen associatedwithmore obvious
depressions in the orbital rim. Particularly has this been so
insevereinjuries orwarwoundswherethepatient's condition
has been so critical that little attention has been paid to
what at the moment was of secondary importance. The
residua of such injuries may at a later date assume consider-
able importance either from the standpoint of ocular dys-
function or from that of cosmetic appearance.
Ithas beenpreviously noted3 that theloss of an eyeball by
enucleation, when associated with adepressed fracture ofthe
orbital floor, may lead to considerable difficulty in the satis-
factory fitting of an ocular prosthesis. If the pathologic and
mechanical problems are understood, then logical measures
can be taken to solve therm. Usually the same principles will
apply whether the fracture is of the orbital floor alone or
whether there is an associated displacement of the orbital
margin.
All of the patients seen in this study had suffered injury
weeks tomonths priorto myfirst observingthem. Therefore,
the late treatment of such fractures will be emphasized. For
the sake of completeness, however, a review of the literature
has been undertaken to determine what measures have been
used and are currently invogue forthe immediate treatment
of orbital floor and rim fractures.
EARLY TREATMENT OF ORBITAL FRACTURES
Since the emergency treatment of such conditions will
rarely fall into the hands of the ophthalmologist, most re-
ports arethose of general, oral, plastic orrhinologic surgeons.
In 1901, LeFort,4subsequent to some40 experiments upon
cadavers, defined 3 main lines of weakness through the facial
504 DEVOE: Fractures of the Orbital Floor
bones along which fractures were most likely to occur. He
applied blows of different degrees ofviolence to various parts
of the face and by careful dissection noted the course of
fracture lines. Anunexpected degree ofviolence was required
to produce a fracture.
The simplest fracture divided the maxilla above the
alveolar processes, crossed the wall of the nose and canine
fossa, passed beneath the zygoma to the pterygomaxillary
fissure and at times divided the pterygoid processes.
Fig. 1.-Fracturelines ofLeFort.
More severe injury produced a fracture at a higher level
startingatthenasalbones, crossingthenasalprocesses ofthe
maxilla, the inner wall and floor of the orbit to the region of
the infraorbital canal. It then cut off the zygomatic process
ofthemaxillafromthezygomatic bone, continuingbackward
to the pterygomaxillary fissure.
Increased violence produced a third type of fracture in
which the entire face was separated from the cranium. The
fracture line crossed the nasal bones, nasal process of the
maxilla, upperpart ofthe innerwall ofthe orbit, openingthe
DEVOE: Fractures of the Orbital Floor 505
ethmoidcells nearlytothe optic foramen. Nearthebackpart
of the sphenomaxillary fissure the fracture line bifurcated,
the front arm of the fracture crossed in the outer wall of
the orbit to separate the zygoma fromthe frontal bonewhile
the posterior arm separated the pterygoid process near its
base.
James and Fickling,5 noting the investigation of LeFort,
went ontopoint outthatthe construction ofthe facialbones
was such that a considerable resistance to injury was de-
veloped. This they felt was due to the arrangement of areas
of density in various bones, as at the orbital rim, and to the
curves, buttresses and tie bars exemplified by the zygomatic
arch, pterygoidprocess andpalatebone. Ablowtothefaceis
transmitted through these structures in a variety of direc-
tions andis dispersed so that no great force is directed to the
cranium and its enclosed vital centers. Firm and resistant
structures lie on a light framework surrounding the nasal
cavity and accessory sinuses. This complex is then attached
to the base of the skull so as to absorb an appliedforcewith-
out transmitting it to the skull. The cushioning effect of the
easily telescoped nasal-antral-ethmoid structures will absorb
much of a directly applied force. Furthermore, the localized
increase in bone density around the teeth and eyes prevents
damage to these structures. McIndoe7 has commented upon
the frequency with which the eye is left uninjured following
a severe blow to the orbital region. Typically, lateral force
applied to the zygomaticomaxillary area falls on the side of
the cheek and is transmitted obliquely inward toward the
cranialbase. The amount oftelescoping andimpactionwhich
occurs determines the degree of orbital deformity which fol-
lows. McIndoe has stated that when moderate force only is
applied the usual clinical fracture sites will be found at the
attachments ofthefrontal, orbital andmaxillaryprocesses of
the zygoma. The maxillary line of weakness is outward and
downward through the infraorbital canal and zygomatico-
maxillary junction and backward along the floor of the orbit
506 DEVOE: Fractures of the Orbital Floor
via the sphenomaxillary fissure. When severe violence is ap-
plied to this region comminution of the zygoma occurs with
impaction into the antrum. A wide separation occurs at the
frontomaxillary suture line and comminution of the thin
orbital floor with prolapse of the orbital content into the
antrum occurs.
It should be emphasized that the types of injuries de-
scribed above are those due to a direct blow such as is more
commonly encountered in civilian injuries, the chief ones of
whichare ablowfromafist andthoseincurredin automobile
accidentswheretheface isthrownagainstthesteeringwheel,
dashboard or windshield. Many military injuries are, on the
other hand, due to explosive fragments and high velocity
projectiles whichproduce severe local destruction in addition
to expending their force along the lines of weakness detailed
above.
Many patients with orbital fractures, and particularly
those who have been in severe accidents, have multiple
wounds which may either obscure the orbital injury com-
pletelyorreduceittoapositionofminorimportancepending
application of lifesaving measures. Nevertheless, a certain
proportion of those so injured are in condition to withstand
reduction ofthe orbitalfracture. Mostwriters agree as to the
desirability of this if possible, pointing out the not incon-
siderable cosmetic blemish which may not be obvious until
local swelling disappears. Some feel that there is less likeli-
hood of diplopia if reduction is rapidly accomplished.
Fractures which are most obvious, such as those involving
the zygomatic arch and orbital rim have been repeatedly
repaired and numerous reports are available. Although there
is complete agreement concerning the desirability of early
treatment there is nosuch unanimity concerning the method
by which this should be accomplished. Roberts8 cites Du-
verney in 1751 as being the first to mention fracture of the
zygoma. Reduction was accomplished by pressure from
withinthemouthbyfingers, amethodwhichothershavenot
DEVOE: Fractures of the Orbital Floor 507
found so successful9 and which Lehmann'0 considered impos-
sible because of interference from the temporal muscle.
In 1897, Weir submitted 2 case reports" which described
successful results following the elevation of fragments
through a canine fossa approach into the antrum. This
method, either with or without entry into the antrum has
beenfoundsatisfactorybyanumberofsurgeons,'2"3"4"5"6"7'2'
although the possibility of thus introducing infection has
beenmentioned byothers.6" 18"19 In this connection thepoint
has been raised by a number of workers'3" 4 20 that since
injury to the antrum is present iii all these cases, usually to
be followed by hemorrhage and infection, their treatment
properly lies in the domain of the rhinologist. Entry of the
antrum and refracturing of the depressed floor followed by
antral packing has also been suggested as a proper approach
to the late treatment of orbital floor fracture3' but Gill32 has
stated that it is best to resist the temptation to effect such a
reduction and to be content with cosmetic improvement by
cartilage and fascial implants. Spaeth agrees with this.33 In
1896, Matas22described amethodofreducingfractures ofthe
zygomatic arch, althoughhemadeno mention ofexistingeye
deformities. Thiswassimplytopass alarge curvedHagedorn
needle threaded with silver wire behind the fragment and
apply traction. Williams23 reported similarly. Numerous
other reports followed.9' 10,16,17,18,24,25,26,27
Open operation and reduction of the fragments has been
described by some'0 25'28 and viewed with disfavor by
others.'8'27 Manwaring,'8 using the ordinary "cow horn"
forcepsofthedentist,placedonepointoftheinstrumentover
the orbital ridge and the other just under the margin of the
body of the bone at its outer side. With a little pressurethe
skin was penetrated and the bone grasped with any desired
firmness. Disengagement andelevationofthebonewaseasily
secured and since there was no external wound no dressing
was needed. Codman27 described an essentially similar pro-
cedure, as have Gill'9 29 and Kazanjian.30 These methods
508 508DEVOE: Fractures of the Orbital Floor
were applicable primarily to fractures involving a large piece
of bone at the orbital margin. If a sizable portion of the
orbital floorweretttacheditwould also be elevated with the
rim. Usually such injuries produced no oculomotor dis-
turbance. (Fig. 2.)
McCurdy24byscrewing a coathook into the bone fragment
secured its elevation by traction. A more refined corkscrew
typeofsurgicalinstrumentwasutilizedbyRoberts.8Fixation
oftheparts afterreductionhas been effected does not appear
r~~~~~~~( r
Fig. 2.-Elevation oforbitalrim-withforceps.
to be necessary in the ordinary patient since there are no
large muscle attachments to pull them out ofplace.
Simple fracture of the zygomatic arch or when the frag-
ment is combined with a portion of the infero-lateral wall of
the orbit may be most simply repaired by the method of
Gillies and Kilner.34 After a temporal incision in the hairline
hasbeenmade, aperiostealelevatoristhenpasseddownward
beneath the zygoma and by the use of the skull as a fulcrum
leverage is exerted to raise the bony fragment into position.
Subsequent fixation is not necessary. (Fig. 3.)
DEVOE: Fractures of the Orbital Floor 509
By any of these methodsi reduction of simple malar frac-
tures is considered relatively simple. Little orbital deformity
other than at the rim is present and there should be little or
no displacement of orbital content with attendant ocular
malfunction. Combined malar-maxillary fractures, such as
weremorecommoninwarinjuriesishoweveranothermatter.
Heresometype ofsplintingis required to retain comminuted
Fig. 3.-Temporal approachforfractureofzygoma.
fragments in place and to re-elevate the orbital floor to its
normalposition. McIndoehas statedthatinsuchindividuals
itisnecessaryto&entertheantrumthroughabuccalapproach
and elevate the fragments with gauze packing. (Fig. 4.)
Matthews'describes theprocedureinsomedetail, entering
the antrum through the upper buccal sulcus above the
premolar and the first molar teeth. After resecting the lower
510 DEVOE: Fractures of the Orbital Floor
part of the anterior antral wall a lever is inserted and the
fractured bone disimpacted. The antrum is then packed
nrmly until the orbital defect is slightly overcorrected. This
is considered to be a simple procedure if performed within
10 days after the original injury but considerably more
difficult later. The pack is allowed to remain in place for
2weeksbeforeitsremoval, whichmustusuallybedoneunder
general anesthesia. Anintranasal antrostomyis performed at
FL X
Fig. 4.-Buccal approachforfractureoforbitalfloor.
the same time in order to allow closure of the buccal wound
and to safeguard against later antral infection. Johnson"5 has
accomplished the antral packing by the insertion of a water-
filled rubber balloon which he allowed to remain in place for
3 weeks.
Itisadmittedthatevenimmediatereductionbythe above
described methods is no guarantee against diplopia.
After fixation of the bony fragments in malunion, which
DEVOE: Fractures of the Orbital Floor 511
may occur in several weeks, reduction is not usually con-
sidered possible. Replacement measures are then necessary.
McIndQe has stated that in his experience it is rare for
diplopia to be overcome bysubperiostealinsertion ofbone or
cartilage in the orbit.
Although most writers on this subject stress the impor-
tance of immediate treatment, Straith35 36 in a discussion of
the management of facial injuries caused bymotor accidents
has warned against too hurried procedures of heroic nature.
Hehas stated that it is farwiser to delay than to attempt an
emergency operation upon apatient inpoor condition andin
the presence of improper facilities. Serious hemorrhage is
considered the only indication for immediate operation. A
warning is also sounded to the effect that any serious facial
injury should be treated as a potential skull fracture until
proved otherwise.
The ophthalmologist is more likely to be called for con-
sultation in late treatment of such cases than immediately.
Frequently diplopia is maskedby edema ofthelids and orbit
and does not become annoying for several weeks after the
injury. Again intracranial damage may be so severe that
immediate repair work must be postponed while lifesaving
measures are instituted. Such was the situation in the pa-
tients seenin thepresent series. All had been injured months
to years prior to my first seeing them.
LATE TREATMENT OF ORBITAL FRACTURES
Orbital floorfracture has beenrecognized in 34individuals
and an arbitrary division made into 3 groups:
1. Those with normal vision in the involved eye.
2. Those with the eye present but with defective vision.
3. Those in whom the eye has been removed.
Group 1. Itis surprising how fewsymptoms apatientmay
have following an orbital floor fracture. He may even be
totally unaware of any deformity. Not infrequently these
patients mayhave had initial diplopia which in the course of