Influence of age on the management of blow-out fractures of the orbital floor
K. de Man ~, R. Wijngaarde 2, J. Hes ~, P. T. de Jong ~ Departments of 1Oral and Maxillofacial Surgery and 2Ophthalmology, University Hospital Rotterdam-Dijkzigt, Rotterdam, The Netherlands
K. de Man, R. Wijngaarde, J. Hes, P. T. de Jong." Influence of age on the management of blow-out fractures of the orbital floor. Int. J. Oral Maxillofac. Surg. 1991; 20: 330-336. Abstract. This study concerns 50 patients with blow-out fractures of the orbital floor, including 15 children, and was designed to evaluate the influence of age on clinical presentation and postoperative results. Fourteen of the 15 children were found to have a trap-door fracture. This type of fracture was not found in adults, who usually present with a large "open-door" fracture. In trap-door fractures, orbital tissues are liable to become trapped and even strangulated. It is therefore suggested that young patients with severely restricted eyeball motility, an unequivocal positive forced duction test, and findings indicating blow-out fracture of the orbital floor on CT, should undergo operative treatment as soon as possible after injury. A "wait and see" policy, keeping the patient under observation, seems to be appropriate for blow-out fractures in adults. Surgical treatment is recommended only in those adult patients who demonstrate impairment of vertical eyeball motility within the mainfield of view after the haemorrhage and oedema have resolved and in whom change in motility is no longer seen and Hertel measurements have stabilized.
In 1889, L A N G 13 provided one of the earliest descriptions of a blow-out fracture. He reported a case of a 13-yearold boy who had received a blunt blow to the right eyebrow. On examination the patient was noted to have diplopia, enophthalmos but an intact infraorbital rim. In 1957, SMITH & REGAN19, introduced the term "blow-out" fracture and described the signs and symptoms of this type of fracture. Since that time, blow-out fractures of the orbital floor have been the subject of much controversy, with discussions relating both to their mechanism of injury as well as to the appropriate management. From the work of SMITH & REGAN 19 evolved the concept that the restricted motility of the eyeball and enophthalmos are caused by incarceration of inferior orbital tissues, more specifically the inferior rectus and/or the inferior oblique muscles, into the fracture site, and it was suggested that surgical exploration of all blow-out fractures should be performed within the first 7 days of injury. During the late 1950s and 1960s, the indications and timing for surgery were
not only based on symptoms present, but also on possible future complications s,~9. Whether or not impairment of vertical movement of the globe was present, it was believed that early surgical repair of the orbital floor was necessary if patients were not to have persistent double vision and unacceptable enophthalmos for the rest of their lives. In the early 1970s, several studies showed that apprehension regarding late development of diplopia and enophthalmos was not justified for all blow-out fractures and that many fractures of the orbital floor would heal without any untoward results 6's,~7. These studies stimulated a more conservative approach to the treatment of blow-out fractures. H6TTE 11 emphasized that the only indication for immediate exploration was rapid onset of serious intraorbital haemorrhage with decreased visual acuity. Muscle entrapment was, according to the author, a rare finding in blow-out fractures. In 1971, EMERY et al. 9 reported on 67 patients with pure blow-out fractures of the orbital floor, including 49 patients
Key words: blow-out fracture; orbital fracture; trauma; diplopia; enophthalmos; lyophilised dura. Accepted for publication 17 July 1991
who were operated and 18 who did not undergo surgical repair. All patients were followed for more than 6 months. At follow-up examination 24 (50%) of the surgical patients and 5 (28%) of the nonsurgically treated group had persistent diplopia. Enophthalmos occurred with approximately the same frequency in both groups (14% and 16% respectively). Since patients who were operated within the 1st week of the accident had persistent diplopia just as frequently as those who had surgery during the 2nd week, the authors advocated operative treatment in patients with diplopia and positive forced ductions after 14 days only, unless roentgenograms showed evidence of a large defect in the orbital floor. In 1974 PUTTERMAN et a l l 7 reported on nonsurgical management of blowout fractures of the orbital floor. They described the clinical course of 57 patients (28 retrospectively, 29 prospectively) with blow-out fractures, who were not operated and were followed for variable periods of time. Although most of the patients had diplopia in primary
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