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We describe a supraorbital approach through an upper eyebrow skin incision to treat a fronto-orbital fracture with pneumocephaly in a 84-year-old cardiac patient. The clinical and cosmetic results are excellent. This case is illustrated by pre- and postoperative CT-scan and MRI as well as pictures showing the minimal invasive technique.

Introduction: Orbital fractures represent 30 % of children facial fractures. Nausea and vomiting are more predictive of entrapment than local trauma stigmatisms. Entrapment and diplopia are more frequent in adults. Delay for surgery is unclear in literature varying from 6 hours to days. The aim of this study is to summarise the aspects of orbital floor fractures in children with regard to clinical and radiological presentation, management, and outcomes., Patients and Methods: We conducted a retrospective study including 34 children presenting isolated orbital floor fracture. Clinical, radiological, ophthalmological, surgical data and outcomes were analyzed., Results: Mean age was 9.4 years. In 15% of cases, no local stigmatism of trauma was present. Entrapment fracture was the most frequent, with 81% of fat or muscles entrapment. In all, 27% of the patient had residual diplopia. Residual diplopia developed after trap-door fracture with muscle entrapment and a more than 24 hours delay for surgery., Conclusion: Trap-door fracture is frequent in childhood population. Clinical diagnosis can be difficult. However, surgical treatment should be considered before 24 hours to avoid complication as residual diplopia., (Copyright © 2012. Published by Elsevier SAS.)

Objective: To assess the management of orbital floor fractures and their aftereffects in children., Patients and Methods: We retrospectively studied five children with isolated orbital floor fractures who were operated (with a perioperative steroid and antibiotic treatment) between 1998 and 2007 in our pediatric hospital. At the first visit, they all had a complete clinical examination, a Hess-Lancaster test, and a computed tomography (CT) scan. At the last visit, they all had a clinical examination and four children underwent a Hess-Lancaster test., Results: After a median follow-up of 26 months (range, 4-100 months), no child had diplopia, all Hess-Lancaster tests were normal, and two children suffered from infraorbital hypoesthesia., Conclusion: Surgical repair associated with steroids and antibiotics in orbital floor fracture with our surgical indications has led to good functional results with minimal complications.

Orbital roof fractures after head injury is rare. Traumatic encephaloceles in the orbital cavity are even rarer, with only 24 cases published to date. We report the case of an adult with a post-traumatic orbital encephalocele. One day after a road traffic accident with head injury, the patient developed progressive pulsatile proptosis. Computed tomography and magnetic resonance imaging revealed an isolated blow-in fracture of the orbital roof with herniation of the left frontal lobe into the orbit. Neurosurgery to repair the orbital defect led to full recovery.

We report a case of growing fracture of the orbital roof in a 5-year-old child. The presenting sign was a pulsatile orbital mass. This child had a history of a minor head injury with orbital impact 2 years ago. Cerebral CT scan revealed a diastatic fracture of the right orbital roof. On MRI a leptomeningeal cyst extending in the orbital cavity was shown. Frontal craniotomy with direct repair of the dural and bone defects was performed. The outcome was excellent. In the literature the exact pathophysiology of the growing fractures is still debated but a dural laceration along the fracture line is noted in all the cases. They are mostly located in the cranial convexity, and rarely affect the skull base. Only 5 similar cases were found in the relevant literature. Growing fracture of the orbital roof should be suspected if ocular symptoms appears in childs who have sustained a head injury several months or years ago.

Unlabelled: We present a retrospective study of 85 patients presenting an isolated orbital floor fracture between 1993 and 1997; 79 of them (93%) were operated via a subciliary or transconjunctival approach. Surgical procedure included autologous graft or biomaterial (coral, polydioxanone) depending on the cases. The study was focused on clinical data (concerning diplopia, enophthalmia and sensorial disturbances) which were recorded pre- and post-operatively., Results: 58 patients (68%) had a pre-operative diplopia, and 9 (11%) had a persistent post-operative diplopia: all of these patients were operated more than 8 days after trauma; no post-operative diplopia occurred without pre-operative diplopia; 8 patients (9%) presented a pre-op enophthalmia: all of them came more than 10 days after the trauma; a perfect symmetry was obtained post-operatively in only one of these 8 patients; no enophthalmia occurred in patients without pre-op enophthalmia; sensorial disturbances were seen pre-operatively in 27 patients (32%) and post-operatively in 17 (20%); no correlation was found with the timing or the procedure of the surgery., Comments: The interest of an early diagnosis and treatment is confirmed, in order to avoid late functional (diplopia) or esthetic (enophthalmos) disturbances. Thus it seems necessary to obtain a computed tomography for any orbital trauma as conventional radiography can be less sensitive. Concerning the surgical procedure, resorbable biomaterials seem to be very well tolerated and easy to use. Autologous bone grafts always lead to a certain degree of morbidity without real advantage. The best way seems to be the trans-conjonctival approach, but subciliary incisions can also be used in these cases. The most important remaining problem to solve is probably focused on sensorial disturbances: their incidence is high and there is a high rate of sequels: further studies are obviously necessary to improve the knowledge of etiopathogenic factors and determine the best therapeutic attitude.

Over a period extending from January 1993 to December 1995, we treated 242 patients with 268 orbital floor fractures in our department. Surgical indications were broad and relied on clinical criteria (enophthalmos, diplopia, hypoesthesia) and/or CT analysis (bony collapse, extrusion of orbital contents, suspicion of muscular entrapment, dislocation of the infraorbital rim). Two years after surgery, 91% of the patients showed good results (absence of diplopia or severe enophthalmos). The analysis of these results points out that the degree of sequelar enophthamos was not only related to the degree of initial bony collapse but above all to the quality of the bony reconstruction. Sequelar diplopia was linked with the presence of a preoperative diplopia and its severity was a direct function of operative delay. Hypoesthesia in the infraorbital nerve territory was the most common sequela; some were postoperative complications. The type of material used for the restoration of the orbital floor was not involved in the development of these sequela. Our good results suggest that an interventionist attitude is warranted in these kind of fractures, the more so as the X-ray examinations often underestimate injuries.

We report our experience with fractures of the orbital floor over the past five years, reporting 80 cases. Different anatomic and clinical forms were defined, particularly trap-door fractures. After a clinical and computed tomography study, we recommend treatment with Teflon implants. Results obtained were analyzed and compared with other series in the literature.

Bone and Cartilage Autograft gather all the necessary qualities for an interpositional material to be used in the fractured orbital floor reconstruction, leading to the binocular vision recovery and in term of tolerance. The initial material choice depends on the clinic and orbital tomodensitometry datas, but the final decision is made on the operating findings. However, schematic indications can be drawn up, depending on material characteristics, curve, rigidity and resorption degree, and fracture particularities.

A madreporic coral graft was used for orbital floor reconstruction following facial trauma. This report presents a multicentric study of 83 patients with a follow-up period of 15 to 24 months. The results of this study indicate no significant rejection or infection opposed to so many synthetic implants outcome. The radiological follow-up demonstrates a partially resorption of the implant within about 2 years and its replacements by new bone. Coral implant was used to correct enophthalmos or diplopia due to enlarged orbital dimensions. It was technically easy to insert and its anatomic shape does not require to be fashioned before use. Its inflexibility allows to bridge large bone defects and this implant should be considered as an attractive alternative to autogenous grafts, avoiding a second surgical site, in reconstructing orbital floor fractures.

The good long term results obtained following the remodeling of the frontal bandeau in craniosynostosis have demonstrated the viability of large bony segments following total periosteal stripping. In this present study, this concept has been applied in the management of acute midfacial fractures and their sequelae. To try to answer the fundamental questions of how wide of an exposure is needed for the treatment of these fractures, how denuded can bone segments be and expect to survive, and above all, how frequently is primary bone grafting needed, the author resorts to the complete detachment and removal of the fractured segments and their reassembly on a side table. This, theoretically, accomplishes the following: the best exposure of fragments, the best anatomical reduction, an accurate assessment of segmental loss and the need for immediate bone grafting, a normal topographical reconstruction. Bone scans have indicated long term perfusion in every case in which they were obtained. Except in cases of post traumatic deformity correction, bone grafts were not needed. The free segment reassembly fractured facial bones is but one additional technique gained from craniofacial surgery. Much, however, remains to be learned about large free segment revascularization and healing.

Optic nerve trauma induces loss of vision and absence of direct pupillary light reflex. Persistence of consensual pupillary light reflex excludes anatomical section. Trans ethmoidal-sphenoidal decompression relieves the optic nerve and allows an improvement of visual function. Ten patients among 15 surgical decompressions recovered visual function. There is a good correlation between improvement and the release of an anatomical nerve compression. Recognition of direct or indirect computed tomographic signs of optic nerve compression are essential in the surgical indications. The prognosis post-surgical improvement is dependent on the sensitivity of computed tomography scan.

In this report, the authors evaluate the indications of the different imaging techniques of the face and the adjacent deep and superficial regions. Thus, CT stays the first examination of the paranasal sinuses completed by MRI especially when an inflammatory pathology is associated with a benign or malignant tumor. Traumatisms of the face must be investigated by CT with an emphasis on the frontal and sagittal reformated sections. The study of the superficial areas of the face (parotid gland) is best explored by US and MRI. MRI gives better results than CT in the exploration of the deep regions of the face. Arteriography remains obligatory in the study of certain tumours specially the nasopharyngeal angiofibroma.

The superior orbital syndrome has been reported as a very rare complication of orbital fracture. In emergency clinical examination and computed tomography of the cranio-orbital region have provided diagnosis of the compression of the superior orbital fissure content by oedema and/or hematoma. These examinations have determined the type of cranio-orbital fractures and the absence of extra-dural haemorrhage, optical nerve damage or compression, which required emergency treatment. After surgical treatment of the cranio-orbital fracture by temporal and transconjunctival approach, the orbital fissure syndrome has required supervision. The recovery of ophthalmoplegia has taken several months. Minor after effects have been observed for the patient reported.

Based on 8 cases, the authors study the mechanisms involved in post-traumatic enophthalmos and demonstrate that they result from an increase in orbital volume. There are no grounds to suggest that the disappearance of orbital fat is involved.

Orbital fractures should be evaluated by CT in frontal and transverse planes. The significance of blow-out floor and medial wall fractures is discussed. Limitation of inferior rectus muscle mobility is thought to be a result of edema, enophthalmos, fat prolapse or scar tissue formation, rather than muscle incarceration. The consequent therapeutic attitude implies a rigorous preoperative exploration by CT or for some orbital floor fractures by MR.

Eighty patients with craniofacial injuries were investigated using a CT scan apparatus of the second generation. The advantages of this examination over conventional methods of exploration are discussed and details provided of projections used. Conventional tomography imaging has now been completely abandoned.

Oculomotor disturbance resulting from orbital floor fractures have different etiologic factors, sometimes damage of one of the ocular motor nerves, caused by direct injury to the orbit; this damage occurs also to one or more of the extrinsic ocular muscles, especially the obliques; frequently, the diplopia is caused by prolapsed orbital tissues with or without muscle entrapment or by a muscle fibrosis; when the diplopia appears after orbital floor reconstruction there is often a palsy of the inferior rectus muscle in front of silicone implant or bone graft on the orbital floor. In oculomotor disturbance after orbital floor fracture, the first stage will be to recognize the mechanism of the diplopia by a clinical examination, motility in the nine positions, Hess Charts, binocular vision and field, forced duction, radiography and sometimes coronal computed tomography which also allow visualization of soft tissues densities, including all extraocular muscles. If there is an indication of orbital surgery, it will be done always in first; oculomotor surgery will be done if necessary at the second stage, if there is a permanent diplopia without evolution during six months. The purpose of the treatment is to obtain orthophoria in primary position and in down gaze. A series of cases of fracture of the orbital floor with resulting diplopia are described. The method, the time, and the indications of orbital or oculomotor surgery are discussed according the variety of cases.

Trapdoor fractures of the floor of the orbit were first described in 1965 by Soll and Poley. The authors discuss the pathology and pathogenic theories for these lesions and present 8 cases. The diagnosis is essentially clinical and is frequently supported by computed tomography when it is performed rapidly. The surgical procedure is designed to release the herniated tissues by lowering the orbital floor so as not to aggravate the constrictive lesions. These fractures constitute surgical emergencies and their prognosis depends on the nature of the tissues incarcerated.

Among isolated fractures of the orbital floor, the authors are pointing out an unusual clinical type characterized by the irreducibility of the orbital contents ruptured in the maxillary sinus by using classical procedures. This primary failure is due to a bone fragment dropped in the sinus and being attracted by the herniated collar when trying to integrate the hernia in the orbit. To name this type of lesion, the word "valve fracture" is proposed because of the analogy of the one way function of a valve and its different mechanism from the classical trapdoor fracture. The different concepts of the pathogenesis of isolated fractures of the orbital floor and the physiopathology of the frequently associated ocular disturbances are briefly exposed. The authors report the case which confronted them to the valve fracture. Following a direct trauma to the right orbital area a 13-year-old child presented a limitation of the upwards movements of the right eye with diplopia and a positive forced duction test. The surgical exploration shows an orbital hernia in the sinus which is impossible to reposition either with a higher incision (under the orbital rim) or with a lever incision, upper vestibular incision (through maxillary sinus). Only the infraorbital marginotomy described by P. Tessier exposes completely the lesions and allows understanding of the mechanism of this primary irreducibility related to the valve movement of the fractured bone fragment. Above all, marginotomy allows an atraumatic set. If is performed combining gentle handles of pulling and forcing back on the ruptured pieces while keeping opened the valve.