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Importance: The nasal bone is one of the most commonly fractured bones of the midface. However, the frequency of coincident fractures of adjacent bones such as the frontal process of the maxillary bone, nasal septum, and medial or inferior orbital walls has not been fully evaluated. Objective: The purpose of this study was to investigate the incidence of fractures of adjacent structures in the setting of a nasal bone fracture. Second, we propose a new classification system of nasal bone fractures with involvement of adjacent bony structures. Design, Setting, and Participants: One thousand, one hundred ninety-three patients with midfacial fractures were retrospectively reviewed. The characteristics of fractures of the nasal bone and the incidence of coincident fractures of the frontal process of maxilla, bony nasal septum, medial, or inferior orbital walls were analyzed. Exposure: All patients included in the study presented with nasal trauma. Main Outcomes and Measures: The coincident fractures of adjacent midfacial structures were assessed, and a new classification of midfacial fractures based on computed tomography (CT) scan images was proposed. Results: Among the 1193 cases, bilateral fractures of the nasal bone were most common (69.24%), and coexistent fracture of the frontal process of the maxilla and bony nasal septum was 66.89% and 42.25%, respectively. Coincident fracture of the orbital walls was observed in 16.51% of cases. The major etiology of fracture for the younger and elderly groups was falls, compared with assault as the most common etiology in the adult group. A classification scheme was generated in which fractures of the nasal bone were divided into five types depending on coexisting fractures of adjacent structures. Conclusions and Relevance: External force applied to the nasal bone can also lead to coexistent fracture of adjacent bony structures including the frontal process of the maxilla, nasal septum, and orbital walls. The proposed classification of nasal fracture based on CT imaging helps to incorporate coincident disruption of adjacent structures.

Background: Currently, there is a paucity of information on the presentation and proper management of pediatric nasoorbitoethmoid fractures. The purpose of this study was to examine the incidence, cause, associated injuries, and management of these fractures. Furthermore, the authors sought to assess outcomes after transnasal wiring or suture canthopexy for type III nasoorbitoethmoid fractures., Methods: A retrospective cohort review was performed of all patients with nasoorbitoethmoid fractures who presented to a Level I trauma center from 1990 to 2010. Charts and computed tomographic imaging were reviewed, and nasoorbitoethmoid fractures were labeled based on the Markowitz-Manson classification system. Patient fracture patterns, demographics, characteristics, and outcomes were recorded. Univariate and multivariate methods were used to compare groups., Results: A total of 63 pediatric patients were identified in the study period. The sample's mean age was 8.78 ± 4.08 years, and 28.6 percent were girls. The sample included 18 type I injuries, 28 type II injuries, and 17 type III injuries. No significant demographic differences were found between patients with type I, II, and III fractures (p > 0.05). Operative intervention was pursued in 16.7, 46.4, and 82.4 percent of type I, II, and III nasoorbitoethmoid fractures, respectively. In patients with type III nasoorbitoethmoid fractures, no patients with transnasal wiring developed telecanthus., Conclusions: Pediatric nasoorbitoethmoid fractures are uncommon injuries. Type I fracture can often be treated with close observation. However, type II and III injury patterns should be evaluated for operative intervention. Transnasal wiring is an effective method to prevent traumatic telecanthus deformity in type III fracture patterns.

Purpose: Detection of optic canal fractures is often difficult because of the subtleness of the fracture. If we could clarify impact on which region around the orbit is likely to accompany the fracture of the optic canal, the knowledge should be useful to make early diagnosis of optic canal fractures. The present study was conducted to elucidate this issue., Methods: Ten finite element models were produced simulating the skulls of ten humans (8 males and 2 females; 43.8 ± 10.2 y/o). The peri-orbital area of each of the ten models was divided into eight regions in a clockwise fashion per 45 degrees. These regions were defined as Superior-Medial (0-45 degrees), Medial-Superior (45-90 degrees), Medial-Inferior (90 to 135 degrees), Inferior-Medial (135 to 180 degrees), Inferior-Lateral (180-225 degrees), Lateral-Inferior (225 to 270 degrees), Lateral-Superior (270-315 degrees), and Superior-Lateral regions (315-360 degrees), respectively. Dynamic simulation of applying traumatic energy on each of these regions was conducted. Resultant fracture patterns were evaluated using finite element analyses. Thereafter, frequencies of fracture involvement of the optic canal were evaluated for each of the eight regions., Results: The involvement of the optic canal was most frequent for the Superior-Medial region (7/10), followed by the Medial-Superior region (5/10)., Conclusion: Optic canal fracture is likely to occur when the area between the supra-orbital notch and the medial canthus are strongly impacted. When evident fracture or serious damage of soft tissue is observed in this area, occurrence of optic canal fracture should be suspected.

Purpose: The purpose of the present study was to clarify the reasons for, types of, and degree of involvement of the orbital wall and the severity of orbital fractures in geriatric patients and to compare the differences between geriatric and younger adult patients., Materials and Methods: A retrospective case-control study of geriatric patients aged at least 65 years (n = 72) and younger controls aged 20 to 50 years (n = 58) with a diagnosis of a unilateral isolated orbital fracture was designed and implemented. The main exposure was age, the primary outcome was the isolated orbital fracture type, and the secondary outcomes were the associated orbital zones, fracture area (cm 2 ), degree of dislocation (mm), involvement of anatomic landmarks, diplopia, altered ocular position, restricted eye movement, and ocular injuries. The confounding variables were gender, trauma mechanism, and alcohol abuse. The statistical methods included χ 2 tests and logistic regression analyses., Results: Among the geriatric patients, the great majority of isolated orbital fractures had been caused by falls (66.7%; P < .001). Geriatric orbital fractures were significantly more often extensive (2 cm 2 or larger; P = .045) and associated with the middle-posterior orbital third (P = .032). In the logistic regression analyses, the elderly had a 2.2-fold greater risk of fractures of the middle-posterior orbital third and a 2.3-fold greater risk of extensive fractures compared with the younger controls. Ocular injuries were only diagnosed in the geriatric patients (5.6%)., Conclusions: Falling is the most common mechanism of elderly orbital fractures. Isolated orbital fractures are extensive and mainly affect the globe supporting the middle and posterior parts of the orbital floor among geriatric patients., (Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

The goal of orbital reconstruction is to repair trauma defects, to correct the position of the eye anatomically, avoiding enophthalmos, and to restore ocular function. For the reconstruction of (trauma) defects, many surgeons recommend materials that can be bent into an anatomical shape and that possess the properties of radiopacity and long-term stability. However, apart from these desired properties, the ideal material for orbital reconstruction remains controversial. Autologous bone is often mentioned as the 'gold standard,' likely because of its mechanical properties, revascularization potential, and its adaptation to the orbital tissue with minimal acute and chronic immune reactivity. However, autologous bone can show unpredictable resorption rates and suboptimal volume correction. In recent years, an increasing interest in the use of alloplasts for orbital reconstruction has become apparent in the literature. Modern technological advantages, such as preoperative planning, navigation, and perioperative imaging, can be beneficial in the decision to choose a certain implant. The aim of this review is to give a comprehensive overview of the advantages and disadvantages of materials used to reconstruct traumatic orbital defects and to provide a practical, evidence-based, complexity-driven set of guidelines., (Copyright © 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: To evaluate the type and cause of orbital blowout fractures in Korea., Design: Retrospective, observational case series., Methods: Patients who underwent reconstruction for blowout fracture from March 2004 to April 2013 at Korea University Guro and Ansan Hospitals were included in this study. Patient demographics and orbital computed tomography (CT) scans were reviewed. On CT, ethmoid air cell septa, blowout fracture type, and other combined fractures were analyzed. Blowout fracture was classified as affecting up to 4 areas: the floor lateral to the infraorbital canal, the floor medial to the canal, the maxilla-ethmoidal strut ("inferomedial" strut), and the medial wall. Furthermore, trauma type and associated injury were reviewed. The results of adolescent patients and adult patients were compared, as were those of males and females., Results: The study included 659 eyes of 659 patients; mean patient age was 31.01 ± 14.27 years. In total, 513 (77.85%) patients were male and 146 (22.15%) were female. The most common blowout fracture type was medial wall fracture, followed by floor wall, floor and medial wall without inferomedial strut, and floor and medial wall fracture with inferomedial strut, in that order. Interestingly, patients with floor wall blowout fracture were younger (26.87 ± 12.90 y) than other groups: medial wall fracture (32.35 ± 14.64 y, P < 0.0001), floor and medial wall fracture (35.22 ± 14.49 y, P < 0.0001), and floor and medial wall fracture involving the maxillaethmoidal strut (32.62 ± 13.75 y, P = 0.002). The number of ethmoidal air cell septa was lowest in the medial wall fracture group (3.62 ± 0.67): floor wall fracture (4.07 ± 0.69, P < 0.0001), floor and medial wall fracture (3.90 ± 0.78, P < 0.0001), and floor and medial wall fracture involving the maxilla-ethmoidal strut (4.05 ± 0.72, P = 0.001)., Conclusions: Our study demonstrated that the blowout fracture type distribution in Korea varied from the results of many other studies. Medial wall fracture is the most common among the 4 types, and anatomic variance, such as number of ethmoid air cell septa, could influence blowout fracture type, especially in medial wall fracture.

Background: The level of difficulty during an endoscopic approach for an inferior orbital fracture depends on the fracture pattern and the presence of a ruptured membrane (orbital periosteum and sinus mucosa). The purpose of our study was to examine fracture patterns according to age group and to determine the relationship between the type of fracture and the type of membrane injury., Methods: We reviewed the records of 30 patients who, from 2006 to 2010, underwent endoscopic transantral and transnasal approach with a balloon catheter technique to repair orbital floor fracture. The procedure was done through middle or inferior meatal antrostomy and two small antrostomies made in the anterior wall of the maxillary sinus by using an endoscope and specially designed curved dissectors., Results: There were 3 linear, 20 trapdoor-type and 7 blowout fractures. There was a tendency toward a higher incidence of linear fractures at younger ages and of blowout fractures in older patients. All linear fractures had rupture of both membranes, whereas both membranes were intact in 15 of the 20 patients with trapdoor fractures. Among blowout fractures, there was no membrane rupture in five and both membranes were ruptured in two patients. No patient reported diplopia after fracture repair., Conclusions: Rupture of the periosteum, which makes visualization and reduction of orbital tissue difficult for the surgeon during endoscopic repair of the orbital floor fracture, was observed in 3 of 3 linear fractures and 5 of 20 trapdoor fractures. We found that linear fractures were more common in pediatric patients. Care of pediatric orbital floor fracture requires particular caution.

Isolated adult orbital roof fractures are uncommon, and the majority of them are typically associated with extensive craniofacial, ophthalmologic, and other body injuries. It is crucial to make an appropriate diagnosis of orbital roof fracture if present. Therefore, the aim of this article was to review the current literature about diagnosis and imaging of orbital roof fracture to obtain current indications. A systematic review of articles published between January 1990 and August 2013 was performed. Early diagnosis of orbital roof fractures can reduce the incidences of intracranial and ocular complications. CT scan still plays a major role in the assessment of acute orbital trauma. Careful assessment and reporting of the CT scan findings are important. In fact, the clinicians managing the patient with acute head and facial trauma should be familiar with the common findings of CT scan in case of an orbital roof fracture.

Objectives: To assess the changing mid-face fracture patterns using a computed tomography scan., Methodology: Fifty patients with mid-face trauma requiring open reduction and fixation were studied using 1.6 mm axial, sagittal, coronal and 3D images. Images were evaluated clinically, intra-operatively and finally were compared with standard Le Fort lines. Results. The male population dominated the female at a ratio of 11.5:1. The majority of the mid-face fractures were seen in the age group of 21-30 years. Road traffic accident (78%) was the major etiological factor followed by work-related accidents (12%) and assaults (10%). The CT scan analysis included categorizing the patients into three groups: (1) Fracture patterns resembling Le Fort lines (24%); (2) Fracture patterns partially resembling Le Fort lines (56%); and (3) Fracture patterns that do not resemble Le Fort lines (20%)., Conclusion: With the change in the velocity of wounding object, there is a change in the mid-face fracture patterns. The majority of the cases present as a variant of classical Le Fort fractures. Computed tomography is a valuable diagnostic tool in assessing the fractures of the mid-face. 2D images are more sensitive than 3D images. However, both the images are required in delivery of an optimal treatment plan.

Purpose: To present a case series review of management of pure orbital floor fractures and propose a protocol., Methods: A retrospective review of medical records and computed tomography (CT) scan findings was completed. Fractures were classified into either trap-door, floor-fracture with incarcerated tissue, or depressed floor-fragment fractures. Criteria for surgical success were: enophthalmos <1mm; no hypoglobus/hyperglobus; extra-ocular muscle restriction <5° in upgaze but normal in all other positions on Hess chart; and no diplopia other than in extreme upgaze (5°)., Results: A total of 79 patients with orbital floor fractures were identified. There were 6 trap-door type fractures, 42 floor fractures with incarcerated tissue, and 31 depressed floor-fragment type fractures. Thirty-six patients were managed conservatively (antibiotics and observation). In nine of these, surgery was avoided by adhering to our protocol of delayed repair. Forty-three had surgical intervention: 6 were trap-door-type, 18 had a floor fracture with incarcerated tissue and 19 were of the depressed floor-fragment variety. All trap-door fractures underwent early repair (6/43, 14%), the rest had delayed repair (37/43, 84%). Four of 6 trap-door fractures had a successful outcome (66.6%). All 18 fractures with incarcerated tissue underwent successful delayed repair. Seventeen of 19 patients with depressed floor-fragment fractures were treated successfully surgically. The follow-up ranged from 12-64 months. The overall success rate was 85.3%., Conclusion: Non-trap-door type of floor fractures can have a successful outcome with delayed repair. This can avoid unnecessary surgery in selected cases. A management protocol is proposed.

Purpose: In our prospective nationwide surveillance study of traumatic optic neuropathy (TON) in the United Kingdom, the prevalence of orbital fractures was found to be 39% (47/121). The prevalence of skull fractures was 7.4% (9/121). This study aims to identify the association of craniofacial-orbital fractures with the severity of visual loss., Methods: TON patients who sustained orbital fractures were identified prospectively by population-based active surveillance through the British Ophthalmic Surveillance Unit over a 2-year period. Available CT scans were classified by a head and neck radiologist according to the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF) scheme: the face was divided into 4 units; fractures in each unit were graded according to displacement (A-C) and severity (1.1-3.3). Correlation between severity of craniofacial orbital fractures and visual acuity as well as number of fractured units and visual acuity were evaluated., Results: Twelve of the 25 patients (48%) with imaging available had adequate high resolution craniofacial CT imaging for review and classification using the AO/ASIF system (i.e. 48 classifiable units). Three of 48 (6%) units were undisplaced (grade A), 18 of 48 (29%) units were minimally displaced (grade B), and 4 of 48 (8%) units had largely displaced (grade C) fractures. Twenty-three units (47.9%) had no fractures; 5 patients had radiological evidence of optic canal fractures. Poor visual acuities positively correlated with severity of fractures graded using the AO/ASIF classification (Spearman's rho = 0.95, p = 0.05) and number of fractured units (Spearman's rho = 1.0, p < 0.0001)., Conclusion: AO/ASIF classification system provides a uniform method in the assessment of orbital fractures which correlates with visual outcome in TON.

There are no clear, evidence-based guidelines that dictate when it is safe for a patient to fly after sustaining a midface fracture. From January 2006 to December 2009, the Royal Darwin Hospital Maxillofacial Unit had 48 out of 201 patients with an orbital fracture that involved a paranasal air sinus transported by a variety of aircraft to the unit for definitive management. No orbital complications were recorded for the 24% of patients requiring air travel to our tertiary referral centre. Furthermore, there were no recorded deviations from the standard flight plan. We believe that this demonstrates there are no absolute contraindications to flying on a variety of aircraft with a midface fracture, but clinical assessment remains crucial for an informed decision to transport these patients by air., (Crown Copyright © 2013. Published by Elsevier Ltd. All rights reserved.)

The third most common facial fractures in children are fractures of the orbit, and the medial wall and floor are the commonest sites affected. The aetiology, clinical presentation, and timing of operation all differ from those of adults. If there are few or no clinical signs, but oculocardiac reflex is present, it is highly suggestive of trapdoor injury. This retrospective study includes all consecutive children (younger than 18 years) referred with confirmed fractures of the orbital floor over a 5-year period (2005-2010). A total of 24 patients were identified with a mean age of 13.5 years, and most injuries were secondary to falls. Isolated injury to the orbital floor occurred in 14 (58%); the rest involved other fractures of the orbital wall or face, or both. There were 11 trapdoor fractures (46%), and 9 open blow-out fractures (38%). Overall, nausea and vomiting occurred in 13 patients (54%); 8 of these had trapdoor fractures. Most patients had operations (22, 92%), and the mean time to operation was 4 days. Complications increased with delays to theatre. Those operated on within 1 day had fewer complications than those who had operations after 3 days. Postoperatively, diplopia (n=6/11) and restricted eye movement (n=3/11) were associated with trapdoor injury, while enophthalmos (n=1/9) and paraesthesia (n=3/9) were related to open blow-out fractures. To reduce compromised outcomes, prompt operation is warranted in all children with fractures of the orbital floor regardless of the configuration., (Crown Copyright © 2013. Published by Elsevier Ltd. All rights reserved.)

As the biomechanical mechanisms of orbital wall fractures are still under research, three different fracture mechanisms were tested in a finite element based investigation. In contrast to earlier studies, a finer skeletal model and a transient dynamic simulation were used to test pure hydraulic, pure buckling and a mixed force transmission. Results showed that each set-up led to different orbital fracture patterns, which correlate well with clinical findings. Therefore the conclusion is that different mechanisms may act together explaining the variety of clinical fracture situations. Biomechanical testing has proven to be appropriate in answering questions regarding fracture mechanisms., (Copyright © 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: To determine the role of fracture size and soft tissue herniation as measured by computed tomography in predicting the development of persistent diplopia in patients with isolated orbital floor fractures., Methods: A retrospective chart review identified patients presenting between March 2009 and 2012 with isolated orbital floor fractures. Computed tomographic scans were assessed for transverse fracture size and absence or presence of soft tissue herniation and rectus involvement. Presence of diplopia at 6-10 days, decision for surgical repair, and presence of diplopia were recorded., Results: Fifty-six patients fulfilled inclusion criteria. Eighteen of 56 patients (32%) had preoperative diplopia. In Type A fractures, 0/9 (0%) small, 1/8 (12.5%) medium, and 2/14 (14%) large fractures had diplopia. For Type B fractures, 3/4 (75%) small, 9/13 (69%) medium, and 4/8 (50%) large fractures had diplopia. Type B fractures were significantly more likely to cause diplopia than Type A fractures in the small (p = 0.003) and medium (p = 0.007) size groups but not in the large groups (p = 0.07)., Conclusion: Transverse fracture size and presence of soft tissue herniation on CT imaging can predict development of persistent diplopia in isolated orbital floor fractures. Small and medium sized fractures with soft tissue herniation are more likely to cause diplopia than large sized fractures. We recommend early repair or closer observation of small and medium sized orbital floor fractures with soft tissue herniation due to the high risk of diplopia., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The treatment of mild and moderate fractures of the orbital wall is controversial. Apart from clinical signs, the size of the defect is often used to aid the decision about treatment. We hypothesised that variables would be present that had an impact on the position and motility of the globe but were independent of the size of the defect, and prevented a balanced judgement of the outcome of conservative treatment. Between January 2000 and December 2007, 48 of 127 patients were included in this retrospective study to analyse the functional outcome of orbital fractures managed without operation. Selection was dependent on the availability of complete clinical records, post-traumatic computed tomographic (CT) scans (axial and coronal sections) and ophthalmic examination. All 48 defects were analysed and allocated to categories of a semiquantitative classification. The area of fracture of each defect was calculated with an integral calculus or geometrical formula and correlated with the associated category. Category A included all orbital walls as a single unit (A1) and combined fracture patterns (A2 and higher). Category B described isolated fractures of the medial wall. There was a significant correlation between classes A1 and A2 (p<0.01) and absolute area of the fracture (0.98 (0.4)cm(2) and 2.42 (0.8)cm(2)). Diplopia was most often seen in fractures in category B1 (the anterior third of the medial wall) and the post-traumatic position of the globe significantly correlated with the area of the fracture (p=0.04). The degree of diplopia was less severe in fractures of the posterior portion of the orbit (zones 2 and 3) compared with fractures of the anterior orbit, even if the defect was larger. The conservative management of category A1-3 and B1-3 fractures up to 2.42 (3.15)cm(2) showed no functional impairment, provided that enophthalmos was less than 2mm and there was no entrapment of periorbital tissue or extraocular muscles. We found good correlation between enopthalmos and the size of the fracture, but not for diplopia or motility of the eye. We conclude that conservative management of an orbital fracture in which the defect is less than 3cm(2) has a low risk of permanent functional damage if enophthalmos is less than 2mm and entrapment of soft tissue or muscles is excluded., (Copyright © 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

The purposes of this study were to observe bony orbital volume (OV) changes in pure blow-out fractures according to fracture location using a facial computed tomographic scan and to investigate whether the OV measurements can be used as a quantitative value for the evaluation of the surgical results of the acute blow-out fracture.Forty-five patients with unilateral pure blow-out fracture were divided into 3 groups: inferior (group I), inferior medial (group IM), and medial (group M) orbital wall fracture. The OV and the orbital volume ratio (OVR) were prospectively measured before and 6 months after surgery with the use of 3-dimensional computed tomographic scans, and the Hertel scale was measured with a Hertel exothalmometer.The preoperative OVR increased to the greatest extent in group IM, and the mean preoperative OVR was 121.46. The mean preoperative OVR in group I was significantly higher than that of group M (P = 0.005). The OV and OVR revealed a statistically significant decrease after the surgery (P = 0.000). The Hertel scale improved from -1.04 mm before the surgery to -0.78 mm after the surgery, but no significant difference was observed (P = 0.051).The OVR was useful as a quantitative value to evaluate pure blow-out fractures, compared with that of the Hertel scale. Fracture location-associated OVR studies are needed to make volume guidelines of blow-out fracture surgery.

Objective: The aim of this study was to retrospectively evaluate the incidence of posttraumatic orbital emphysema (OE) and to propose a radiologic topographic classification as well as a possible pathophysiologic model., Study Design: Orbital fine-cut (1 mm) computerized tomographic scan slices from 137 patients were used to assess the fracture's type, the presence and position of OE, and periorbital tissue herniation. The OE was categorized into the following 5 compartments: subcutaneous periorbital, peribulbar, retrobulbar extra- and intraconal, and pterygopalatine fossa., Results: The incidence of OE was 61%. OE was more frequently associated with isolated medial wall (78%; P < .001) and combined medial wall/orbital floor (82%; P < .01) fractures. Palpable isolated subcutaneous eyelid emphysema was not related to fracture's type (P = .85)., Conclusions: OE suggested medial wall fractures alone or combined with orbital floor fractures. Pathophysiologically, according to the Poiseuille law, the difference in length between the ethmoid and sinusal infundibulii could explain the increased incidence of OE when the medial wall is involved., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Fractures of the medial and basal orbital wall as well as the petrous part of the temporal bone were described first in 1980 by a Berlin-based study group led by Geserick as new cranium findings resulting from a contrecoup mechanism. Experimental and comparative examinations revealed that indirect fractures of the orbital walls are caused by a coup action of the eyeballs, whereas the mechanogenesis of the petrous bone fractures continues to be unclear. The frequently combined occurrence with the orbital sign nonetheless permits an allocation to the contrecoup mechanism. Both signs are important criteria for forensic and clinical assessment of craniocerebral injuries.

In children, differences in the properties and proportions of bone in the craniofacial skeleton and the lack of development of the paranasal sinuses result in orbital fractures that present differently from those in adults. Facial growth may be disturbed by such injuries and also by surgical intervention, which should therefore be as conservative as possible. However, urgent operation is needed to prevent irreversible changes when fractures of the orbital floor involve entrapped muscle. We present an approach to such injuries., (Copyright © 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

In the present article, the authors want to present the results of a retrospectively evaluated consecutive series of patients with surgically treated isolated orbital floor fractures (OFF; "blow-out fractures") concerning the functional outcome after OFF and give detailed recommendations based on the clinical and radiological findings. A series of 60 patients with isolated OFF over a 5-year period needing surgically repair at the same institution were evaluated. Patient data were analysed in terms of preoperative and postoperative clinical parameters and radiological findings. The analysed parameters were type of fracture, diplopia, gaze restriction, enophthalmos, materials used for repair, surgical approach and timing of the surgical intervention. Burst type fractures were more often found than punched-out fractures. The most frequently used surgical approach was a preseptal transconjunctival approach. An overall decrease of gaze restriction (93%), diplopia (89%) and enophthalmos (86%) was observed. According to the fracture size, we used Ethisorb patches in smaller fractures and resorbable or titanium meshes or autologous bone in larger fractures in most cases. Patients who underwent surgery more than 7 days after the trauma showed better results with regard to an improvement of diplopia and motility disturbances than patients who were treated immediately. In indicated cases, the surgical repair of OFF leads to very good results if the anatomical and functional properties of the orbit and its contents are respected. The applied strategy and means presented in our study proved of value and can therefore be recommended.

We sought to investigate the correlation between type of orbital fracture and occurrence of traumatic enophthalmos. The 119 patients with orbital fractures were divided into the enophthalmos group (71 cases) and the nonenophthalmos group (48 cases). The 2 groups were compared by location and type of orbital fracture based on observation of computed tomography scans. We found the incidence of medial wall fractures significantly higher in the enophthalmos group (76.06%) than in the nonenophthalmos group (22.92%, χ(2) = 32.63, P < 0.05). The incidence of combined medial-inferior wall fractures was also significantly higher in the enophthalmos group (52.93%) than in the nonenophthalmos group (12.5%, χ(2) = 23.21, P < 0.05). However, the incidence of lateral-inferior wall fractures was significantly lower in the enophthalmos group (36.62%) than in the other group (58.33%, χ(2) = 4.11, P < 0.05). In most cases of lateral-inferior orbital wall fracture in the enophthalmos group, the zygomatic complex was displaced toward the lateral-posterior direction. The combined medial-inferior wall fracture is likely the primary type of multiple wall fracture leading to traumatic enophthalmos. Enophthalmos caused by a combined lateral-inferior fracture may be correlated with lateral-posterior displacement of the zygomatic complex.

Many different materials are proposed for reconstruction of traumatic orbital floor defects. Donor-site morbidity of autologous transplants and infections or extrusions of nonresorbable implants lead to a widespread use of resorbable, alloplastic materials such as polydioxanone (PDS). The goal of this study was to evaluate the prevalence of orbital floor fracture-related problems after surgical treatment using PDS. Ophthalmologic and clinical examinations were performed at 194 patients before orbital floor reconstruction, 14 days and 6 months after surgery (approximate defect sizes: <1 cm², n=50; 1-2 cm², n=97; >2 cm², n=47). Clinical findings including the ocular motility, the sensibility of the infraorbital nerve, and the position of the globe were evaluated. For statistical analysis of categorical data, confidence intervals of percentages were determined. Linear relationships between 2 variables were assessed with Pearson correlation analysis. A reduced ocular motility was diagnosed in 60 patients (31%) before surgery; in 14 patients (7%), 2 weeks; and in 10 patients (5%), 6 months after surgery. Infraorbital hypesthesia was found in 120 patients (62%) before surgery; in 47 patients (24%), 2 weeks; and in 35 patients (18%), 6 months after surgery. An enophthalmos was present in 10 patients (5%) before surgery, and in 4 patients (2%), 6 months after surgery. Our data suggest that PDS is a suitable implant for orbital floor reconstruction with acceptable low rates of infraorbital hypesthesia, bulbus motility disturbances, and enophthalmos. Polydioxanone can also be used for orbital floor defects exceeding 2 cm².

Fractures of the midface and internal orbit occur isolated or in combination with other injuries. Frequently, the patients are first seen in emergency rooms responsible for the coordination of initial diagnostic procedures, followed by the transfer to specialties for further treatment. It is, therefore, important for all colleagues in traumatology to understand the basic principles of injuries to the midface. Thus, the aim of this article is the description of the anatomy and the current classification systems in use, the related clinical symptoms, and the essential diagnostic measures to obtain precise information about the injury pattern. Issues for treatment will be illustrated and discussed in "Part 2" of this article.

The pediatric craniofacial trauma literature largely focuses on the management of mandible fractures, with very little information focusing on pediatric midface fractures, specifically nasoorbitethmoid (NOE) fractures. Because the diagnosis and surgical treatment plan for adult NOE fractures is well established in the literature, the treatment algorithms for NOE are essentially a transfer of adult practices to pediatric patients. This article reviews the differences between the pediatric and adult facial skeleton and the pathology and presentation of NOE fractures in the pediatric craniomaxillofacial skeleton. It also presents the effects of NOE fractures on the growth and development of the pediatric facial skeleton and describes the current surgical management for NOE fractures.

Purpose: To examine the type of orbital blowout fracture and its variation with race., Design: Retrospective review of computed tomography (CT) scans and demography in an unselected cohort of patients with orbital blowout fractures., Participants: Patients with a high-resolution CT scan of adequate quality for analysis who presented with an orbital blowout fracture to the Orbital Clinic at Moorfields Eye Hospital. Patients with fractures involving the orbital rim or the cranium, or with penetrating injuries of the globe or orbit, were omitted from the study., Methods: Demographic and ethnic information was collected for each patient, and the orbital scans were reviewed by a single observer. On the basis of coronal and axial imaging, a fracture was classified as affecting up to 4 areas: the floor lateral to the infraorbital canal (area 1, "A1"), the floor medial to the canal ("A2"), the maxillo-ethmoidal strut ("inferomedial" strut, "A3"), and the medial wall blowout fracture ("A4"); with fractures involving the inferomedial strut, it was noted whether there was displacement or rotation of the strut. Ethnic origin was classified as Caucasian, Afro-Caribbean, or Asian (Oriental or Indian)., Main Outcome Measures: The proportion of different walls involved in orbital blowout fractures within 3 ethnic groups., Results: A total of 152 patients (125 men, 82%) had imaging adequate for analysis; 103 (68%) were Caucasian, 19 (12%) were Afro-Caribbean, and 30 (20%) were Asian. Caucasians most commonly had floor fractures (A1 or A2 in 56 orbits, 54%) compared with 10 of 103 purely medial fractures (A4, 10%); in contrast, medial fractures were the most common type in Afro-Caribbean patients (7/19 cases, 37%), and purely floor fractures occurred in only 2 cases (10%) (P<0.005). Asian patients had results similar to those for Caucasian patients, with isolated floor fractures being the most common (14/30 cases, 47%)., Conclusions: Most blowout fractures involve the orbital floor in Caucasian and Asians, whereas in Afro-Caribbeans the most common site for fracture is the medial wall., Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article., (Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

The clinical presentation and management of pediatric orbital fractures have many unique features that differentiate them from orbital injuries encountered in the adult population. An understanding of the particular anatomic and mechanical properties of pediatric orbital bone and soft tissue helps to explain most of these differences. This article reviews the epidemiology, anatomy, growth implications, pathomechanics, particular clinical features, assessment, and surgical management of pediatric orbital fractures.

In blow-out fractures, some nonoperative cases have a poor outcome, and a method for accurate prognosis is required. To address this need, we retrospectively reviewed blow-out fractures presenting at Teikyo University Hospital between July 2004 and May 2007 and conducted a survey regarding diplopia and enophthalmos for nonoperative cases. Computed tomographic scan findings were divided according to fracture width and the degree of protrusion of the inferior rectus muscle into the maxillary sinus. We had 106 patients presenting with blow-out fractures, and 89 patients had been treated nonoperatively. In medial orbital wall fractures, no patient had diplopia, and 1 patient had enophthalmos after nonoperative treatment. In punched-out orbital floor fractures, all cases had diplopia when the fracture width was less than half the diameter of the globe, and the protrusion of the inferior rectus muscle into the maxillary sinus was half or more of its section. Even if the fracture width was less than half the diameter of the globe, 2 of 3 patients had enophthalmos when the protrusion of the inferior rectus muscle into the maxillary sinus was half or more of its section. Among the linear orbital floor fractures, 1 case required an emergency operation. We suggest a new algorithm for treatment of blow-out fractures based on computed tomographic scan findings that can also contribute to making a prognosis.

Purpose: We classified the outcomes of non-trapdoor-type blowout fracture repair by surgical indications and then compared the outcomes according to the time of treatment., Methods: The medical records of 591 patients with orbital fractures that were treated surgically within 30 days of trauma were included in the study. The enrolled patients were classified into 2 groups by the major surgical indications: 1 group included patients with diplopia or limited extraocular motion, and the other group of patients had significant enophthalmos (>2 mm) or a large fracture on computed tomography (>½). The clinical outcomes were compared between the patients who received surgical repair within 14 days of trauma (early) and those who received treatment from 15 to 30 days after the trauma (delayed) in each group., Results: Two hundred thirty-three patients received surgical repair because of diplopia or limited extraocular motion. Both the early repaired group (n = 195) and the delayed repaired group (n = 38) showed significant improvement after surgeries. The degree of preoperative and postoperative diplopia and limited extraocular motion was not associated with differences between the 2 groups. Four hundred one patients received surgical repair because of enophthalmos (>2 mm) or a large fracture on computed tomography (>½). Both the early repaired group (n = 328) and the delayed repaired group (n = 73) showed significant improvement of the enophthalmos after surgeries. The degree of preoperative/postoperative enophthalmos did not show differences between the 2 groups., Conclusions: If the blowout fracture repairs were performed within a month, the surgical outcomes did not differ according to the time of surgery in the cases of nontrapdoor blowout fracture.

Background: The term "orbital blow-out fracture" is referred to as the mechanism by which an impact to the eyeball is transposed as a mechanical energy to the orbital walls, causing them to fracture. Despite a proper surgical technique, a successful anatomic reconstruction of the orbit, and an accurate follow-up, 3 complications are still frequently observed at long-term follow-up: diplopia, enophthalmos, and hypesthesia of the infraorbital nerve territory. In this retrospective study, we analyze the incidence, the specific characterization, and the potential risk factors of these 3 complications., Methods: The records of 75 patients who underwent surgical repair of isolated orbital blow-out fracture from January 2001 to December 2007 at the Maxillofacial Surgery Unit of the Novara Major Hospital were reviewed retrospectively. Patients who had other coexisting facial fractures or orbital rim involvement were excluded from this study. The mean follow-up reached 39 months (range, 6-81 months). Enophthalmos was measured by a Hertel exophthalmometer; diplopia was evaluated by an optometrist with cover test, red glass test, and Hess-Lancaster test; and hypesthesia of the infraorbital nerve territory was checked by clinical examination. The studied parameters included patient's age and sex, time interval between trauma and surgery, location of the fracture, and implant material. The χ test for nonparametric data was used, and a P value of less than 0.05 was considered statistically significant., Results: Sex, location of the fracture, and implant material were not considered statistically significant (P > 0.05). The unique variable that influenced our data was the time interval between trauma and surgery (P > 0.05)., Discussion: Although the surgical technique was executed properly and the immediate postoperative recovery was uneventful, diplopia, enophthalmos, and infraorbital nerve dysfunction were the frequent complications. We stress the fact that orbital blow-out fracture is generally not considered a technically demanding procedure, but the outcome can be very disappointing; the surgical procedure must be managed very carefully by experienced surgeons to lower the high rates of these 3 common complications. However, we can report that the incidence of diplopia, enophthalmos, and infraorbital nerve dysfunction are decreased by an immediate intervention and an early surgical repair of the orbital blow-out fracture. Patients who had surgery within 2 weeks of trauma have a lower risk to develop postoperative complications; this study supports an early surgical treatment of orbital blow-out fractures, when it is indicated.

Objective: The objective of the study was to compare the functional and aesthetic results of fractured orbital wall reconstruction with an auricular cartilage graft or absorbable polyacid copolymer., Materials and Methods: Twenty patients with blow-out orbital fracture/orbital floor associated or not with the medial wall were assessed by the same craniofacial surgical group. All were evaluated preoperatively and postoperatively by an ophthalmologist for diplopia, enophthalmos, exophthalmos, sensitivity, ophthalmic reflexes, intraocular pressure, and visual field.The patients were subjected to a preoperative facial multislice computed tomographic scan, repeated 6 months after surgery. Eight patients underwent reconstruction with an auricular cartilage graft, and 12 patients, with blade absorbable polyacid copolymer. Subtarsal access was used for all patients., Results: Two patients showed temporary ectropion, 1 in each group. All patients presented satisfactory ocular function, and all tests revealed good orbital delineation, orbital symmetry, periorbital sinus individualization, and reduction of blow-out., Conclusions: The blow-out orbital wall reconstruction can be performed with the use of an auricular cartilage or with a blade absorbable copolymer without differences regarding functional or aesthetic complications and sequelae.

The study objective was to evaluate the outcome of a periosteal suturing technique in eyes with orbital blowout fractures. Fifteen orbital floor fractures were classified into: type 1, linear fracture; type 2, middle fracture; and type 3, posterior fracture extending two-thirds into the orbit. The feasibility of periosteal suturing without silicone plates or one of minimal size was determined. The improvement of ocular movements and surgical complications were evaluated. A complete suture of the torn periosteum without implanting a silicone plate was achieved in 2/2 (100%) type 1 cases, 5/7 (71%) type 2 cases and 0/6 (0%) type 3 cases. A partial fixation was achieved in 3/6 (50%) type 3 cases with an implantation of a silicone plate of approximate one-third of the usual size in one case. Conventional surgery with silicone plates after failed periosteal suture was required in 2/7 (29%) type 2 cases and 3/6 (50%) type 3 cases. Eye movements were improved postoperatively in all eyes, and a complete range of eye movements was achieved in 6/7 (86%) cases with complete periosteal closure, 1/3 (33%) of cases with partial closure and 2/5 (40%) cases without closure. In conclusion, periosteal suturing can minimize the need for silicone plates especially for anterior or middle orbital floor factures., (© 2010 The Authors. Clinical and Experimental Ophthalmology © 2010 Royal Australian and New Zealand College of Ophthalmologists.)

Purpose: To prospectively evaluate the use of titanium mesh plates in a combined transcaruncular-transconjunctival approach for severe medial orbital wall fractures., Patients and Methods: We analyzed the clinical and radiologic data of 10 patients with isolated blow-out orbital fractures. The fracture location was the medial wall in 5 (50%) and the floor/medial wall in 5 (50%). Of the 10 patients, 8 (80%) were treated using 3-dimensionally preformed orbital titanium mesh plates and 2 (20%) with nonpreformed radial orbital mesh plates fixed at the inferior orbital rim with 1 or 2 monocortical screws (diameter 1.3 mm)., Results: All the patients had satisfactory and anatomically correct orbital wall reconstruction as assessed on the immediate postoperative computed tomography scan. None of the patients experienced ophthalmic complications related to the transcaruncular-transconjunctival approach or developed enophthalmos as determined using Hertel exophthalmometry. One patient (10%) developed a nonhandicapping diplopia related to post-traumatic muscular contusion of the medial rectus muscle., Conclusions: The present study has demonstrated that titanium mesh plates placed using a combined transcaruncular-transconjunctival approach for the reconstruction of severe medial orbital wall fractures results in a high rate of success., (Copyright © 2011 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

One of the concerns after a major trauma to the orbit is to be rebuilt. This can be achieved with care in management of orbital reconstruction, techniques, types of materials, and osseointegrated implants; it allows satisfactory aesthetic recuperation and well-being, whereas psychological therapy allows for patients' reinsertion in social and family environment to make them feel happier and safer.

Much has been written about the repair of orbital fractures, yet some debate still exists among surgeons with regard to indications for and timing of fracture repair and various surgical techniques. Controversies regarding the surgical maneuvers include the incision, surgical approach, and methods of wound closure. More detailed imaging modalities have allowed clinicians to understand the injuries more completely and plan for and execute more ideal reconstructions. Recent advances in orbital implant materials and the role of endoscopy in orbital fracture repair add to this debate about which techniques would be best for particular injuries. This article discusses these issues and provides the most current literature review regarding the management of various orbital fractures., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Background: The orbital blowout fracture is a common facial injury, but full consensus has not been reached regarding its optimal management. The authors retrospectively explored consecutive cases of blowout fractures and proposed new recommendations for treatment., Methods: Two hundred eight newly registered patients were selected from the database of Nagasaki University Hospital over the past 5 years. One hundred nine patients in the authors' department were then reviewed regarding computed tomographic classification of fracture types, preoperative complaints, and outcomes., Results: Of the 208 patients reviewed, 43 underwent surgical repair: 37 for diplopia and 14 for enophthalmos, including eight patients who were treated for both conditions. Regarding floor fractures, the punched-out type fracture was the most common, but the burst type was associated with the highest likelihood of undergoing surgery. For medial wall fractures, the punched-out type dominated, but the overall operative incidence was lower than that observed for the floor fractures. For diplopia, more than half of the operations were performed within 2 weeks, but only two cases were performed within 3 days. For enophthalmos, over 60 percent of operations were carried out after 1 month. Two cases, later discovered to involve muscle strangulation, continued to demonstrate residual diplopia in ordinary use, and two patients continued to show enophthalmos. However, overall outcomes were considered satisfactory., Conclusions: If computed tomographic findings disclose a linear fracture with muscular strangulation, urgent surgery must be performed. However, for linear fractures without impaction of the muscle, or punched-out or burst type fractures, close observation for days may be appropriate. In addition, surgical intervention can be performed electively when diplopia persists for several days of observation.

These clinical studies were carried out in maxillofacial unite, 10th floor, Surgical Specialties Hospital, Medical City, Baghdad. These orbital injuries included 236 patients during 15 years of experience. Their ages ranged from 2 to 72 years (mean, 37 years); 172 were male, and 64 were female. Orbital injuries are classified into isolated orbital walls, roof, floor, lateral wall, and zygoma and medial wall and complex wall injuries, as orbital skeleton injuries, or as part of cranio-orbito-facial injuries. There were 110 cases (46.6%) with orbital floor, and 85 cases (36%) with lateral wall and zygomatic complex injuries; 6 cases (3.6%) had isolated roof injuries; there were 15 cases (6.3%) with medial wall fractures and dislocation of medial canthal ligaments; 8 cases (3.3%) were orbital skeleton injuries with superior orbital fissure syndrome in 2 cases and eyeball laceration in 1 case, and 12 cases (5.08%) were cranio-orbito-facial injuries. These cases were treated and reconstructed by chrome-cobalt mesh for orbital floor, and also, Silastic rubber silicone was used in the floor and roof. Bone graft was used for reconstruction of large defect of the floor and medial wall, and Silastic was used for secondary operation for reconstruction of the floor as additional layer in cases with slight resorption of bone graft to correct residual enophthalmos, and lyophilized dura was used for reconstruction of the roof. Follow-up of the cases was extended for 15 years. The aim of these studies was to show some interesting clinical cases and surgical challenges for the management of these cases.

Fractures of the medial orbital wall can be isolated or associated with other orbital defects arising from maxillofacial fractures. However, a medial orbital wall defect results in a relative increase of the orbital volume. The decision regarding surgical intervention in the management of medial orbital wall fractures is influenced by a variety of factors, including the presence and severity of restricted ocular motility, the degree of enophthalmos, the estimated fracture size, and the clinical judgment of the surgeon; however, untreated medial orbital wall fractures can result in secondary enophthalmos. The aim of this study was to describe our experience with deantigenated swine bone cortex for the reconstruction of the fractured medial orbital wall.

According to the result of retrospective studies for patients who have not taken medical treatment, most patients experience late enophthalmos and perceive their facial asymmetry. Thus, correct diagnosis method and concrete operative indication were required for medial orbital wall fracture. Retrospective investigation on all patients with facial trauma, who had visited the emergency room between January 1, 2000 and December 31, 2006, was made. Height and longitudinal length of the defect were obtained, and computed tomographic scan of the defect area was obtained. The degree of enophthalmos was measured, and investigation on enophthalmos and presence of facial asymmetry perceived by the patients was made. When the defect area of medial orbital wall fracture was 0.55 cm, late enophthalmos of 1 mm occurred, and patients with late enophthalmos of 1 mm or more perceived their enophthalmos and facial asymmetry. In conclusion, medial orbital wall fracture whose defect area is 0.55 cm or more requires operation.

Background: Scarce literature exists addressing the presentation, classification, and management of pediatric orbital fractures. The aim of this study is to review the authors' experience with the presentation, management, and early follow-up of pediatric orbital fractures., Methods: A retrospective review of pediatric orbital fractures presenting to the Children's Hospital of Pittsburgh between 2003 and 2007 was performed. Demographics, associated injuries, computed tomographic scan findings, management, and follow-up were collected. From these data, a pediatric orbital fracture classification system was devised., Results: Seventy-four patients (81 orbits) were reviewed. Average age at presentation was 8.6 years. Fractures were distributed as follows: type 1, 40.7 percent; type 2, 33 percent; and type 3, 25.9 percent. Twenty-three orbits were treated surgically and 58 were treated nonoperatively. The operative rates were as follows: type 1, 9.1 percent; type 2, 14.8 percent; and type 3, 76.2 percent. Complications included minor enophthalmos in seven patients, and persistent cerebrospinal fluid leak in two growing skull fractures. For type 1 (pure orbital) fractures, three (12 percent) underwent surgical treatment for acute enophthalmos, vertical orbital dystopia, or muscle entrapment. Twenty-two orbits (88 percent) were managed nonoperatively. At an average follow-up of 13 months, minimal enophthalmos (1 to 2 mm) was found in one of the surgically treated fractures (33 percent) and in three of the conservatively managed fractures (13.6 percent)., Conclusions: For type 1 (pure orbital) fractures, unless there is evidence of acute enophthalmos, vertical orbital dystopia, or muscle entrapment, a nonoperative approach is advocated. Type 2 (craniofacial) fractures should be followed with serial computed tomographic scans; and type 3 (common fracture patterns) fractures have a greater chance of requiring surgery.

Purpose: To evaluate the incidence of ocular injuries and clinical ocular signs in patients with orbitozygomatic fractures of varying severity, presenting to a regional oral and maxillofacial surgery service., Patients and Methods: This is a retrospective study of patients presenting to Limerick Regional Hospital (Limerick, Ireland) with orbitozygomatic fractures from January 1998 to December 2004. Patients with panfacial fractures and those with isolated zygomatic arch fractures were excluded. All patients were examined by the ophthalmology service preoperatively and reviewed postoperatively as indicated. The study population was divided into 3 subgroups based on the extent of the bony injury (confirmed by clinical, plain radiographic, and CT examination) as follows: group 1: "simple" noncomminuted orbitozygomatic complex fractures; group 2: comminuted orbitozygomatic complex fractures; group 3: "pure" orbital blowout fractures. Patient demographics, fracture etiology, and ocular findings were recorded., Results: The study population included 148 patients (130 males, 18 females). All fractures were unilateral. Ocular findings were present in 29 (20%) patients, consisting of 8 of 85 patients (9%) in group 1; 15 of 53 patients (28%) in group 2; and in 6 of 10 patients (60%) in group 3., Conclusions: Clinical ocular findings and injuries are a relatively common complication of orbitozygomatic fractures, occurring in 29 (20%) patients in this study. These injuries occur more often in patients with orbital blowout fractures compared with comminuted orbitozygomatic complex fractures or simple orbitozygomatic complex fractures. Ophthalmology consultation is recommended for all patients presenting with orbitozygomatic fractures, and is essential for patients with orbital blowout fractures, based on the high incidence of clinical ocular findings and injuries in this subgroup of patients.

This article presents a systematic approach for interpreting a craniofacial CT scan that is clinically useful to the reconstructive surgeon. By categorizing the fracture patterns and highlighting the variables that may affect fracture management, the radiologist can expand his interpretation of the fracture pattern into a clinically useful diagnosis that may affect fracture management.

Objective: To analyze the incidence and pattern of lacrimal pathways obstruction after naso-orbital-ethmoid fractures (NOE), and to investigate the relationship between lacrimal obstruction and fracture types., Methods: One hundred and one patients with NOE fractures were analyzed retrospectively. These patients were treated in the Department of Ophthalmology, Ninth People's Hospital, Medical School of Shanghai Jiao Tong University from January 2000 to January 2005. The fractures were grouped in according to the classification of Markowitz. All of the patients were assessed with syringing and probing or dacryocystography. The incidence of obstruction in different NOE fracture types was analyzed to illustrate the relationship between obstructions and fracture types. The incidence of different obstruction parts of lacrimal system was evaluated to find which part was more vulnerable., Results: In 101 NOE cases, 63 cases were accompanied with lacrimal obstruction. The naso-lacrimal system was more vulnerable in its bony canal than in the lacrimal canalicular. Obstruction was found in the bony nasolacrimal canal in 39 patients (61.90%), and in the lacrimal canaliculus in 12 patients (19.48%). The defect of lacrimal sacs was found in 7 cases (11.11%), and lacrimal punctum was lost in 5 cases (7.94%). Three patterns of fracture were defined according to the Markowitz classification. Sixteen patients were classified into type I; 37 into type II; 48 into type III according to the Markowitz standard. The incidence of obstructions were 25% in type INOE fracture, 54.05%% in type II, 81.25% in type III, respectively., Conclusions: NOE fracture can cause lacrimal obstruction. Naso-lacrimal obstruction is the most common type. The incidence of obstruction changes with the severity of injury and the pattern of fracture.

A clinically applicable, comprehensive reporting system for the diagnosis of facial fractures was developed with three guiding principles: (1) preservation of classical anatomical terminology and nomenclature, (2) facilitation of uniform interpretation of radiographs between radiologists and (3) non-redundant diagnostic descriptions of complex fractures, in a manner that correlates with treatment modality. Twenty-two fracture types (17 simple fracture types and 5 complex fracture types) are included in the system. Each patient's fracture pattern is described by listing the component fractures present. A short narrative (modifying description) is provided after each fracture listed. Simple fractures that help to comprise more complex fractures are not listed separately, but are described within the modifying description of the complex fracture they help to comprise. When components of multiple complex fractures are present, a hierarchy of complex fractures dictates which fracture is described first. Additional complex fractures are only described separately when they do not share common components. In all other cases, the second (lower order) complex fracture is best described by simply listing the component (simple or complex) fractures that are not accounted for in the higher order complex fracture. Adoption of this reporting system should improve communication between emergency medicine physicians, radiologists and surgeons.

Between January 1996 and December 2001, 72 out of 354 patients were included in a retrospective study analysing the outcome of repaired orbital wall defects. Selection was dependent on the availability of pre and postoperative CT scans and on ophthalmologic examination. In particular, orthoptical assessment was performed up to 1 year after operation. In 72 patients, 83 orbital wall defects were analysed and allocated to one of five categories. Accuracy and type of reconstruction were assessed in unilateral orbital wall defects (n=61) and compared with functional outcome. Reconstruction was performed by using PDS membrane (39%), calvarian bone (13%), titanium mesh (7%) or a combination of these materials (37%). Postoperatively, 91% of the patients had normal vision without double images within 20 degrees at every gaze. Accuracy of reconstruction correlated with severity of orbital injury and functional outcome. Functional outcome between category II and III fractures showed no significant difference. The medial margin of the lateral infraorbital fissure being preserved (category II fracture) facilitates reconstruction technically. Accuracy of orbital reconstruction is one important factor to obtain best functional outcome, but other determinants like displacement and/or atrophy of intramuscular cone fat should be considered.

The orbit is located in the middle third of the face, composed of several bones and surrounded by complex anatomic structures so that orbital fractures (OF) often involve other parts of the face. A staging system for classifying OF is of paramount importance in order to exchange information between trauma centers. Several classifications have been proposed for describing OF but they have not a single method applicable to the whole orbit. Here, a classification for OF that can be summarized with four abbreviations is proposed. Four letters define the localization (F = frontal, N = nasal, M = maxillary and Z = zygomatic bone fracture), two acronyms describe fragment shift (in = blow-in or out = blow-out), four numbers define ocular movement impairment (1 = superior, 2 = internal, 3 = inferior, and 4 = external extrinsic muscular deficit) and two acronyms describe eye position (EX = exophthalmos and ENO = enophthalmos). To evaluate the suitability of the proposed classification a retrospective study on a series of 190 OFs is performed. Age, gender, new stage, clinical diagnosis at admission, type of surgery, and need for graft for orbital reconstruction are considered. A good correlation between the proposed classification and the studied variables is detected. In conclusion, the proposed classification is a simply and precise method to stage OF. It can summarize OF and be used in the daily practice. However, it is our belief that a multi-center study should be performed before the effectiveness of the proposed classification can be clearly stated.

Ocular contusions are common and cause significant morbidity. The mechanism of ocular contusion is a decrease in the length of the anterioposterior axis whereas the transversal axis increases. Epidemiology data shows that young men are most injured in relation with sports, aggression, work, or car or work accidents. Injury to the ocular surface (conjunctiva and cornea) is minor. The iris is very frail, usually leading to hyphema which can progress to glaucoma. A cataract can appear after a contusion but usually years after the trauma. Final visual acuity can be compromised by retinal contusion or retinal detachment (due to a retinal dehiscence or post-traumatic dialysis). The worst outcome is optic neuropathy. The most difficult task is to predict visual acuity after the initial ocular lesion.

Unlabelled: Orbital fractures are one of the most frequent consequences following midfacial trauma. If not treated they can lead to serious optical complications as: double vision (diplopia), restriction of ocular motility, eyeball sinking (enophthalmos). Autogenic bone grafts although still wide and effectively used for reconstruction of the fractured orbital walls present some disadvantages. This is morbidity of the donor site, unforeseen resorption, time-consuming procedure and longer postoperative care. Because of that introduction of new materials for orbital reconstruction seems to be desirable. The aim of the work was to evaluate usefulness of the polydioxanone sheets (PDS) as a reconstructive material for orbital floor fractures., Material and Methods: From 1. 09. 2004 to 1. 02. 2006 111 patients with orbital fractures were treated in the Department of Maxillofacial Surgery Klinikum Minden. Age of the patients was between 15- 89 years (mean 43 y.); m:w ratio 78:33. There were 54 isolated orbital floor fractures (in 3 cases with additional medial wall fracture) and 57 zygomatico-orbito-maxillary fractures. The diagnosis was based on the clinical picture and coronal CT scans. The patients were operated through a transconjunctival (72%) or an infraorbital-Mustarde (28%) access and the orbital floor (medial orbital wall) was reconstructed with PDS sheet. Control examination was performed immediately, 1 moth and 6 months after the operative treatment., Results: There were 47% true "blow-out", 34% "trap-door" and 19% "en-clapet" fractures. The most important preoperative symptom was double vision (23%), restriction of ocular motility (18%), enophthalmos (3,6%), impairment of function of the infraorbital nerve (41%). Size of the defect was 3+/-1,13 cm(2) in "blow out" fracture, 1,8 +/-0,9 cm(2) in "trap-door" and 2+/-0,5 cm(2) in ,"en-clapet" ones. The primary reconstruction was successful in 97,3% of the cases. Any inflammation or reaction against implant was noted. Persistent double vision was present in 2,7%, restriction of ocular motility in 1,8% and enophthalmos in 0,9% after the primary procedure. These patients were submitted to reoperation. In 1 case badly positioned PDS sheet causing diplopia was removed. In another one, eyeball movement restriction was due to adhesions between the sheet and periorbital tissue. Visual status of this patient has improved after adhesiolysis. In 1 patient with a large bony destruction reconstruction only with PDS sheet was an inadequate treatment. In 7,2% of patients disturbances in the field of innervation of the infraorbital nerve were present 6 months after the surgery., Conclusions: Alloplastic, resorbable PDS sheets in most cases were a valuable material for the reconstruction of the orbital floor (medial orbital wall). Mechanical properties of PDS seem to be not sufficient for the reconstruction of extremely large bony defects. In these cases use of autogenic bone grafts or a titanium mesh should be rather considered.