An anomalous case of an indirect orbital floor fracture
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Please cite this article in press as: Nicolotti M, et al. An anomalous case of an indirect orbital floor fracture. Br J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.bjoms.2014.03.004 ARTICLE IN PRESS YBJOM-4215; No. of Pages 3 British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx.e1–xxx.e3 Available online at www.sciencedirect.com Short communication An anomalous case of an indirect orbital floor fracture Matteo Nicolotti ∗,1 , Giuseppe Poglio, Fabrizio Grivetto, Arnaldo Benech S.C.D.U. Chirurgia Maxillo-Facciale, A.O.U. Maggiore della Carità di Novara, Università degli studi del Piemonte Orientale “Amedeo Avogadro”, Reparto di Chirurgia Maxillo-Facciale, C.so Mazzini 18, 28100 Novara, NO, Italy Accepted 6 March 2014 Abstract Fractures of the orbital floor are common in facial trauma. Those that comprise only the orbital floor are called indirect fractures or pure internal orbital floor fractures. We present the case of an indirect fracture of the orbital floor after direct trauma to the back of the head caused by a bicycle accident. To the best of our knowledge this is the first time that this mechanism for such a fracture has been reported. © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Indirect orbital fracture; Blowout fracture Introduction Fractures of the orbital floor alone are called indirect fractures of the orbital floor or pure internal fractures of the orbital floor. These differ from those that involve the orbital rim and are caused by direct trauma. 1 Among all maxillofacial fractures, the incidence of orbital fractures is reported to be about 57% and the incidence of isolated fractures of the orbital floor about 21%. 2 We present the case of an indirect fracture of the orbital floor diagnosed after a cycling accident and direct blow to the back of the head. Case report A 37-year-old white woman presented after a cycling acci- dent. She had fallen and hit her right occipital area and had not lost consciousness. The cerebral computed tomography (CT) scan showed a linear fracture of the right side of the occipital bone and a small extradural haematoma (Fig. 1). ∗ Corresponding author. Tel.: +39 3393863951; fax: +39 03213733894. E-mail address: [email protected] (M. Nicolotti). 1 Resident Maxillofacial Surgeon. She reported vertical diplopia despite the absence of any sign of facial trauma, periorbital swelling, or haematoma. She had no abrasions of the eyelid or lacerations. There was only minimal left enophthalmos (Fig. 2). Later CT of the orbits showed a blow-out fracture of the left orbital floor with entrapment of the inferior rectus muscle. The orbital rim was intact. The orthoptic evaluation confirmed that the left globe was raised and Hertel exophthal- mometry values (left eye 13 mm; right eye 17 mm) showed left enophthalmos (Fig. 3). After routine medical examination we repaired the frac- ture through a transconjunctival approach to the orbital floor, using resorbable bovine pericardium membrane (Tutopatch ® ). The patient was discharged the day after oper- ation and at repeated orthoptic examination one month later the left ocular globe was in its normal position and the Herthel exophthalmometry values were 16 mm on the left and 17 mm on the right. Discussion The mechanism involved in indirect blowout has been investi- gated by several authors, and 2 theories have been postulated. http://dx.doi.org/10.1016/j.bjoms.2014.03.004 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Transcript of An anomalous case of an indirect orbital floor fracture
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ARTICLE IN PRESSBJOM-4215; No. of Pages 3
British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx.e1–xxx.e3
Available online at www.sciencedirect.com
hort communication
n anomalous case of an indirect orbital floor fractureatteo Nicolotti ∗,1, Giuseppe Poglio, Fabrizio Grivetto, Arnaldo Benech
.C.D.U. Chirurgia Maxillo-Facciale, A.O.U. Maggiore della Carità di Novara, Università degli studi del Piemonte Orientale “Amedeo Avogadro”,eparto di Chirurgia Maxillo-Facciale, C.so Mazzini 18, 28100 Novara, NO, Italy
ccepted 6 March 2014
bstract
ractures of the orbital floor are common in facial trauma. Those that comprise only the orbital floor are called indirect fractures or purenternal orbital floor fractures.
We present the case of an indirect fracture of the orbital floor after direct trauma to the back of the head caused by a bicycle accident. Tohe best of our knowledge this is the first time that this mechanism for such a fracture has been reported.
2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
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eywords: Indirect orbital fracture; Blowout fracture
ntroduction
ractures of the orbital floor alone are called indirectractures of the orbital floor or pure internal fractures ofhe orbital floor. These differ from those that involve therbital rim and are caused by direct trauma.1 Among allaxillofacial fractures, the incidence of orbital fractures
s reported to be about 57% and the incidence of isolatedractures of the orbital floor about 21%.2
We present the case of an indirect fracture of the orbitaloor diagnosed after a cycling accident and direct blow to
he back of the head.
ase report
37-year-old white woman presented after a cycling acci-ent. She had fallen and hit her right occipital area and had
Please cite this article in press as: Nicolotti M, et al. An anomalous cas(2014), http://dx.doi.org/10.1016/j.bjoms.2014.03.004
ot lost consciousness. The cerebral computed tomographyCT) scan showed a linear fracture of the right side of theccipital bone and a small extradural haematoma (Fig. 1).
∗ Corresponding author. Tel.: +39 3393863951; fax: +39 03213733894.E-mail address: [email protected] (M. Nicolotti).
1 Resident Maxillofacial Surgeon.
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ttp://dx.doi.org/10.1016/j.bjoms.2014.03.004266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Pu
She reported vertical diplopia despite the absence of anyign of facial trauma, periorbital swelling, or haematoma. Shead no abrasions of the eyelid or lacerations. There was onlyinimal left enophthalmos (Fig. 2).Later CT of the orbits showed a blow-out fracture of
he left orbital floor with entrapment of the inferior rectususcle. The orbital rim was intact. The orthoptic evaluation
onfirmed that the left globe was raised and Hertel exophthal-ometry values (left eye 13 mm; right eye 17 mm) showed
eft enophthalmos (Fig. 3).After routine medical examination we repaired the frac-
ure through a transconjunctival approach to the orbitaloor, using resorbable bovine pericardium membraneTutopatch®). The patient was discharged the day after oper-tion and at repeated orthoptic examination one month laterhe left ocular globe was in its normal position and the Herthelxophthalmometry values were 16 mm on the left and 17 mmn the right.
e of an indirect orbital floor fracture. Br J Oral Maxillofac Surg
iscussion
he mechanism involved in indirect blowout has been investi-ated by several authors, and 2 theories have been postulated.
blished by Elsevier Ltd. All rights reserved.
ARTICLE IN PRESSYBJOM-4215; No. of Pages 3
xxx.e2 M. Nicolotti et al. / British Journal of Oral and Maxillofacial Surgery xxx (2014) xxx.e1–xxx.e3
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Fig. 3. Coronal computed tomographic slice. Evidence of a blowout fractureof the orbital floor and entrapment of the inferior rectus muscle.
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ig. 1. Axial computed tomographic slice. (A) Blowout fracture of therbital floor. The rim is intact. (B) Composite fracture of the occipital bone.
mith and Regan proposed the so called “hydraulic theory”y which the compression of the eyeball by an external forcencreases the hydraulic pressure and applies a force to therbital floor which, if sufficient, results in a fracture.3 Thebuckling theory”, described by Fujino, postulated that forcespplied to the inferior orbital rim are transmitted posteriorlyhrough the thin orbital floor and may result in a buckling
Please cite this article in press as: Nicolotti M, et al. An anomalous cas(2014), http://dx.doi.org/10.1016/j.bjoms.2014.03.004
f bone and so produce an indirect fracture of the orbitaloor.4 Both these mechanisms have been supported by vari-
ig. 2. Left profile showing no periorbital swelling or haematoma, but theres evidence of enophthalmos. The horizontal line A indicates the normalrotrusion of the eyeball measured on the right eye; the horizontal line Bndicates the difference between the normal protrusion and the enophthalmicyeball (published with the permission of the patient).
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us clinical and experimental studies conducted on dry skulls,adavers, and animals.
After a review of papers published on the subject, weound just one that analysed the direction of the striking force.agasao et al.5 studied the effect of the angle of strike on theuckling mechanism in blowout fractures, and stated that theheoretical width of the fracture was the greatest when thetriking angle was 30◦, followed by 15◦ and 0◦. We found noapers that described the mode of injury seen in our case.
We think that the forces applied by the trauma were trans-itted to the orbital floor, and resulted in its fracture as in
he “buckling mechanism” described.4 The difference is thathe trauma was directed at the back of the head and not athe orbital rim. Not only the fracture is indirect, but also therauma.
thics statement
he patient has given her consent to the publication of per-onal data and photos necessary to complete this study.
uthors’ contributions
r. Matteo Nicolotti and Dr. Giuseppe Poglio contributed to
e of an indirect orbital floor fracture. Br J Oral Maxillofac Surg
he conception and design of study, review and case series.r. Giuseppe Poglio and Dr. Fabrizio Grivetto performed the
cquisition of data: laboratory or clinical/literature search.rof. Arnaldo Benech and Dr. Matteo Nicolotti provided thenal approval and were the guarantors of the manuscript.
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Please cite this article in press as: Nicolotti M, et al. An anomalous cas(2014), http://dx.doi.org/10.1016/j.bjoms.2014.03.004
analysis. Middle East Afr J Ophthalmol 2010;17:138–41.. Scherer M, Sullivan WG, Smith Jr DJ, Phillips LG, Robson MC. An anal-
ysis of 1423 facial fractures in 788 patients at an urban trauma center. JTrauma 1989;29:388–90.
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illofacial Surgery xxx (2014) xxx.e1–xxx.e3 xxx.e3
. Smith B, Regan Jr WF. Blowout fracture of the orbit; mechanism andcorrection of internal orbital fracture. Am J Ophthalmol 1957;44:733–9.
. Fujino T. Experimental fracture of the orbit. Plast Reconstr Surg blowout
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1974;(54):81–2.. Nagasao T, Miyamoto J, Nagasao M, et al. The effect of striking angle
on the buckling mechanism in blowout fracture. Plast Reconstr Surg2006;117:2373–80.
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