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An unusual case of medial orbital blowout fracture caused by a headlock
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e291ee293
CASE REPORT
An unusual case of medial orbital blowout fracture caused by a headlock Jung Hoon Lee* Department of Plastic and Reconstructive Surgery, Kosin University Gospel Hospital, 34, Amnam-dong, Seo-gu, Busan 602-702, Republic of Korea Received 30 May 2007; accepted 5 September 2007
KEYWORDS Blowout fracture; Headlock; Hydraulic theory
Summary The mechanism of orbital blowout fractures has been proposed in three different theories: the globe-to-wall theory, the hydraulic theory, and the bone conduction theory. However, it is very difficult to identify which mechanism applies in each clinical case from either a history or a physical examination. This report presents an unusual case of an orbital blowout fracture produced by a headlock in a 16-year-old male, which supports the hydraulic theory. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The term ‘blowout fracture’ of the orbit was first introduced in 1957 by Converse et al.,1 and refers to an orbital wall fracture with no associated fracture of the orbital rim. It is often accompanied by herniation of the orbit soft tissue structure. The common sites of occurrence are the posterior orbital floor medial to the infraorbital groove and the lamina papyracea. This fracture is usually produced by the application of a blunt intensive force in the orbital region. Three different theories have been proposed to explain the mechanism of blowout fractures: the globe-to-wall contact theory, the hydraulic theory, and the bone conduction theory. However, its mechanism is still controversial and has not been precisely identified clinically in most cases of blowout fracture. This report illustrates an unusual case of blowout fracture caused by a headlock, which supports the pure hydraulic theory. * Tel.: þ82 51 990 6710; fax: þ82 51 990 6711. E-mail address: [email protected]
Case report A 16-year-old male presented at our hospital complaining of eyeball pain and dizziness. His history revealed that the face of the patient had been headlocked firmly and tightly around the orbital region by his friend’s arms during a break at school. As the force of the headlock gradually increased in the left orbital region, the patient started to feel pain in his left eyeball caused by the compression. He then heard a sudden popping sound from the orbital cavity. Ecchymosis was found in the left medial epicanthal area and epistaxis was also observed at that site. The patient had difficulty moving his left eyeball laterally because of the pain, but showed no significant diplopia or visual disturbance. A facial computed tomography (CT) scan revealed a blowout fracture of the medial wall of the left orbit with herniation of the orbital soft tissue into the ethmoid sinus (Figure 1). No entrapment of the medial rectus muscle was evident
1748-6815/$ - see front matter ª2008British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.09.048
e292
J.H. Lee
Figure 1 Coronal CT scan showing a blowout fracture of the left medial orbital wall.
on the CT images. The medial orbital wall was repaired with a transcaruncular approach to release the herniated soft tissue because his symptoms had not improved after 2 weeks.
Discussion The mechanism of blowout fractures has been discussed by a number of authors. The three previously proposed mechanisms are: (1) the globe-to-wall contact theory; (2) the hydraulic theory; and (3) the bone conduction theory. Pfeiffer2 reported 24 cases of internal fracture of the orbit causing enophthalmos, and suggested that the force of the blow received by the eyeball was transmitted by it to the walls of the orbit, with fracture of the more delicate portions. This globe-to-wall contact theory has been superseded by other theories. However, this theory was highlighted again by Erling et al.,3 who investigated CT scans of blowout fractures of the medial orbital wall. They demonstrated that the size of the orbital wall displacement exactly fitted the globe in many cases.
Table 1
Smith et al.4 defined the term ‘orbital blowout fracture’ as a fracture of the orbital floor caused by a sudden increase in intraorbital pressure, and described experimental evidence for the mechanism of such fractures. They consider that objects with a diameter larger than that of the bony orbit, such as a baseball, fail to rupture the globe because part of the force is absorbed by the orbital rim. When the force is not great enough to fracture the heavy orbital rim, the soft tissues pressed into the orbital cavity penetrate the fragile orbital floor. The fluid malleability of the contents of the globe helps to prevent the rupture of the globe. Jones et al.5 investigated this mechanism with a quantitative analysis of the orbital anatomy. The hydraulic theory was the mainstream interpretation of the mechanism of blowout fractures until the bone conduction theory was proposed. Fujino6 investigated the bone conduction theory experimentally. In that study, weights were dropped from a fixed height onto the infraorbital margin of a dried human skull. The punched out fractures that resulted suggested that the increased hydraulic pressure from the orbital contents against the orbital floor was not essential for the development of an orbital blowout fracture. Fujino demonstrated that a direct compression force or buckling force was the causative factor in that experiment. Waterhouse et al.7 have produced one of the most elegant studies, which was the first to compare the two mechanisms of force transmission and hydraulic force under identical experimental conditions. They quantified the striking force, using unfixed intact human cadaver orbits, and quantified the restoration of the intraocular pressure. They found that a force applied to the orbital rim produced a small fracture confined to the anterior to mid medial floor of the orbit, whereas a force applied to the globe produced a large fracture, always involving the floor and medial orbital wall, in which herniation of the orbital contents was frequent. Burm et al.8 reviewed 82 cases of pure orbital blowout fracture and suggested that the force causing the nasal fracture, as the buckling force from the medial orbital rim, was a very important causative factor in pure medial wall fractures. In most cases, more than one mechanism may act simultaneously in blowout fractures. Even if a blowout fracture is caused by a single mechanism, it is very difficult to identify which mechanism has been involved in each clinical case by taking a history or physical examination of the patient. This may be a reason why there are not many reported clinical cases of blowout fractures based on the pure hydraulic theory, although several experimental
Unusual cases of blowout fracture caused by increased hydraulic pressure
Cases
Agea/Sex
Etiological factor
Orbital fracture site
References
1 2 3 4 5 6 7
19 16 70 29 32 32 16
High diving High diving Nose blowing High diving Nose blowing Bombing Headlock
Floor, left Floor, left Floor, right Floor, right Medial wall, right Floor, bilateral Medial wall, left
Wright et al.9 Rubinstein et al.10 Oluwole et al.12 Richard et al.11 Suzuki et al.13 Agir et al.14 Present case
a
Age in years.
M M F M F F M
Blowout fracture caused by a headlock studies supporting the theory have been published. Wright et al.,9 Rubinstein et al.,10 and Richard et al.11 have presented cases of blowout fracture caused by hydrostatic pressure during high diving. Oluwole et al.12 and Suzuki et al.13 have reported cases of blowout fractures caused by barotrauma after nose blowing. Agir et al.14 described a case of bilateral orbital blowout fractures caused by the direct blast effect of a bomb. These unusual cases represent some of the few clinical cases that strongly support the hydraulic theory among the three theories of orbital blowout fractures (Table 1). The present case was a medial blowout fracture in a 16year-old male who felt an increased intraorbital pressure after being caught in a headlock around his orbital region. This caused him pain in his eyeball and produced a popping sound, suggesting a fracture of the bone in the orbit. This case indicates that an orbital blowout fracture may be caused by independently increased pressure on the orbital cavity. We believe that compression applied to the globe by the headlock itself caused the medial orbital blowout fracture by applying a hydraulic force to the orbital cavity. This unusual case of medial blowout fracture caused by a headlock supports the validity of the hydraulic theory.
References 1. Converse JM, Smith B. Enophthalmos and diplopia in fractures of the orbital floor. Br J Plast Surg 1957;9:265e74. 2. Pfeiffer RL. Traumatic enophthalmos. Arch Ophthalmol 1943; 30:718e26.
e293 3. Erling BF, Iliff N, Robertson B, et al. Footprints of the globe: a practical look at the mechanism of orbital blowout fractures, with a revisit to the work of Raymond Pfeiffer. Plast Reconstr Surg 1999;103:1313e6. 4. Smith B, Regan Jr WF. Blow-out fracture of the orbit: mechanism and correction of internal orbital fracture. Am J Ophthalmol 1957;44:733e9. 5. Jones DEP, Evans JNG. ‘‘Blow-out’’ fractures of the orbit: an investigation into their anatomical basis. J Laryngol Otol 1967;81:1109e20. 6. Fujino T. Experimental ‘‘blowout’’ fracture of the orbit. Plast Reconstr Surg 1974;54:81e2. 7. Waterhouse N, Lyne J, Urdang M, et al. An investigation into the mechanism of orbital blowout fractures. Br J Plast Surg 1999;52:607e12. 8. Burm JS, Chung CH, Oh SJ. Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture. Plast Reconstr Surg 1999;103:1839e49. 9. Wright H, Bowen Jr SF, Morgan SS. Orbital blowout fracture due to a diving accident: case report. Mo Med 1979;76:487e8. 10. Rubinstein C, Ferguson A, Brown P. Orbital blowout fracture from hydrostatic pressure. Aust N Z J Surg 1991;61:792e4. 11. Richard L, Bouletreau P, Cantaloube D. An unusual fracture of the orbital floor. Rev Stomatol Chir Maxillofac 1999;100: 315e8. 12. Oluwole M, White P. Orbital floor fracture following nose blowing. Ear Nose Throat J 1996;75:169e70. 13. Suzuki H, Furukawa M, Takahashi E, et al. Barotraumatic blowout fracture of the orbit. Auris Nasus Larynx 2001;28: 257e9. 14. Agir H, Ustundag E, Iscen D. Bilateral isolated blowout fractures among terrorist bombing victims: a very rare entity. J Plast Reconstr Aesthet Surg 2006;59:306e7.
CASE REPORT
An unusual case of medial orbital blowout fracture caused by a headlock Jung Hoon Lee* Department of Plastic and Reconstructive Surgery, Kosin University Gospel Hospital, 34, Amnam-dong, Seo-gu, Busan 602-702, Republic of Korea Received 30 May 2007; accepted 5 September 2007
KEYWORDS Blowout fracture; Headlock; Hydraulic theory
Summary The mechanism of orbital blowout fractures has been proposed in three different theories: the globe-to-wall theory, the hydraulic theory, and the bone conduction theory. However, it is very difficult to identify which mechanism applies in each clinical case from either a history or a physical examination. This report presents an unusual case of an orbital blowout fracture produced by a headlock in a 16-year-old male, which supports the hydraulic theory. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
The term ‘blowout fracture’ of the orbit was first introduced in 1957 by Converse et al.,1 and refers to an orbital wall fracture with no associated fracture of the orbital rim. It is often accompanied by herniation of the orbit soft tissue structure. The common sites of occurrence are the posterior orbital floor medial to the infraorbital groove and the lamina papyracea. This fracture is usually produced by the application of a blunt intensive force in the orbital region. Three different theories have been proposed to explain the mechanism of blowout fractures: the globe-to-wall contact theory, the hydraulic theory, and the bone conduction theory. However, its mechanism is still controversial and has not been precisely identified clinically in most cases of blowout fracture. This report illustrates an unusual case of blowout fracture caused by a headlock, which supports the pure hydraulic theory. * Tel.: þ82 51 990 6710; fax: þ82 51 990 6711. E-mail address: [email protected]
Case report A 16-year-old male presented at our hospital complaining of eyeball pain and dizziness. His history revealed that the face of the patient had been headlocked firmly and tightly around the orbital region by his friend’s arms during a break at school. As the force of the headlock gradually increased in the left orbital region, the patient started to feel pain in his left eyeball caused by the compression. He then heard a sudden popping sound from the orbital cavity. Ecchymosis was found in the left medial epicanthal area and epistaxis was also observed at that site. The patient had difficulty moving his left eyeball laterally because of the pain, but showed no significant diplopia or visual disturbance. A facial computed tomography (CT) scan revealed a blowout fracture of the medial wall of the left orbit with herniation of the orbital soft tissue into the ethmoid sinus (Figure 1). No entrapment of the medial rectus muscle was evident
1748-6815/$ - see front matter ª2008British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.09.048
e292
J.H. Lee
Figure 1 Coronal CT scan showing a blowout fracture of the left medial orbital wall.
on the CT images. The medial orbital wall was repaired with a transcaruncular approach to release the herniated soft tissue because his symptoms had not improved after 2 weeks.
Discussion The mechanism of blowout fractures has been discussed by a number of authors. The three previously proposed mechanisms are: (1) the globe-to-wall contact theory; (2) the hydraulic theory; and (3) the bone conduction theory. Pfeiffer2 reported 24 cases of internal fracture of the orbit causing enophthalmos, and suggested that the force of the blow received by the eyeball was transmitted by it to the walls of the orbit, with fracture of the more delicate portions. This globe-to-wall contact theory has been superseded by other theories. However, this theory was highlighted again by Erling et al.,3 who investigated CT scans of blowout fractures of the medial orbital wall. They demonstrated that the size of the orbital wall displacement exactly fitted the globe in many cases.
Table 1
Smith et al.4 defined the term ‘orbital blowout fracture’ as a fracture of the orbital floor caused by a sudden increase in intraorbital pressure, and described experimental evidence for the mechanism of such fractures. They consider that objects with a diameter larger than that of the bony orbit, such as a baseball, fail to rupture the globe because part of the force is absorbed by the orbital rim. When the force is not great enough to fracture the heavy orbital rim, the soft tissues pressed into the orbital cavity penetrate the fragile orbital floor. The fluid malleability of the contents of the globe helps to prevent the rupture of the globe. Jones et al.5 investigated this mechanism with a quantitative analysis of the orbital anatomy. The hydraulic theory was the mainstream interpretation of the mechanism of blowout fractures until the bone conduction theory was proposed. Fujino6 investigated the bone conduction theory experimentally. In that study, weights were dropped from a fixed height onto the infraorbital margin of a dried human skull. The punched out fractures that resulted suggested that the increased hydraulic pressure from the orbital contents against the orbital floor was not essential for the development of an orbital blowout fracture. Fujino demonstrated that a direct compression force or buckling force was the causative factor in that experiment. Waterhouse et al.7 have produced one of the most elegant studies, which was the first to compare the two mechanisms of force transmission and hydraulic force under identical experimental conditions. They quantified the striking force, using unfixed intact human cadaver orbits, and quantified the restoration of the intraocular pressure. They found that a force applied to the orbital rim produced a small fracture confined to the anterior to mid medial floor of the orbit, whereas a force applied to the globe produced a large fracture, always involving the floor and medial orbital wall, in which herniation of the orbital contents was frequent. Burm et al.8 reviewed 82 cases of pure orbital blowout fracture and suggested that the force causing the nasal fracture, as the buckling force from the medial orbital rim, was a very important causative factor in pure medial wall fractures. In most cases, more than one mechanism may act simultaneously in blowout fractures. Even if a blowout fracture is caused by a single mechanism, it is very difficult to identify which mechanism has been involved in each clinical case by taking a history or physical examination of the patient. This may be a reason why there are not many reported clinical cases of blowout fractures based on the pure hydraulic theory, although several experimental
Unusual cases of blowout fracture caused by increased hydraulic pressure
Cases
Agea/Sex
Etiological factor
Orbital fracture site
References
1 2 3 4 5 6 7
19 16 70 29 32 32 16
High diving High diving Nose blowing High diving Nose blowing Bombing Headlock
Floor, left Floor, left Floor, right Floor, right Medial wall, right Floor, bilateral Medial wall, left
Wright et al.9 Rubinstein et al.10 Oluwole et al.12 Richard et al.11 Suzuki et al.13 Agir et al.14 Present case
a
Age in years.
M M F M F F M
Blowout fracture caused by a headlock studies supporting the theory have been published. Wright et al.,9 Rubinstein et al.,10 and Richard et al.11 have presented cases of blowout fracture caused by hydrostatic pressure during high diving. Oluwole et al.12 and Suzuki et al.13 have reported cases of blowout fractures caused by barotrauma after nose blowing. Agir et al.14 described a case of bilateral orbital blowout fractures caused by the direct blast effect of a bomb. These unusual cases represent some of the few clinical cases that strongly support the hydraulic theory among the three theories of orbital blowout fractures (Table 1). The present case was a medial blowout fracture in a 16year-old male who felt an increased intraorbital pressure after being caught in a headlock around his orbital region. This caused him pain in his eyeball and produced a popping sound, suggesting a fracture of the bone in the orbit. This case indicates that an orbital blowout fracture may be caused by independently increased pressure on the orbital cavity. We believe that compression applied to the globe by the headlock itself caused the medial orbital blowout fracture by applying a hydraulic force to the orbital cavity. This unusual case of medial blowout fracture caused by a headlock supports the validity of the hydraulic theory.
References 1. Converse JM, Smith B. Enophthalmos and diplopia in fractures of the orbital floor. Br J Plast Surg 1957;9:265e74. 2. Pfeiffer RL. Traumatic enophthalmos. Arch Ophthalmol 1943; 30:718e26.
e293 3. Erling BF, Iliff N, Robertson B, et al. Footprints of the globe: a practical look at the mechanism of orbital blowout fractures, with a revisit to the work of Raymond Pfeiffer. Plast Reconstr Surg 1999;103:1313e6. 4. Smith B, Regan Jr WF. Blow-out fracture of the orbit: mechanism and correction of internal orbital fracture. Am J Ophthalmol 1957;44:733e9. 5. Jones DEP, Evans JNG. ‘‘Blow-out’’ fractures of the orbit: an investigation into their anatomical basis. J Laryngol Otol 1967;81:1109e20. 6. Fujino T. Experimental ‘‘blowout’’ fracture of the orbit. Plast Reconstr Surg 1974;54:81e2. 7. Waterhouse N, Lyne J, Urdang M, et al. An investigation into the mechanism of orbital blowout fractures. Br J Plast Surg 1999;52:607e12. 8. Burm JS, Chung CH, Oh SJ. Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture. Plast Reconstr Surg 1999;103:1839e49. 9. Wright H, Bowen Jr SF, Morgan SS. Orbital blowout fracture due to a diving accident: case report. Mo Med 1979;76:487e8. 10. Rubinstein C, Ferguson A, Brown P. Orbital blowout fracture from hydrostatic pressure. Aust N Z J Surg 1991;61:792e4. 11. Richard L, Bouletreau P, Cantaloube D. An unusual fracture of the orbital floor. Rev Stomatol Chir Maxillofac 1999;100: 315e8. 12. Oluwole M, White P. Orbital floor fracture following nose blowing. Ear Nose Throat J 1996;75:169e70. 13. Suzuki H, Furukawa M, Takahashi E, et al. Barotraumatic blowout fracture of the orbit. Auris Nasus Larynx 2001;28: 257e9. 14. Agir H, Ustundag E, Iscen D. Bilateral isolated blowout fractures among terrorist bombing victims: a very rare entity. J Plast Reconstr Aesthet Surg 2006;59:306e7.