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An unusual maxillo-facial injury
AN UNUSUAL
MAXILLO-FACIAL
INJURY
By W. SIMPSON,B.D.S., F.D.S.
Senior Registrar, Maxillo-faeial and Oral Surgery Unit, Withington Hospital, Manchester Case R e p o r t . - - T h e patient, a young boy of 14 years, was referred to this unit because of diplopia, thought to be due to a fracture of the left malar bone. He gave a history of a blow on the eye three weeks previously when he attended the Casualty
Radiograph showing prolapse of the left orbital contents into the left maxillary sinus, Department of another hospital and was allowed to return home after clinical and radiological examinations. Some time later the boy complained of diplopia and returned to the hospital, when he was then referred to this department with a possible diagnosis of a fractured left malar bone. The ophthalmic report indicated that the patient had limitation of downward movement of the left eye especially to the temporal side and diplopia in the upper and lower fields of vision becoming less. The extent of the diplopia was not stated. Examination revealed a healthy boy with no relevant medical history apart from his complaint of diplopia. None of the classical signs of a fractured zygoma, as described by Rowe and Killey (I955), were present apart from his persistent diplopia, already mentioned. At his original examination, three weeks previously, however, he had shown circumorbital and subconjunctival ecchymosis. Radiographs revealed no fracture of the left malar bone, but there was some opacity of the left maxillary sinus, involving the superior part of the sinus (see illus.). From the clinical and radiological examinations it was postulated that the blow on the left eye had raised the intra-orbital pressure and subsequently fractured the thin orbital floor with the resultant prolapse of the orbital contents into the maxillary sinus. It was felt that no operative treatment by way of elevation of the zygoma was indicated, although a bone graft to the orbital floor was considered. In view of the time lapse, however, it was decided to 283
284
BRITISH JOURNAL OF PLASTIC SURGERY
see if the diplopia would improve without resorting to surgery, and as the condition has shown considerable improvement in the last six months no operative treatment is contemplated at present. DISCUSSION Perusal of the literature revealed a great deal of writing on fractures of the malar bones, but very little on fractures of the orbital floor without a combined fracture of the malar bone. Smith and Converse (196o) report fourteen cases and review the literature and treatment of such cases. They consider that the weakest part of the orbital floor is the area just anterior to the inferior orbital fissure, and they substantiate their statement by discussing the experimental work on cadavers by Smith and Regan (1957) who held a hurling ball against the eye and hit the ball with a hammer, with a resultant fracture of the orbital floor just anterior to the inferior orbital fissure. They consider that a blow on the eye is capable of increasing intra-orbital pressure sufficiently to cause such a fracture and have called these injuries " b l o w outs." It would appear that the globe is in fact pushed backwards and downwards, and that the suspensory ligament is stretched to allow this movement. Apart from the actual prolapse of the orbital contents, it is suggested that hmmatoma in the inferior rectus and inferior obliquus muscles may be to some extent responsible for the diplopia. A further complication is that the lower division of the 3rd cranial nerve may be damaged or at least trapped in the fracture of the orbital floor. The treatment suggested by Smith and Converse is to elevate the orbital contents into their correct position by means of a bone graft from the iliac crest to the orbital floor. The bone may be inserted by a Caldwell-Luc approach or an infra-orbital exposure, but the writers suggest a combined Caldwell-Luc and infraorbital exposure. It may be that other materials can be used to reposition the orbital contents, including acrylic and polythene sheeting. The latter would certainly be very much finer than acrylic or bone and therefore less likely to over-correct the orbital contents, but its strength and durability are likely to be less. Acrylic, although stronger, would appear to be as bulky as a bone graft and yet offer none of the advantages of bone. Smith and Regan, discussing this matter, feel that an autogenous bone graft is superior to any other material, and if successful will become consolidated. They do stipulate, however, that treatment must not be long delayed and in the fourteen cases recorded the longest time before operation was twelve days. SUMMARY An unusual fracture of the orbital floor without involvement of the infraorbital ridge is recorded and discussed. M y thanks are due to M r A . Vd. Moule for permission to publish this case.
REFERENCES RowE, N., and KILLEY,H. (1955). " Fractures of the Facial Skeleton." Edinburgh: E. & S. Livingstone. SMITH,B~ and CONVERSE,J. (196o). Trans. int. Soc. plast. Surg., Second Congress, 1959, P. 28o. Edinburgh : E. & S. Livingstone. SMITH, B, and REGAN,J. (1957). Amer. ft. Ophthal., 44, 733. Submitted for publication,May I964.
MAXILLO-FACIAL
INJURY
By W. SIMPSON,B.D.S., F.D.S.
Senior Registrar, Maxillo-faeial and Oral Surgery Unit, Withington Hospital, Manchester Case R e p o r t . - - T h e patient, a young boy of 14 years, was referred to this unit because of diplopia, thought to be due to a fracture of the left malar bone. He gave a history of a blow on the eye three weeks previously when he attended the Casualty
Radiograph showing prolapse of the left orbital contents into the left maxillary sinus, Department of another hospital and was allowed to return home after clinical and radiological examinations. Some time later the boy complained of diplopia and returned to the hospital, when he was then referred to this department with a possible diagnosis of a fractured left malar bone. The ophthalmic report indicated that the patient had limitation of downward movement of the left eye especially to the temporal side and diplopia in the upper and lower fields of vision becoming less. The extent of the diplopia was not stated. Examination revealed a healthy boy with no relevant medical history apart from his complaint of diplopia. None of the classical signs of a fractured zygoma, as described by Rowe and Killey (I955), were present apart from his persistent diplopia, already mentioned. At his original examination, three weeks previously, however, he had shown circumorbital and subconjunctival ecchymosis. Radiographs revealed no fracture of the left malar bone, but there was some opacity of the left maxillary sinus, involving the superior part of the sinus (see illus.). From the clinical and radiological examinations it was postulated that the blow on the left eye had raised the intra-orbital pressure and subsequently fractured the thin orbital floor with the resultant prolapse of the orbital contents into the maxillary sinus. It was felt that no operative treatment by way of elevation of the zygoma was indicated, although a bone graft to the orbital floor was considered. In view of the time lapse, however, it was decided to 283
284
BRITISH JOURNAL OF PLASTIC SURGERY
see if the diplopia would improve without resorting to surgery, and as the condition has shown considerable improvement in the last six months no operative treatment is contemplated at present. DISCUSSION Perusal of the literature revealed a great deal of writing on fractures of the malar bones, but very little on fractures of the orbital floor without a combined fracture of the malar bone. Smith and Converse (196o) report fourteen cases and review the literature and treatment of such cases. They consider that the weakest part of the orbital floor is the area just anterior to the inferior orbital fissure, and they substantiate their statement by discussing the experimental work on cadavers by Smith and Regan (1957) who held a hurling ball against the eye and hit the ball with a hammer, with a resultant fracture of the orbital floor just anterior to the inferior orbital fissure. They consider that a blow on the eye is capable of increasing intra-orbital pressure sufficiently to cause such a fracture and have called these injuries " b l o w outs." It would appear that the globe is in fact pushed backwards and downwards, and that the suspensory ligament is stretched to allow this movement. Apart from the actual prolapse of the orbital contents, it is suggested that hmmatoma in the inferior rectus and inferior obliquus muscles may be to some extent responsible for the diplopia. A further complication is that the lower division of the 3rd cranial nerve may be damaged or at least trapped in the fracture of the orbital floor. The treatment suggested by Smith and Converse is to elevate the orbital contents into their correct position by means of a bone graft from the iliac crest to the orbital floor. The bone may be inserted by a Caldwell-Luc approach or an infra-orbital exposure, but the writers suggest a combined Caldwell-Luc and infraorbital exposure. It may be that other materials can be used to reposition the orbital contents, including acrylic and polythene sheeting. The latter would certainly be very much finer than acrylic or bone and therefore less likely to over-correct the orbital contents, but its strength and durability are likely to be less. Acrylic, although stronger, would appear to be as bulky as a bone graft and yet offer none of the advantages of bone. Smith and Regan, discussing this matter, feel that an autogenous bone graft is superior to any other material, and if successful will become consolidated. They do stipulate, however, that treatment must not be long delayed and in the fourteen cases recorded the longest time before operation was twelve days. SUMMARY An unusual fracture of the orbital floor without involvement of the infraorbital ridge is recorded and discussed. M y thanks are due to M r A . Vd. Moule for permission to publish this case.
REFERENCES RowE, N., and KILLEY,H. (1955). " Fractures of the Facial Skeleton." Edinburgh: E. & S. Livingstone. SMITH,B~ and CONVERSE,J. (196o). Trans. int. Soc. plast. Surg., Second Congress, 1959, P. 28o. Edinburgh : E. & S. Livingstone. SMITH, B, and REGAN,J. (1957). Amer. ft. Ophthal., 44, 733. Submitted for publication,May I964.