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Blowout Fracture of Medial Orbital Wall
B L O W O U T F R A C T U R E O F M E D I A L ORBITAL W A L L WILLIAM C. EDWARDS, M.D.
AND ROBERT W.
RIDLEY,
M.D.
Louisville, Kentucky Trauma to the medial orbital wall may oc cur with automobile accidents, and blows from fists and blunt missiles.1 It is accompa nied by nasal hemorrhage and subcutaneous emphysema. Serious complications of medial orbital wall trauma are rare. Miller and Glaser2 reported a case in 1966 of fracture of the medial wall with medial rectus muscle incarceration. This was referred to as the "retraction syndrome and trauma." This report describes a similar case in which blunt trauma to the orbit was followed by the unusual, but serious complication of me dial rectus muscle entrapment with resulting diplopia and impairment of ocular motility. CASE HISTORY
J. S., a 26-year-old Negro woman, presented to the Eye Clinic of the Louisville General Hospital with diplopia following blunt trauma to the left orbit from a bottle. The patient was in good health otherwise. Ocular examination revealed visual acuity of 20/20 in both eyes without correction. The right globe was normal. The left lids were moderately ecchymotic and slightly swollen. There was anesthesia over the cutaneous distribution of the left infraorbital nerve. The left globe showed no evidence of injury. The versions and ductions of the eyes were abnormal and were the principal findings. Ductions of the left eye showed severe limitation of both ele vation and depression. In addition, the eye would abduct only to the midline where, upon performing this maneuver, the globe became enophthalmic and the patient complained of pain. Adduction was lim ited to 10 degrees. Oblique movements showed se vere restriction of the left globe to a few degrees from the primary position. Skull X-Rays, stereoviews of the orbit and planograms of the floor were normal. Diplopia and pain persisted during a threeday observation period. With the patient under general anesthesia the area of restriction was then explored surgically. When forced ductions were performed on the left eye the source of the difficulty became apparent immediately. The globe could be elevated and de pressed with relative ease; however, on attempted abduction, rigid resistance was met medially, pre venting freedom of lateral movement of the globe. From the Department of Ophthalmology, Univer sity of Louisville School of Medicine.
Fig. 1 (Edwards and Ridley). Sketch of left medial rectus muscle incarceration as it appeared at surgery. Further exploration of the medial rectus muscle was done by peritomy and exposure of the muscle and its fascial attachments back to the equator of the globe. The medial rectus muscle was found to be drawn toward the medial wall of the orbit in the ethmoid area, firmly entrapped in the bony struc ture (fig. 1). Gentle efforts to free the muscle were unsuccessful. A second approach was made subperiosteally through a cutaneous incision over the inner can thus (Callahan medial approach to orbit). The muscle sheath and a portion of the muscle belly were then seen to be incarcerated in an ethmoid bone fracture. There was a small hole in the eth moid plate. A bone chip was removed and the mus cle was released with difficulty. Forced ductions then became normal. Postoperatively there was no abduction of the eye for several weeks, but thereafter the medial rectus muscle began to function and the left exotropia improved rapidly. One year postoperatively, the patient is asymptomatic. There is orthophoria in primary position of gaze and ocular movements are full, but in extreme dextroversion there is a mild restriction of left adduction and diplopia. DISCUSSION
T h e history and examination in this case were suggestive of a blowout fracture of the floor of the orbit. Some degree of injury to the floor must have been present because of the inf raorbital cutaneous anesthesia and this made the clinical findings somewhat confus-
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VOL. 65, NO. 2
BLOWOUT FRACTURE OF MEDIAL ORBITAL WALL
ing. The mechanism of incarceration of the medial rectus muscle in the ethmoid bone is speculative. It may have been done by direct injury although there was no evidence of trauma over this aspect of the globe. An other explanation might be an unusual form of blowout fracture similar to the more com mon problems encountered in trauma to the orbital floor with muscle trapping.3"7 Noth ing was used to reconstruct or cover the bony defect in the ethmoid bone although this has been recommended where large sec tions of the medial wall are resected, as for osteoma or fibrous dysplasia. We believe that in cases where the globe becomes partially immobile following blunt trauma, forced ductions should be performed, and where indicated, the medial rectus mus cle should be explored. Surgical intervention in this manner can offer the patient a good prognosis in this rare complication of orbital trauma.
249
SUMMARY
A case of blowout fracture of the medial orbital wall with incarceration of the medial rectus muscle is presented. The value of forced ductions is emphasized. 323 East Chestnut Street (40202) REFERENCES
1. Macdonald, R., Jr.: Industrial and Traumatic Ophthalmology, Allen, J. H., ed., St. Louis, Mosby 1964, p. 82. 2. Miller, G. R. and Glaser, J. S.: The retraction syndrome and trauma. Arch. Ophth. 76:662, 1966. 3. Lang, W.: Injuries and diseases of the orbit: Traumatic enophthalmos and retention of perfect acuity of vision. Tr. Ophth. Soc. U.K. 9:41, 1889. 4. Lukens, C.: Traumatic enophthalmos with re port of a case. Ophthalmology 3:30, 1907. 5. Pfeiffer, R. L.: Traumatic enophthalmos. Arch. Ophth. 30:718,1943. 6. Converse, J. M. and Smith, Byron: Enophthal mos and diplopia in fractures of the orbital floor. Brit. J. Plastic Surg. 9:26S-274, 1957. 7. Smith, B., and Regan, W. F., Jr.: Blow-out fracture of the orbit: Mechanism and correction of internal orbital fractures, Am. J. Ophth. 44:733, 1957.
OPHTHALMIC MINIATURE
I set up a meeting at Ernest's sixty-second street apartment on the afternoon he arrived, and I had also arranged an appointment for Ernest with the Chief of Ophthalmology at New York's biggest hospital. He was reputably the country's foremost specialist and he had a Park Avenue office where he saw a few private patients. He had told me on the phone that keratitis sicca was a rare and serious condition that not only caused blindness but was, in most cases, fatal. A. E. Hotchner, Papa Hemingway Random House, 1966
AND ROBERT W.
RIDLEY,
M.D.
Louisville, Kentucky Trauma to the medial orbital wall may oc cur with automobile accidents, and blows from fists and blunt missiles.1 It is accompa nied by nasal hemorrhage and subcutaneous emphysema. Serious complications of medial orbital wall trauma are rare. Miller and Glaser2 reported a case in 1966 of fracture of the medial wall with medial rectus muscle incarceration. This was referred to as the "retraction syndrome and trauma." This report describes a similar case in which blunt trauma to the orbit was followed by the unusual, but serious complication of me dial rectus muscle entrapment with resulting diplopia and impairment of ocular motility. CASE HISTORY
J. S., a 26-year-old Negro woman, presented to the Eye Clinic of the Louisville General Hospital with diplopia following blunt trauma to the left orbit from a bottle. The patient was in good health otherwise. Ocular examination revealed visual acuity of 20/20 in both eyes without correction. The right globe was normal. The left lids were moderately ecchymotic and slightly swollen. There was anesthesia over the cutaneous distribution of the left infraorbital nerve. The left globe showed no evidence of injury. The versions and ductions of the eyes were abnormal and were the principal findings. Ductions of the left eye showed severe limitation of both ele vation and depression. In addition, the eye would abduct only to the midline where, upon performing this maneuver, the globe became enophthalmic and the patient complained of pain. Adduction was lim ited to 10 degrees. Oblique movements showed se vere restriction of the left globe to a few degrees from the primary position. Skull X-Rays, stereoviews of the orbit and planograms of the floor were normal. Diplopia and pain persisted during a threeday observation period. With the patient under general anesthesia the area of restriction was then explored surgically. When forced ductions were performed on the left eye the source of the difficulty became apparent immediately. The globe could be elevated and de pressed with relative ease; however, on attempted abduction, rigid resistance was met medially, pre venting freedom of lateral movement of the globe. From the Department of Ophthalmology, Univer sity of Louisville School of Medicine.
Fig. 1 (Edwards and Ridley). Sketch of left medial rectus muscle incarceration as it appeared at surgery. Further exploration of the medial rectus muscle was done by peritomy and exposure of the muscle and its fascial attachments back to the equator of the globe. The medial rectus muscle was found to be drawn toward the medial wall of the orbit in the ethmoid area, firmly entrapped in the bony struc ture (fig. 1). Gentle efforts to free the muscle were unsuccessful. A second approach was made subperiosteally through a cutaneous incision over the inner can thus (Callahan medial approach to orbit). The muscle sheath and a portion of the muscle belly were then seen to be incarcerated in an ethmoid bone fracture. There was a small hole in the eth moid plate. A bone chip was removed and the mus cle was released with difficulty. Forced ductions then became normal. Postoperatively there was no abduction of the eye for several weeks, but thereafter the medial rectus muscle began to function and the left exotropia improved rapidly. One year postoperatively, the patient is asymptomatic. There is orthophoria in primary position of gaze and ocular movements are full, but in extreme dextroversion there is a mild restriction of left adduction and diplopia. DISCUSSION
T h e history and examination in this case were suggestive of a blowout fracture of the floor of the orbit. Some degree of injury to the floor must have been present because of the inf raorbital cutaneous anesthesia and this made the clinical findings somewhat confus-
248
VOL. 65, NO. 2
BLOWOUT FRACTURE OF MEDIAL ORBITAL WALL
ing. The mechanism of incarceration of the medial rectus muscle in the ethmoid bone is speculative. It may have been done by direct injury although there was no evidence of trauma over this aspect of the globe. An other explanation might be an unusual form of blowout fracture similar to the more com mon problems encountered in trauma to the orbital floor with muscle trapping.3"7 Noth ing was used to reconstruct or cover the bony defect in the ethmoid bone although this has been recommended where large sec tions of the medial wall are resected, as for osteoma or fibrous dysplasia. We believe that in cases where the globe becomes partially immobile following blunt trauma, forced ductions should be performed, and where indicated, the medial rectus mus cle should be explored. Surgical intervention in this manner can offer the patient a good prognosis in this rare complication of orbital trauma.
249
SUMMARY
A case of blowout fracture of the medial orbital wall with incarceration of the medial rectus muscle is presented. The value of forced ductions is emphasized. 323 East Chestnut Street (40202) REFERENCES
1. Macdonald, R., Jr.: Industrial and Traumatic Ophthalmology, Allen, J. H., ed., St. Louis, Mosby 1964, p. 82. 2. Miller, G. R. and Glaser, J. S.: The retraction syndrome and trauma. Arch. Ophth. 76:662, 1966. 3. Lang, W.: Injuries and diseases of the orbit: Traumatic enophthalmos and retention of perfect acuity of vision. Tr. Ophth. Soc. U.K. 9:41, 1889. 4. Lukens, C.: Traumatic enophthalmos with re port of a case. Ophthalmology 3:30, 1907. 5. Pfeiffer, R. L.: Traumatic enophthalmos. Arch. Ophth. 30:718,1943. 6. Converse, J. M. and Smith, Byron: Enophthal mos and diplopia in fractures of the orbital floor. Brit. J. Plastic Surg. 9:26S-274, 1957. 7. Smith, B., and Regan, W. F., Jr.: Blow-out fracture of the orbit: Mechanism and correction of internal orbital fractures, Am. J. Ophth. 44:733, 1957.
OPHTHALMIC MINIATURE
I set up a meeting at Ernest's sixty-second street apartment on the afternoon he arrived, and I had also arranged an appointment for Ernest with the Chief of Ophthalmology at New York's biggest hospital. He was reputably the country's foremost specialist and he had a Park Avenue office where he saw a few private patients. He had told me on the phone that keratitis sicca was a rare and serious condition that not only caused blindness but was, in most cases, fatal. A. E. Hotchner, Papa Hemingway Random House, 1966