- Email: [email protected]
Treatment experience in a child with heterochronous bilateral blowout fractures
Short reports and correspondence
963 ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.02.022
Treatment experience in a child with heterochronous bilateral blowout fractures
Figure 5 Classification of Stahl’s ear. Type 1: a third crus extends from the crura anthelicis posterosuperiorly and the ridge is sharp. Type 2: a third crus extends from the crura anthelicis posterosuperiorly and the ridge is round. Type 3: a third crus extends posterosuperiorly and which is wide with two ridges. Type 4: a third crus extends from the crura anthelicis posteroinferiorly.
members of the same family, with its most frequent expression in identical twins, among whom it manifests with an incidence of about 75%.4 Treatment of Stahl’s ear should initially be attempted non-surgically in patients whose third crus easily disappears when pressed with a fingertip. However, in fact, elimination of the abnormal fold by non-surgical treatment or simple surgical methods such as mattres sutures is difficult.6 Torikai et al.1 reported the ‘crucial incision methods’ based on the premise that cartilage should not be excised according to conventional procedures but should be extended. Thus, crucial incisions are made on the back of the third crus. Moreover, a conchal cartilage is harvested and grafted on the incised cartilage to stabilise the released third crus by the splinting effect. In the five cases we reconstructed using this method, the fixation was stable and the deformity did not recur. We confirm that this method is easy, effective, and successful.
References 1. Torikai K, Kamiishi H, Ohtsuka H, et al. A new technique for repair of Stahl’s ear. Jpn J Plast Surg 1981;1:276e83 [in Japanese]. 2. Yamada A, Fukuda O. Evaluation of Stahl’s ear, third crus of antihelix. Ann Plast Surg 1980;4:511e5. 3. Furukawa M, Mizutani Z, Hamada T. A simple operative procedure for the treatment of Stahl’s ear. Br J Plast Surg 1985;38: 544e5. 4. Tatlidede S, Gonen E, Bas L. Bilateral Stahl’s ear: a rarely seen anomaly. Plast Reconstr Surg 2005;115:345e6. 5. Ferraro GA, Perrotta A, Rossano F, et al. Stahl syndrome in clinical practice. Aesthetic Plast Surg 2006;30:348e9. 6. Yotsuyanagi T, Nihei Y, Shinmyo Y, et al. Stahl’s ear caused by an abnormal intrinsic auricular muscle. Plast Reconstr Surg 1999; 103:171e4.
Rei Ogawa Hiko Hyakusoku Department of Plastic and Reconstructive Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo 113-8603, Japan E-mail address: [email protected]
The incidence of blowout fracture is generally considered to be lower in children than in adults. There have been no reports of children with bilateral blowout fractures.1 We encountered a child with heterochronous bilateral fractures that occurred over a short interval during basketball practice. The patient was a 13-year-old boy. On 3 November 2005, during basketball practice, the elbow of a player hit a child hard in the right eye, and he noticed diplopia immediately after the injury. The first consultation at our department 5 days after injury showed limitation in the elevation of the right eyeball (Fig. 1A), and CT revealed linear fracture of the right inferior wall. The diplopia did not improve even 2 weeks after injury. Since a Hess red green test also showed impaired elevation of the right eye (Fig. 1B), an operation was performed on 17 November 2005. The lesion was approached by a skin incision on the right lower eyelid. A linear fracture was observed, and soft tissue impacted in the fracture area was released. The postoperative course was good, and the limitation in elevation and diplopia disappeared 2 weeks after the operation. He resumed basketball practice thereafter. On 10 January 2006, about 2 months after the resumption of practice, the head of a player hit him hard in his left eye, and he noticed diplopia immediately after the injury. The initial consultation at our department showed limitation in the elevation of the left eye (Fig. 2A), and CT showed linear fracture of the left inferior wall on 11 January. Since a Hess red green test also showed impaired elevation of the left eye (Fig. 2B), an operation was performed under general anaesthesia on 16 January. Since vertical oculomotor disorder improved after traction of the inferior rectus muscle, the operation was completed. Immediately after the operation, the elevation impairment and diplopia improved, and he resumed basketball practice 2 days after the operation.
Discussion In blowout fractures in children, the definition of the age of children varies between studies.2 In western countries, since the age limit has been often regarded as 15 years, this patient aged 13 years was considered to be a child with a blowout fracture. There have been reports on bilateral blowout fractures in adults but not heterochronous bilateral blowout fractures in children.3 Compared with adults, children have soft and flexible bone walls with thick periosteum. Therefore, in children, comminuted fracture infrequently develops, and linear fracture is often observed. Herniation of a large amount of orbital contents rarely occurs, and diagnostic imaging shows apparently mild lesions. However, impairment of the
964
Short reports and correspondence
Figure 1 A. Preoperative appearance showed limitation in the elevation of the right eyeball. B. Hess red green test also showed impaired elevation of the right eye.
extraocular muscles themselves is often present. In our patient, the bilateral fractures were linear, and though the fractures were relatively mild, oculomotor disorder was marked.
Opinions have been long divided concerning the pathogenesis and treatment methods of blowout fracture since the establishment of the disorder concept by Converse.4 However, recently, evaluation of treatment methods according
Figure 2 A. Preoperative appearance showed limitation in the elevation of the left eyeball. B. Hess red green test also showed impaired elevation of the left eye.
Short reports and correspondence to the classification of the fracture type have become general, and surgical indications finally began to converge in one direction. Concerning the treatment principles of blowout fracture in children, there are still various opinions, and no consensus has been reached on surgical indications. Burnstine5 described that surgery should be selected based on symptoms, clinical findings, and informed consent after explanation of surgical risks and advantages. In patients such as ours who need supraversion for ball games, when conservative treatment is selected, possible persistent diplopia may cause inconvenience for a long period. In the first treatment (right side), since a Hess red green test showed negligible improvement in oculomotor disorder even 2 weeks after injury, an operation was performed with the consent of the patient and his family. As a result, he showed improvement and could play basketball 2 weeks after operation. In the second treatment (left side), the operation was performed 6 days after injury with adequate informed consent because of slightly less limitation in supraversion in the left eye than in the right eye, good results of the first operation, and his wish to resume basketball soon. Since the oculomotor disorder was less on the left side than on the right side, the adhesion of impacted orbital tissue was released by traction of the inferior rectus muscle prior to other procedures under general anaesthesia. As the limitation in supraversion was released, the operation was completed. As a result, he could resume basketball 2 days after operation. We evaluated the timing of surgery for blowout fracture in children. Opinions are divided into two: one recommends operation as early as possible while the other suggests that operation within 2 months after injury has adequate surgical effects.6 Concerning the cause of a delay in oculomotor improvement in children with blowout fracture, Waddell et al.7 speculated that scar formation in the orbit is marked in children, and Cope et al.8 reported that the reduction of impacted tissue is difficult because blowout fracture in children often comprises linear fracture. In addition, in children, since bone restoration mechanisms are observed early, impairment of the extraocular muscles tends to progress. It is also a widespread opinion that operation should be performed as early as possible in patients requiring surgical reduction because adhesion of the herniated and impacted orbital tissue to the surrounding tissue progresses with time. In our department, we have often encountered adult patients surgically treated 1 month or more after injury in whom fat tissue which had herniated into the maxillary cavity was white and hard, showing scar formation, adhering to the mucosa of the maxillary sinus, and its dissection was difficult. Therefore, in patients showing no oculomotor improvement even 2 weeks after injury, we recommend active surgical reduction of impacted tissue even in children. In the second operation in this patient, operation was performed considerably early (6 days after injury). This was because the sport was a main activity in his daily life, and improvement was observed soon after the previous operation on the right side. Therefore, the timing of surgery should be decided after adequate consultation with the family along with consideration of the patient’s background. We encountered a child with very rare heterochronous bilateral blowout fractures and performed treatment based
965 on the patient’s background, clinical findings, and the clinical course. In the future, the surgical indications and timing in children with blowout fracture will require adequate evaluation after talking with the family and consideration of the patient’s background.
References 1. Anderson PJ. Fractures of the facial skeleton in children. Injury 1995;26:47e50. 2. Man K, Wijngaarde R, Hes J. Influence of age on the management of blow-out fractures of the orbital floor. Int J Oral Maxillofac Surg 1991;20:330e6. 3. Charles R, Leon JR, Roger H. Bilateral blowout fractures. Ann Ophthalmol 1972;6:495e502. 4. Converse JM, Smith B. Enophthalmos and diplopia in fracture of the orbital floor. Br J Plast Surg 1957;9:265e74. 5. Burnstine MA. Clinical recommendations for repair of the isolated orbital floor fractures. Curr Opin Ophthalmol 2003;14: 236e40. 6. Leitch RJ, Burke JP, Strachan IM. Orbital blowout fractures - the infuenence of the age on surgical outcome. Acta Ophthalmol 1990;68:118e24. 7. Waddel E, Fells P, Koornneef L. The natural and unnatural histology of a blow-out fracture. Br Orthopt J 1982;39:29e32. 8. Cope MR, Moos KF, Speculand B. Does diplopia persist after blow-out fractures of the orbital floor in children? Br J Oral Maxillofac Surg 1999;37:46e51.
Shinichi Asamura Kazuhide Matunaga Hirohisa Kusuhara Takahiro Hashimoto Noritaka Isogai Department of Plastic and Reconstructive Surgery, Kinki University School of Medicine, 377-2 Ohno-higashi, Osaka-sayama, Osaka 5898511, Japan E-mail address: [email protected] ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.02.010
Randomised clinical trials in plastic surgery: Survey of output and quality of reporting We were interested to read the article by Karri1 describing the survey of randomised clinical trials in plastic surgery as we feel this is a research area in which more could and should be done. Of relevance to this review, although not published in the journals covered by the above paper, we have conducted a randomised trial comparing conventional wound dressing against an open dressing involving a herbal medicine-based preparation in 115 patients admitted to hospital for second degree burns.2,3 Interestingly, we were able to show very similar wound healing characteristics and pain control with the two strategies despite prior claims of much
963 ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.02.022
Treatment experience in a child with heterochronous bilateral blowout fractures
Figure 5 Classification of Stahl’s ear. Type 1: a third crus extends from the crura anthelicis posterosuperiorly and the ridge is sharp. Type 2: a third crus extends from the crura anthelicis posterosuperiorly and the ridge is round. Type 3: a third crus extends posterosuperiorly and which is wide with two ridges. Type 4: a third crus extends from the crura anthelicis posteroinferiorly.
members of the same family, with its most frequent expression in identical twins, among whom it manifests with an incidence of about 75%.4 Treatment of Stahl’s ear should initially be attempted non-surgically in patients whose third crus easily disappears when pressed with a fingertip. However, in fact, elimination of the abnormal fold by non-surgical treatment or simple surgical methods such as mattres sutures is difficult.6 Torikai et al.1 reported the ‘crucial incision methods’ based on the premise that cartilage should not be excised according to conventional procedures but should be extended. Thus, crucial incisions are made on the back of the third crus. Moreover, a conchal cartilage is harvested and grafted on the incised cartilage to stabilise the released third crus by the splinting effect. In the five cases we reconstructed using this method, the fixation was stable and the deformity did not recur. We confirm that this method is easy, effective, and successful.
References 1. Torikai K, Kamiishi H, Ohtsuka H, et al. A new technique for repair of Stahl’s ear. Jpn J Plast Surg 1981;1:276e83 [in Japanese]. 2. Yamada A, Fukuda O. Evaluation of Stahl’s ear, third crus of antihelix. Ann Plast Surg 1980;4:511e5. 3. Furukawa M, Mizutani Z, Hamada T. A simple operative procedure for the treatment of Stahl’s ear. Br J Plast Surg 1985;38: 544e5. 4. Tatlidede S, Gonen E, Bas L. Bilateral Stahl’s ear: a rarely seen anomaly. Plast Reconstr Surg 2005;115:345e6. 5. Ferraro GA, Perrotta A, Rossano F, et al. Stahl syndrome in clinical practice. Aesthetic Plast Surg 2006;30:348e9. 6. Yotsuyanagi T, Nihei Y, Shinmyo Y, et al. Stahl’s ear caused by an abnormal intrinsic auricular muscle. Plast Reconstr Surg 1999; 103:171e4.
Rei Ogawa Hiko Hyakusoku Department of Plastic and Reconstructive Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo 113-8603, Japan E-mail address: [email protected]
The incidence of blowout fracture is generally considered to be lower in children than in adults. There have been no reports of children with bilateral blowout fractures.1 We encountered a child with heterochronous bilateral fractures that occurred over a short interval during basketball practice. The patient was a 13-year-old boy. On 3 November 2005, during basketball practice, the elbow of a player hit a child hard in the right eye, and he noticed diplopia immediately after the injury. The first consultation at our department 5 days after injury showed limitation in the elevation of the right eyeball (Fig. 1A), and CT revealed linear fracture of the right inferior wall. The diplopia did not improve even 2 weeks after injury. Since a Hess red green test also showed impaired elevation of the right eye (Fig. 1B), an operation was performed on 17 November 2005. The lesion was approached by a skin incision on the right lower eyelid. A linear fracture was observed, and soft tissue impacted in the fracture area was released. The postoperative course was good, and the limitation in elevation and diplopia disappeared 2 weeks after the operation. He resumed basketball practice thereafter. On 10 January 2006, about 2 months after the resumption of practice, the head of a player hit him hard in his left eye, and he noticed diplopia immediately after the injury. The initial consultation at our department showed limitation in the elevation of the left eye (Fig. 2A), and CT showed linear fracture of the left inferior wall on 11 January. Since a Hess red green test also showed impaired elevation of the left eye (Fig. 2B), an operation was performed under general anaesthesia on 16 January. Since vertical oculomotor disorder improved after traction of the inferior rectus muscle, the operation was completed. Immediately after the operation, the elevation impairment and diplopia improved, and he resumed basketball practice 2 days after the operation.
Discussion In blowout fractures in children, the definition of the age of children varies between studies.2 In western countries, since the age limit has been often regarded as 15 years, this patient aged 13 years was considered to be a child with a blowout fracture. There have been reports on bilateral blowout fractures in adults but not heterochronous bilateral blowout fractures in children.3 Compared with adults, children have soft and flexible bone walls with thick periosteum. Therefore, in children, comminuted fracture infrequently develops, and linear fracture is often observed. Herniation of a large amount of orbital contents rarely occurs, and diagnostic imaging shows apparently mild lesions. However, impairment of the
964
Short reports and correspondence
Figure 1 A. Preoperative appearance showed limitation in the elevation of the right eyeball. B. Hess red green test also showed impaired elevation of the right eye.
extraocular muscles themselves is often present. In our patient, the bilateral fractures were linear, and though the fractures were relatively mild, oculomotor disorder was marked.
Opinions have been long divided concerning the pathogenesis and treatment methods of blowout fracture since the establishment of the disorder concept by Converse.4 However, recently, evaluation of treatment methods according
Figure 2 A. Preoperative appearance showed limitation in the elevation of the left eyeball. B. Hess red green test also showed impaired elevation of the left eye.
Short reports and correspondence to the classification of the fracture type have become general, and surgical indications finally began to converge in one direction. Concerning the treatment principles of blowout fracture in children, there are still various opinions, and no consensus has been reached on surgical indications. Burnstine5 described that surgery should be selected based on symptoms, clinical findings, and informed consent after explanation of surgical risks and advantages. In patients such as ours who need supraversion for ball games, when conservative treatment is selected, possible persistent diplopia may cause inconvenience for a long period. In the first treatment (right side), since a Hess red green test showed negligible improvement in oculomotor disorder even 2 weeks after injury, an operation was performed with the consent of the patient and his family. As a result, he showed improvement and could play basketball 2 weeks after operation. In the second treatment (left side), the operation was performed 6 days after injury with adequate informed consent because of slightly less limitation in supraversion in the left eye than in the right eye, good results of the first operation, and his wish to resume basketball soon. Since the oculomotor disorder was less on the left side than on the right side, the adhesion of impacted orbital tissue was released by traction of the inferior rectus muscle prior to other procedures under general anaesthesia. As the limitation in supraversion was released, the operation was completed. As a result, he could resume basketball 2 days after operation. We evaluated the timing of surgery for blowout fracture in children. Opinions are divided into two: one recommends operation as early as possible while the other suggests that operation within 2 months after injury has adequate surgical effects.6 Concerning the cause of a delay in oculomotor improvement in children with blowout fracture, Waddell et al.7 speculated that scar formation in the orbit is marked in children, and Cope et al.8 reported that the reduction of impacted tissue is difficult because blowout fracture in children often comprises linear fracture. In addition, in children, since bone restoration mechanisms are observed early, impairment of the extraocular muscles tends to progress. It is also a widespread opinion that operation should be performed as early as possible in patients requiring surgical reduction because adhesion of the herniated and impacted orbital tissue to the surrounding tissue progresses with time. In our department, we have often encountered adult patients surgically treated 1 month or more after injury in whom fat tissue which had herniated into the maxillary cavity was white and hard, showing scar formation, adhering to the mucosa of the maxillary sinus, and its dissection was difficult. Therefore, in patients showing no oculomotor improvement even 2 weeks after injury, we recommend active surgical reduction of impacted tissue even in children. In the second operation in this patient, operation was performed considerably early (6 days after injury). This was because the sport was a main activity in his daily life, and improvement was observed soon after the previous operation on the right side. Therefore, the timing of surgery should be decided after adequate consultation with the family along with consideration of the patient’s background. We encountered a child with very rare heterochronous bilateral blowout fractures and performed treatment based
965 on the patient’s background, clinical findings, and the clinical course. In the future, the surgical indications and timing in children with blowout fracture will require adequate evaluation after talking with the family and consideration of the patient’s background.
References 1. Anderson PJ. Fractures of the facial skeleton in children. Injury 1995;26:47e50. 2. Man K, Wijngaarde R, Hes J. Influence of age on the management of blow-out fractures of the orbital floor. Int J Oral Maxillofac Surg 1991;20:330e6. 3. Charles R, Leon JR, Roger H. Bilateral blowout fractures. Ann Ophthalmol 1972;6:495e502. 4. Converse JM, Smith B. Enophthalmos and diplopia in fracture of the orbital floor. Br J Plast Surg 1957;9:265e74. 5. Burnstine MA. Clinical recommendations for repair of the isolated orbital floor fractures. Curr Opin Ophthalmol 2003;14: 236e40. 6. Leitch RJ, Burke JP, Strachan IM. Orbital blowout fractures - the infuenence of the age on surgical outcome. Acta Ophthalmol 1990;68:118e24. 7. Waddel E, Fells P, Koornneef L. The natural and unnatural histology of a blow-out fracture. Br Orthopt J 1982;39:29e32. 8. Cope MR, Moos KF, Speculand B. Does diplopia persist after blow-out fractures of the orbital floor in children? Br J Oral Maxillofac Surg 1999;37:46e51.
Shinichi Asamura Kazuhide Matunaga Hirohisa Kusuhara Takahiro Hashimoto Noritaka Isogai Department of Plastic and Reconstructive Surgery, Kinki University School of Medicine, 377-2 Ohno-higashi, Osaka-sayama, Osaka 5898511, Japan E-mail address: [email protected] ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.02.010
Randomised clinical trials in plastic surgery: Survey of output and quality of reporting We were interested to read the article by Karri1 describing the survey of randomised clinical trials in plastic surgery as we feel this is a research area in which more could and should be done. Of relevance to this review, although not published in the journals covered by the above paper, we have conducted a randomised trial comparing conventional wound dressing against an open dressing involving a herbal medicine-based preparation in 115 patients admitted to hospital for second degree burns.2,3 Interestingly, we were able to show very similar wound healing characteristics and pain control with the two strategies despite prior claims of much