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Background: Orbital floor fractures result in critical changes in the shape and inferior rectus muscle (IRM) position. Radiological imaging of IRM changes can be used for surgical decision making or prediction of ocular symptoms. Studies with a systematic consideration of the orbital floor defect ratio in this context are missing in the literature. Accordingly, this study on human cadavers aimed to systematically investigate the impact of the orbital floor defect ratio on changes in the IRM and the prediction of posttraumatic enophthalmos., Methods: Seventy-two orbital floor defects were placed in cadaver specimens using piezosurgical removal. The orbital defect area (ODA), orbital floor area (OFA), position and IRM shape, and enophthalmos were measured using computed tomography (CT) scans., Results: The ODA/OFA ratio correlated significantly (p < 0.001) with the shape (Spearman's rho: 0.558) and position (Spearman's rho: 0.511) of the IRM, and with enophthalmos (Spearman's rho: 0.673). Increases in the ODA/OFA ratio significantly rounded the shape of the IRM (ß: 0.667; p < 0.001) and made a lower position of the IRM more likely (OR: 1.093; p = 0.003). In addition, increases in the ODA/OFA ratio were significantly associated with the development of relevant enophthalmos (OR: 1.159; p = 0.008), adjusted for the defect localization and shape of the IRM. According to receiver operating characteristics analysis (AUC: 0.876; p < 0.001), a threshold of ODA/OFA ratio ≥ 32.691 for prediction of the risk of development of enophthalmos yielded a sensitivity of 0.809 and a specificity of 0.842., Conclusion: The ODA/OFA ratio is a relevant parameter in the radiological evaluation of orbital floor fractures, as it increases the risk of relevant enophthalmos, regardless of fracture localization and shape of the IRM. Therefore, changes in the shape and position of the IRM should be considered in surgical treatment planning. A better understanding of the correlates of isolated orbital floor fractures may help to develop diagnostic scores and standardize therapeutic algorithms in the future., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier GmbH.. All rights reserved.)

Purpose: Determining the hemodynamic characteristics of an orbital vascular malformation is a critical step in management. The purpose of this study is to assess the relationship between enophthalmos and clinically apparent distensibility of orbital vascular malformations, to optimize imaging and treatment., Methods: In this cross-sectional cohort study consecutive patients at a single institution were screened for study entry. Data extracted included age, sex, Hertel measurements, presence or absence of distensibility during the Valsalva maneuver, whether lesions were primarily venous or lymphatic based on imaging, and location of the lesion relative to the globe. Enophthalmos was defined as ≥ 2 mm difference from the opposite side. Parametric and nonparametric statistics were used, and linear regression was performed to examine factors predictive of Hertel measurement., Results: Twenty-nine patients met the inclusion criteria. Relative enophthalmos ≥2 mm was significantly associated with distensibility ( p = 0.03; odds ratio = 5.33). Distensibility and venous dominant morphology were the 2 most important factors associated with enophthalmos on regression analysis. The relative position of the lesion anterior or posterior to the globe did not have a significant bearing on baseline enophthalmos., Conclusions: The presence of enophthalmos increases the likelihood that an orbital vascular malformation is distensible. This group of patients was also more likely to be characterized by venous dominant malformations. Baseline clinical enophthalmos may serve as a useful surrogate marker for distensibility and venous dominance, which may be useful in guiding the selection of appropriate imaging., Competing Interests: D.B.R. has acted as a marketing consultant for Horizon pharmaceuticals and is a member of the speaker’s bureau. The other authors have no conflicts of interest to disclose, (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Considering the interplay between orbital bones and intraorbital soft tissues, commonly accepted patterns of the blow-out type of trauma within the human orbit require more thorough investigation to assess the minimal health-threatening impact value. Two different three-dimensional finite element method (FEM) models of the human orbital region were developed to simulate the pure "buckling" mechanism of orbital wall fracture in two variants: the model of orbital bone elements and the model of orbital bone, orbit and intraorbital tissue elements. The mechanical properties of the so-defined numerical skull fragment were applied to the model according to the unique laboratory tensile stress tests performed on small and fragile specimens of orbital bones as well as using the data available in the literature. The nonlinear transient analysis of the contact problem between bodies that differ substantially in terms of the Young's modulus was carried out to investigate the interaction of different bodies within an instant injury. Potential damage areas were found within the lower orbital wall as well as the destructive load values for both FEM skull models (7,660 N and 8,520 N). Moreover, numerical simulations were validated by comparing them with computed tomography scans of real injuries.

Background: This study aims to assess the efficacy of transconjunctival approach (TCA) for the treatment of orbital fractures (OF) comprehensively and systematically., Methods: In this study, we plan to search electronic databases of Cochrane Library, MEDLINE, EMBASE, Web of Science, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, China National Knowledge Infrastructure and for relevant randomized controlled trials. All these databases will be searched from inception to the March 1, 2020 without limitations of language and publication status. Two independent authors will carry out study selection, data collection, and study quality assessment. Any disagreements will be resolved by discussion with another author if necessary. The study quality will be assessed using Cochrane risk of bias tool. Statistical analysis will be conducted using RevMan 5.3 software., Results: This study will be the first 1 to exert direct evidence to evaluate the efficacy of TCA for the treatment of OF., Conclusions: The findings of this study will provide an exhaustive view of TCA for the treatment of OF., Study Registration Number: INPLASY202040154.

Background: Enophthalmos is one of the most distressing complications of orbital fracture, and when faced with a blowout fracture, plastic surgeons often find it difficult to determine the need for surgical correction. Although a number of studies have been conducted on this topic, no study has yet been performed using a set of measurable parameters., Methods: We quantitatively measured orbital fracture areas (OFA), volumes (OFV), and medial rectus muscle cross-sectional ratios in patients with an isolated medial orbital wall fracture defect during a 5-year period from 2014 to 2018. Only conservatively treated patients constituted the study cohort. Enophthalmos was measured by two plastic surgeons at ≥6 months after trauma. We analyzed correlations between various parameters and degrees of late enophthalmos in the study cohort., Results: Significant correlations were observed between several parameters and late enophthalmos. Multiple regression analysis resulted in the following coefficients: -0.449 is constant (p = 0.017), 0.596 and 0.460 for OFA (p = 0.000) and OFV (p = 0.005), respectively. However, no significant relationship was observed between enophthalmos and medial rectus muscle cross-sectional ratios (p = 0.340)., Conclusions: The results of this study enable the degree of late enophthalmos in conservatively treated patients to be predicted using OFV and OFA values. We suggest five indications that require surgical correction without long-term clinical follow-ups: (1) OFA ≥ 1.90 cm 2 , (2) OFV ≥ 1.00 cm 3 , (3) 1.30 OFA + OFV > 5.32, (4) signs of muscle incarceration, and (5) signs of severe retrobulbar hematoma. The more satisfactory the five indications are, the greater is the need for surgery., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2019 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Orbital fractures are common injuries found in facial trauma. Typical etiologies of orbital fractures include motor vehicle collisions and assault. We report the case of a 32-year-old male who suffered an orbital fracture from a water balloon. Additionally, we describe the aeromedical complications that may result from this injury. Finally, we attempt to answer the question of when a patient may return to flying after sustaining such an injury through review of the literature., Case Presentation: A 32-year-old male pilot with the United States Air Force was at an outdoor event with his unit when he was struck with a water balloon launched from a sling shot into his left orbit. Shortly afterwards, he had an onset of subcutaneous emphysema and was escorted to a nearby Emergency Department. Computed tomography identified an orbital fracture with associated orbital and subcutaneous emphysema. The patient was evaluated by a plastic surgeon and was determined not to be a surgical candidate. Four weeks later, he returned to flying status., Conclusions: Water balloons are thought to be safe and harmless toys. However, when coupled with slingshots, water balloons can become formidable projectiles capable of significant orbital injury including orbital fractures. These injuries are concerning to aviators, as the most common sites for fractures of the orbit are the thin ethmoid and maxillary bones adjacent to the sinuses. At altitude, gases in the sinuses may expand and enter the orbit through these fractures, which may suddenly incapacitate the flyer. It is important for flight surgeons to identify and assess these individuals to determine suitability for flying.

Objective: To determine the predictive value of vertical incomitance for diplopia outcome in orbital fracture patients., Patients and Methods: A prospective cohort study composed of patients with orbital fractures was designed. The predictor variable was vertical incomitance, and the primary outcome variable was diplopia. Incomitance was calculated in prism diopters (Δ) as the difference of the maximum absolute deviation between the upper and lower three gaze directions. Standard statistics for patient characteristics, the Fisher exact test for categorical variables and the Wilcoxon rank sum test for continuous variables were computed., Results: The sample was composed of 188 patients grouped as follows: non-operated (n = 124) and operated (n = 64). Fifty-one patients showed vertical incomitance of whom 10 (19.6%) had persistent diplopia at the 1-year follow-up. The mean incomitance was 9.6Δ in the diplopia group versus 2Δ in the non diplopia group (OR = 1.13; p < 0.001). There was a statistically significant association between vertical incomitance of >2Δ and persistent diplopia at 1 year after adjusting for the surgery variable (OR = 1.07; p < 0.04)., Conclusion: The present study has demonstrated that in orbital fracture patients, vertical incomitance was associated with (1) persistence of long-term diplopia, (2) the decision to perform surgery, and (3) the severity of the fracture., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: In evaluating patients sustaining bilateral isolated internal orbital fractures, the authors have observed both similar fracture locations and also similar expansion of orbital volumes. In this study, we aim to investigate if there is a propensity for the 2 orbits to fracture in symmetrically similar patterns when sustaining similar trauma., Methods: A retrospective chart review was performed studying all cases at our institution of bilateral isolated internal orbital fractures involving the medial wall and/or the floor at the time of presentation. The similarity of the bilateral fracture locations was evaluated using the Fisher's exact test. The bilateral expanded orbital volumes were analyzed using the Wilcoxon signed-rank test to assess for orbital volume similarity., Results: Twenty-four patients with bilateral internal orbital fractures were analyzed for fracture location similarity. Seventeen patients (70.8%) had 100% concordance in the orbital subregion fractured, and the association between the right and the left orbital fracture subregion locations was statistically significant (P < 0.0001). Fifteen patients were analyzed for orbital volume similarity. The average orbital cavity volume was 31.2 ± 3.8 cm on the right and 32.0 ± 3.7 cm on the left. There was a statistically significant difference between right and left orbital cavity volumes (P = 0.0026)., Conclusions: The data from this study suggest that an individual who suffers isolated bilateral internal orbital fractures has a statistically significant similarity in the location of their orbital fractures. However, there does not appear to be statistically significant similarity in the expansion of the orbital volumes in these patients.

Orbital reconstruction in cases of trauma is usually performed using the unaffected side orbital volume as a reference, but this measurement does not fully consider the anatomical characteristics of orbital surfaces. We propose a novel procedure based on the registration of 3D orbital segmented surfaces. Reconstructed orbits from 20 patients and healthy orbits from 13 control subjects were segmented from the post-operative CT-scans. The 3D orbital model from the unaffected orbit was "mirrored" according to the sagittal plane and superimposed onto the reconstructed one, with calculation of volumes, asymmetry index and point-to-point RMS (root mean square) distances. Inter- and intra-observer errors were tested through Bland-Altman plot. Differences in volume, asymmetry index and RMS value between the control group and the treated patients were assessed through two-way ANOVA and Student's t-test (p < 0.05). According to Bland-Altman test, intra- and inter-operator repeatability was respectively 87% and 89%. No significant differences in volume or asymmetry index between the control group and the treated patients were observed (p > 0.05), but the RMS value was significantly larger in the latter ones (on average, 0.90 ± 0.26 mm vs. 0.67 ± 0.17 mm, p < 0.05). Results show that the reconstructed orbits present a morphologically different surface from the unaffected ones., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: The detection of intracranial injury in patients with facial injury rather than traumatic brain injury (TBI) remains a challenge for emergency physicians. This study aimed to evaluate the incidence and risk factors of intracranial injury in patients with orbital wall fracture (OWF), who were classified with a chief complaint of facial injury rather than TBI., Methods: This retrospective case-control study enrolled adult OWF patients (age ≥18 years) who presented at the hospital between January 2004 and March 2016. Patients with definite TBI were excluded because non-contrast head computed tomography (CT) is recommended for such patients., Results: A total of 1220 patients with OWF were finally enrolled. CT of the head was performed on 677 patients, and the incidence of concomitant intracranial injury was found to be 9% (62/677). Patients with definite TBI were excluded. Symptoms raising a suspicion of TBI, such as loss of consciousness, alcohol intoxication, or vomiting, were present in 347 of the patients, with 44 of these patients (13%) showing a concomitant intracranial injury. Of the 330 patients without such symptoms, 18 (6%) demonstrated a concomitant intracranial injury. In OWF patients, superior wall fracture (odds ratio [OR], 4.15; 95% confidence interval [CI], 2.06-8.34; P < 0.001), associated frontal bone fracture (OR, 4.38; 95% CI, 2.08-9.23; P < 0.001), and older age (decades) (OR, 1.03; 95% CI, 1.01-1.04; P = 0.002) were independent risk factors for concomitant intracranial injury., Conclusions: Emergency physicians should maintain a high degree of suspicion of TBI, even when their primary concern is facial trauma with OWF. Head CT is recommended for OWF patients with a superior OWF, frontal bone fracture, or increased age., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Facial fractures often result in changes of the orbital volume. These changes can be measured in three-dimensional (3D) computed tomography (CT) scans for preoperative planning and postoperative evaluation. The aim of this study was to analyze the orbital volume and shape before and after surgical treatment of unilateral orbital fractures using semi-automatic image segmentation and registration techniques. The orbital volume in 21 patients was assessed by a semi-automatic model-based segmentation method. The fractured orbit was compared relative to the contralateral orbit. The same procedure was performed for the postoperative evaluation. Two observers performed the segmentation procedure, and the inter- and intraobserver variability was evaluated. The interobserver variability (mean volume difference ± 1.96 SD) was -0.6 ± 1.0 ml in the first trial and 0.7 ± 0.8 ml in the second trial. The intra-observer variability was -0.2 ± 0.7 ml for the first observer and 1.1 ± 0.9 ml for the second observer. The average volume overlap (Dice similarity coefficient) between the fractured and contralateral side increased after surgery, while the mean and maximum surface distance decreased, indicating that the surgery contributed to a re-establishment of size and shape. In conclusion, our study shows that the semi-automatic segmentation method has precision for detecting volume differences down to 1.0 ml. The combination of semi-automatic segmentation and 3D shape analysis provides a powerful tool for planning and evaluating treatment of orbital fractures., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Enophthalmos is caused by an increase of orbital volume after blowout fracture and is one of the most critical complications of such fractures, but is often masked by swelling soon after injury. If surgery is performed after swelling resolves, it becomes more difficult to treat enophthalmos because of atrophy and fibrosis. Accordingly, it is important to estimate the severity of enophthalmos soon after injury. We developed a new criterion for determining whether orbital fractures are indicated for surgery in Asian patients using analysis of orbital volume. We retrospectively calculated the orbital volume of patients treated surgically or conservatively and analyzed the correlation between changes of orbital volume and the severity of enophthalmos. Regression analysis of the correlation between enophthalmos and increased orbital volume (y = 0.8x + 0.2; correlation coefficient: 0.92) showed that enophthalmos of 2.0 mm corresponded to an increase in orbital volume of 2.25 cm 3 . This result is similar to data reported previously for Caucasian patients - enophthalmos of 2.0 mm is a common surgical indication worldwide. Our results suggest that an increase of orbital volume of >2.25 cm 3 could be a new criterion for surgical treatment of blowout fractures in Asians., (Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Silent sinus or imploding antrum syndrome is a very rare condition, consisting of a usually asymptomatic spontaneous collapse of the sinus walls and floor of the orbit. It is associated with negative pressures, and when this occurs, it presents with manifestations such as enophthalmos, hypoglobus, and tilt flow orbital floor. As its incidence is very low, it is frequently missed as a diagnosis, and in fact there are currently fewer than 150 cases reported in the literature., Clinical Cases: Three patients have been identified in our practice over a period of two years, with different symptoms that influenced the decision of the treatment modality, which were: watch and wait, endoscopic sinus surgery, or endoscopic sinus surgery plus orbitoplasty., Conclusions: Despite being a rare entity, it stills catches the attention of the ENT, OMF surgery and Ophthalmologist. The diagnosis is mainly radiological, due to the late clinical manifestations and symptomatology. The treatment should be individualised and based on the symptoms and the individual decision of each patient, firstly by Functional Endoscopic sinus surgery, and once sinus permeability is restored, it may require augmentation surgery of the orbital floor, either with autologous bone implant, titanium or other material. It is important to be aware of this pathology, to know and to suspect it, avoiding misdiagnosis., (Copyright © 2016 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. All rights reserved.)

The infraorbital nerve (ION) can easily be damaged by orbital trauma and periorbital surgical manipulations, due to its abutment to the orbital floor. Anatomic variability of the ION and surrounding structures has infrequently been documented. The aim of this study is to give precise anatomical knowledge about the ION with surrounding structures, to avoid iatrogenic injury of the ION during periorbital procedures.Forty orbits of 40 skull subjects (20 males and 20 females) were studied to analyze structures around the ION. The authors located the ION, infraorbital canal/groove (IOC/G), and infraorbital foramen (IOF), using several reference points. The various distances were also measured between those structures, and statistically analyzed. The authors compared the left and right sides, and analyzed the differences between both sexes. The IOF was also investigated regarding the shape and presence of the accessory IOF.Three different types of orbital floor osseous anatomy were made based on macroscopic analysis. Type 1 shows no groove, and the ION enters the canal covered by the roof (5 patients, 12.5%). Type 2 revealed a pseudocanal, which has a very thin, almost transparent roof (26 patients, 65.0%). Type 3 consists of the ION traveling in a true groove, before entering an IOC (9 patients, 22.5%). IOG/C complexes took the upward lateral course, until exiting via the IOF. The mean ± SD length of the IOC was 12.86 ± 3.79 mm, and of the IOG was 16.15 ± 2.88 mm. The calculated combined mean length of the IOC/G complex was found to be 29.01 ± 3.17 mm. An accessory IOF was found in 35% of the skulls (50% in male and 20% in female skulls), with a higher frequency on the left side in both male and female skulls.These results can increase the authors' knowledge of the anatomic variability of the infraorbital region, and help facial plastic surgeons during their surgical manipulations prevent any possible iatrogenic injury of the ION.

Purpose: To determine the correlation between the degree of enophthalmos and interpalpebral fissure (IPF) measurements in a group of patients with unilateral orbital wall fractures., Materials and Methods: The medical charts of 45 patients diagnosed with unilateral enophthalmos resulting from an orbital wall fracture were reviewed. Demographic characteristics were investigated, including patient age, sex, medical history, and type of orbital wall fracture. The correlation between the degree of enophthalmos and IPF was determined, adjusting for confounding demographic factors., Results: In the group with orbital wall fractures, the correlation between the degree of enophthalmos and the IPF measurements was positive and significant (R = 0.299, p = 0.046, Pearson's correlation). The correlation coefficient increased after adjusting for age, sex, medical history, and type of orbital wall fracture (R = 0.316, p = 0.044)., Conclusion: The patient group with more severe enophthalmos tended to have lower IPF values., (Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Introduction: One of the most important complications of orbital floor fractures is diplopia and restricted ocular movement. The role of the volume of soft tissue herniation on these clinical symptoms after orbital floor fractures is unclear and potentially may predict development of persistent clinical symptoms. Therefore the aim of this study was to assess pre- and postoperative complications associated to the volume of soft tissue herniation, with special interest to diplopia and bulbus motility impairment., Material and Methods: 204 untreated patients with orbital floor fractures from 2009 to 2011 were included in this retrospective study. Contingency tables and χ 2 -test were performed to analyze associations between two qualitative variables. p-Values p < 0.05 were considered as significant. Volume measurement was performed in a semiautomatic segmentation method with the software "ITK-Snap"., Results: The volume of soft tissue herniation correlated significantly with pre- and postoperative diplopia (p = 0.003; p = 0.002), persistent diplopia (p = 0.009) as well as pre- and postoperative bulbus motility impairment (both p < 0.001). Furthermore we found out significant associations between the volume of soft tissue herniation and pre- and postoperative complications depending on fracture type and reconstruction technique., Conclusions: Volume measurement of soft tissue herniation may help to predict postoperative complications, particularly bulbus motility restriction and persistent diplopia. The risk for these symptoms rises with increasing volume of soft tissue herniation after orbital floor fractures. Therefore we recommend for these patients within indication an early repair and/or closer observation., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

In this study, the authors describe the first report of 2 patients of fat prolapse into the nasal cavity by orbital blowout fracture. The patients were a 58-year-old male and an 86-year-old female. The patients could not attain binocular single vision in any eye position because of severe impairment of the extraocular muscle motility. Computed tomographic images of both patients revealed orbital blowout fractures with orbital fat prolapse into the nasal cavity. The fractures were reduced under transconjunctival/transcaruncular and endonasal endoscopic approaches. Six months postoperatively, the patients attained a binocular single vision field, including in the primary eye position.

Orbital floor fractures are one of the most commonly encountered maxillofacial fractures due to their weak anatomical structure. Restoration of the orbital floor following a traumatic injury or a tumor surgery is often difficult due to inadequate visibility and lack of knowledge on its anatomical details. The aim of this study is to investigate the locations of the inferior orbital fissure (IOF), infraorbital groove (G), and infraorbital foramen (Fo) and their relationship with the orbital floor using a software. Measurements from the inferior orbital rim (IOR) using the Fo, the IOF, G, and the optic canal (OC) were calculated in 268 orbits as reference points. The surgical landmarks from the G and the OC, the G and the IOF, the G and the intersection point were measured as 31.6 ± 6, 12.9 ± 4, and 12 ± 5 mm, respectively. The mean distances between the G and the IOR, the Fo and the IOF, and the Fo and the OC were found as 8.3 ± 2.1, 28.7 ± 3.5, and 53.6 ± 5.9 mm, respectively. The mean angles were calculated as OC-IOF-G 68.1° ± 16.4°; intersection-G-IOF as 61.4° ± 15.8°; IOF-OC-G as 19° ± 5.5°; OC-G-intersection as 31.5° ± 11.9°, G-intersection-OC as 129.5°, IOF-intersection-G as 50.5°. Furthermore, variable bony changes on the orbital floor which may lead to the differences at intersection point of the G and Fo were determined. In 28 specimens (20.9 %), unilateral accessory Fo (AcFo) was present. In 27 specimens, AcFo was situated supermaedially (96.4 %) on the main aperture. In one specimen, two intraorbital canals and Fo emerged from different points and coursed into different apertures. The measured mean distances of the AcFo-IOR and the AcFo-Fo were as 7 ± 2 and 7.3 ± 3.2 mm, respectively. The primary principle in the oculoplastic treatment of orbital floor reconstructions must be repositioning the herniated orbital aperture by maintaining the infraorbital artery and the nerve in the orbital floor. The IOF and the G were recommended as the more reliable oculoplastic surgical landmarks for identifying the orbital floor. To avoid pinching of the orbital floor structures, the triangle (IS-G-IOF) should be equilateral with an exigence of a 70° angle within it. Among each distance of the intersection-IOF, IOF-G, G-intersection should be equal. With the help of certain software, this study made possible to investigate the variability of the orbital floor structures, observe the variety in measurements and calculate the parameters which are crucial in implementing personalized reconstruction and implanting support.

Purpose: The aim of this study was to evaluate the usefulness of intra-operative visualisation, endoscopic assistance, and CT measurements for estimating the orbital fracture size and complexity., Methods: Ten human cadaver heads were subjected to thin-slice computed tomography (CT). Standardised fractures were created using piezoelectric surgery in accordance with the Jaquiéry classification system. Four surgeons and one anatomist used six different observation methods to visualise and describe the orbital defects., Results: The intraclass correlation coefficients (ICCs) for the fracture length measurements were relatively low for all observation methods (range, 0.666-0.883). CT measurements of width showed high consistency (ICC, 0.910). The surface area of the defect was highly overestimated by all methods (range, 121-184%). None of the observers was able to accurately estimate the length or width of 95% of the defects within an error range of ±0.75 cm., Conclusion: CT measurements are the most consistent and accurate tool for estimating the critical size of orbital factures. In daily practice, a measurement tool in a DICOM viewer could be used, although software packages that allow manual adjustments are advisable. Direct intraoperative visualisation and surgeon experience are of limited value in the estimation of fracture size and complexity, and endoscopy provides no additional advantages., (Copyright © 2016. Published by Elsevier Ltd.)

Background: Orbital fractures and the concomitant soft tissue injuries within the bony orbit result in well-recognized complications such as diplopia and enophthalmos. Guidelines for timing and indications for surgery for achieving an optimal outcome remain elusive. This study examined the effects of timing and fracture type on the outcome of orbital fracture repair., Material and Methods: Data on 255 patients treated for orbital fractures were retrospectively reviewed to determine the effects of the facial bones involved in the fractures, the types of orbital wall fracture, the timing of surgical repair, and diplopia evident before and after corrective surgery on surgical outcomes., Results: The incidence of posttraumatic diplopia increased with the number of orbital wall fractures (P < 0.001). The rate of diplopia resolution after corrective surgery was slow in the first 3 months irrespective of the severity of orbital wall fracture. The diplopia resolution rate for type I orbital wall fractures was significantly higher than that for type II and type III fractures. Patients treated within 2 weeks of sustaining an orbital fracture exhibited a higher diplopia resolution rate than did patients treated 2 to 4 weeks and more than 4 weeks after sustaining the fracture (58% vs 38.1%)., Conclusions: A higher number of orbital wall fractures are associated with a higher incidence of diplopia and a poorer long-term result. The timing of surgical repair influences the diplopia outcome. Performing corrective surgery for orbital fractures with diplopia after 2 weeks tends to result in a slower complete recovery rate.

Calcium phosphate (CaP) materials have been proven to be efficacious as bone scaffold materials, but are difficult to fabricate into complex architectures because of the high processing temperatures required. In contrast, polymeric materials are easily formed into scaffolds with near-net-shape forms of patient-specific defects and with domains of different materials; however, they have reduced load-bearing capacity compared to CaPs. To preserve the merits of CaP scaffolds and enable advanced scaffold manufacturing, this manuscript describes an additive manufacturing process that is coupled with a mold support for overhanging features; we demonstrate that this process enables the fabrication of CaP scaffolds that have both complex, near-net-shape contours and distinct domains with different microstructures. First, we use a set of canonical structures to study the manufacture of complex contours and distinct regions of different material domains within a mold. We then apply these capabilities to the fabrication of a scaffold that is designed for a 5 cm orbital socket defect. This scaffold has complex external contours, interconnected porosity on the order of 300 μm throughout, and two distinct domains of different material microstructures.

Background: Restoring the volume of orbital fracture is a challenge to the surgeons. We combined the transnasal balloon technique and the transorbital approach during orbital floor reconstruction, and compared the outcomes of this technique with those of the conventional transorbital approach., Methods: Patients with unilateral pure orbital floor fracture were divided according to the surgical method: the direct transconjunctival approach (group A, 20 patients, control group) or the combination approach with the transnasal balloon technique (group B, 20 patients, experimental group). The orbital volume ratio (OVR) was measured with the use of computed tomographic scans, and enophthalmos was checked with a Hertel exophthalmometer., Results: The orbital volume ratios in both groups decreased after surgery: it was more effectively decreased in group B (7.88%) than that in group A (1.69%) (P < 0.05)., Conclusions: A combination of transconjunctival exploration and transnasal restoration with balloon support was more effective in restoring the orbital volume than the conventional method.

A case of traumatic delayed meningo-encephalocele suffered orbital fracture, but bony defects in frontal sinus had not been found on CT scanning. We treated the patient with surgery of intranasal endoscopy and repaired the skull base defect successfully during the first attempt. There was no recurrence in 10 months followed up. The leak site may not correlate with imaging in traumatic delayed meningo-encephalocele by comparing operative findings with the imaging estimate and endoscopy. Therefore, endoscopical approaching is effective in seeking and treatment.

The aim of this study is to investigate preoperative and postoperative properties, the management of unilateral complex orbital fractures, and to offer an algorithm for orbital fractures. For this research study, 248 patients with orbital trauma were evaluated according to an offered algorithm. Diplopia, enophthalmos, dystopia, infraorbital nerve dysfunction, and ocular movement limitations were documented for clinical assessment. Orbital rim displacement and an orbital volume check with computed tomography (CT) were used for indication of surgery. The injured orbital volume was compared with the healthy orbital volume in the preoperative and postoperative periods. In total, 58 patients required operations among the 248 patients, according to the algorithm. The preoperative mean injured orbital volume measurements of the operated patients were statistically different than the healthy orbital volume measurements (30.13 cm3 ± 2.69 cm3 and 27.15 cm3 ± 1.29 cm3, respectively). In the postoperative period, there was no difference between the injured and healthy orbital volume. In conclusion, an algorithm may facilitate the approach to unilateral complex orbital fractures. Ophthalmic examination, rim displacement, and the measurement of orbital volume using computed tomography are key points of orbital fractures with regard to management.

We describe here a peculiar case of a 30-year-old woman presenting with an orbital trapdoor fracture. Preoperative and postoperative magnetic resonance images are provided to explain the mechanism of the injury.

Purpose: To characterize the location of orbital blowout fractures in Asian individuals., Methods: This was a retrospective review of 470 consecutive Asian patients with orbital blowout fractures who presented to four tertiary care hospitals in Japan and China. Computed tomography (CT) characterized the location and severity of fractures involving the medial wall, the orbital floor, and/or the maxilloethmoidal strut., Results: A total of 475 orbital blowout fractures were identified. More than one fracture location was involved in 19% of all cases. The medial orbital wall was the most commonly involved location, presenting in 29 cases (61%), of which 204 (43%) were isolated medial blowout fractures. The orbital floor was the second most common location involved, present in 226 cases (48%) with 150 isolated orbital floor fractures (32%), while the maxilloethmoidal strut was involved in 45 cases (9%) with 30 of those being isolated strut fractures (6%). The majority of fractures (62%) were classified as moderately severe, whilst 14% were mild, and 24% were severe. Associated nasal fractures were present in 16% of the cases., Conclusions: Orbital blowout fractures in Japanese and Chinese individuals occur most commonly in the medial wall. This is in contrast to previous reports on white individuals, who tend to sustain fractures involving the orbital floor rather than the medial wall.

The unique and complex anatomy of the orbit requires significant contouring of the implants to restore the proper anatomy. Fractures of the orbital region have an incidence of 10-25% from the total facial fractures and the most common age group was the third decade of life. The majority of cases required reconstruction of the orbital floor to support the globe position and restore the shape of the orbit. The reason for this was that the bony walls were comminuted and/ or bone fragments were missing. Therefore, the reconstruction of the missing bone was important rather than reducing the bone fragments. This could be accomplished by using various materials. There is hardly any anatomic region in the human body that is so controversial in terms of appropriate material used for fracture repair: non resorbable versus resorbable, autogenous/ allogeneic/ xenogenous versus alloplastic material, non-prebent versus preformed (anatomical) plates, standard versus custom-made plates, nonporous versus porous material, non-coated versus coated plates. Thus, the importance of the material used for reconstruction becomes more challenging for the ophthalmologist and the oral and maxillofacial surgeon.

Purpose: The aim of this study was to analyze the occurrence and characteristics of orbital roof fractures, periorbital hematoma, conjunctival hemorrhage, orbital roof discoloration, and concomitant head injuries in falls from a standing height., Methods: A prospective autopsy study was performed over a 4-year period (from 2010 to 2013). Subjects who had died due to traumatic brain injury caused by falls from a standing height were included in the study., Results: Fifty cases of ground level falls were recorded. This group consisted of 39 men and 11 women, with an average age of 67.3 ± 13.6 years, and median age of 70 years. Skull fractures originating in the proximity of impact site were found in 47 of 50 individuals, and 22 had isolated orbital roof fractures not connected to the fracture line. Bluish discoloration of the orbital roof was noted in 19 subjects, 14 had periorbital hematomas, and 12 had blotchy or purpura-like conjunctival hemorrhages., Conclusions: Isolated orbital roof fractures in falls from a standing height are easily detected using a standard autopsy technique, with special regard to careful removal of the dura in the anterior cranial fossa. Our study shows that orbital roof fractures can occur in accidental falls from a standing height and may not be associated with concomitant skull fractures and brain injuries.

Learning Objectives: After studying this article, the participant should be able to: 1. Explain the epidemiology, anatomy, and pathophysiology of orbital floor fractures. 2. Select the optimal timing of--and understand the indications for-operative repair of orbital floor fractures. 3. List advantages and disadvantages of the surgical approaches and materials available for orbital floor reconstruction. 4. Identify special considerations in treating pediatric patients presenting with orbital floor fractures., Summary: This maintenance of certification module reviews the anatomy, pathophysiology, diagnosis, and management of orbital floor fractures in addition to special considerations for pediatric patients. The shows the evidence rating scale used for the literature review in creating this maintenance of certification article.

Background and Objective: In an orbital fracture involving diplopia, enophthalmos is a major problem to be corrected because ofsoft tissue swelling and limited incision, which causes inaccurate restoration oforbital anatomy and reestablishing orbital volume. Pre-operative computerized planning combined with intra-operative navigation and endoscopy are used to create the accurate anatomical orbital position and effectively correct the posttraumatic diplopia and enophthalmos., Case Report: An 18-year-old Thai male with diplopia and enophthalmospresented aposttraumatic left orbital fracture two months prior Three-dimensional CTscan of the facial bone confirmed the fracture. The patient required surgical treatment for correction of the orbital fracture. The intra-operative navigator and endoscopy-assisted technique were used. Pre- and post-operative pictures were compared, indicated the successful correction of enophthalmos and clinical correction of diplopia., Conclusion: Intra-operative navigator combined with endoscopy-assisted technique were a new surgical procedure that could correct the orbital deformity problem involving enophthalmos and diplopia more effective.

Purpose: To determine the extent to which the accuracy of magnetic resonance imaging (MRI) based virtual 3-dimensional (3D) models of the intact orbit can approach that of the gold standard, computed tomography (CT) based models. The goal was to determine whether MRI is a viable alternative to CT scans in patients with isolated orbital fractures and penetrating eye injuries, pediatric patients, and patients requiring multiple scans in whom radiation exposure is ideally limited., Materials and Methods: Patients who presented with unilateral orbital fractures to the Royal Brisbane and Women's Hospital from March 2011 to March 2012 were recruited to participate in this cross-sectional study. The primary predictor variable was the imaging technique (MRI vs CT). The outcome measurements were orbital volume (primary outcome) and geometric intraorbital surface deviations (secondary outcome) between the MRI- and CT-based 3D models., Results: Eleven subjects (9 male) were enrolled. The patients' mean age was 30 years. On average, the MRI models underestimated the orbital volume of the CT models by 0.50 ± 0.19 cm(3). The average intraorbital surface deviation between the MRI and CT models was 0.34 ± 0.32 mm, with 78 ± 2.7% of the surface within a tolerance of ±0.5 mm., Conclusions: The volumetric differences of the MRI models are comparable to reported results from CT models. The intraorbital MRI surface deviations are smaller than the accepted tolerance for orbital surgical reconstructions. Therefore, the authors believe that MRI is an accurate radiation-free alternative to CT for the primary imaging and 3D reconstruction of the bony orbit., (Copyright © 2014 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

The unique and complex anatomy of the orbit requires significant contouring of the implants to restore the proper anatomy. Fractures of the orbital region have an incidence of 10-25% from total facial fractures and the most common age group was the third decade of life. The majority of cases require reconstruction of the orbital floor to support the globe position and restore the shape of the orbit. The reason for this is that the bony walls are comminuted and/or bone fragments are missing. Therefore, the reconstruction of missing bone is important rather than reducing bone fragments. This can be accomplished using various materials. There is hardly any anatomic region in the human body that is so controversial in terms of appropriate material used for fracture repair: nonresorbable versus resorbable, autogenous/allogenous/xenogenous versus alloplastic material, non-prebent versus preformed (anatomical) plates, standard versus custom-made plates, nonporous versus porous material, non-coated versus coated plates. Thus, the importance of material used for reconstruction becomes more challenging for the ophthalmologist and the oral and maxillofacial surgeon.

Objective: The most accurate orbital reconstructions result from an anatomic repair of the premorbid orbital architecture. Many different techniques and materials have been used; unfortunately, there is currently no optimal method. This study compares the use of preformed vs intraoperative bending of titanium mesh for orbital reconstruction in 2-wall orbital fractures., Study Design: Cadaver-based study., Setting: University hospital., Subjects and Methods: Preinjury computed tomography scans were obtained in 15 cadaveric heads (30 orbits). Stereolithographic (STL) models were fabricated for 5 of the specimens (10 orbits). Two wall fractures (lamina papyracea and floor) were then generated in all orbits. Surgical reconstruction was performed in all orbits using 1 of 3 techniques (10 orbits each): (1) patient-specific implant molded from the preinjury STL model, (2) titanium mesh sheet bent freehand, and (3) preformed titanium mesh. Each technique was evaluated for orbital volume correction, contour accuracy, ease of use, and cost., Results: No difference in volume restoration was found between the 3 techniques. Patient-specific implants had the greatest contour accuracy, poor ease of use, and highest cost. Freehand bending implants had the poorest contour accuracy, acceptable ease of use, and lowest cost. Preformed mesh implants had intermediate contour accuracy, excellent ease of use, and low cost., Conclusion: All 3 techniques provide equivalent orbital volume correction. However, preformed mesh implants have many advantages based on contour accuracy, ease of use, and relative cost.

Before undergoing repair of zygomaticomaxillary complex fractures, most patients are worried about their postoperative appearance. Furthermore, there is an ongoing discussion about the selection of the surgical approach to the inferior orbita and resulting eyelid deformities. We present a photo-assisted postoperative evaluation of zygomaticomaxillary complex fracture repair based on reference anthropometric data. Two hundred and twenty-one patients underwent zygomaticomaxillary complex fracture repair. An analysis of standardized postoperative photographs included measurements of eye fissure width and height, lid sulcus height, upper lid height, upper and lower coverage, position of cornea to palpebra inferior, canthal tilt, scleral show, ectropion and entropion. It was clearly distinguished between operated and contralateral eyelid, and whether a transconjunctival or a subciliary approach was performed. Surgery per se significantly influenced eyelid deformities as measured by its impact on eye fissure index, lower iris coverage and rate of scleral show and ectropion. The surgical approach selected significantly affected eye fissure index, lower iris coverage and rate of scleral show, indicating distortion of the lower eyelid. Investigations regarding orbital fractures should clearly differentiate the type of fracture. The subciliary approach included the highest risk of postoperative lower eyelid deformity in zygomaticomaxillary complex fracture repair. The standardized measurements described here are accurate and objective to evaluate postoperative results., (Copyright © 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Tissue-engineering approach can result in significant bone regeneration. We aimed to reconstruct the segmental orbital rim defects with antigen-free bovine cancellous bone (BCB) scaffolds combined with bone marrow mesenchymal stem cells (BMSCs) in rats., Methods: BCB was prepared by degreasing, deproteinization and partly decalcification. BMSCs isolated from green fluorescent protein (GFP) transgenic rats were osteogenically induced and seeded onto BCB scaffolds to construct induced BMSCs/BCB composites. An 8-mm full-thickness defect on the rat inferior-orbit rim was established. Induced BMSCs/BCB composites cultured for 5 days were implanted into the orbital defects as the experimental group. Noninduced BMSCs/BCB group, BCB group and exclusive group were set. General condition, spiral CT, 3D orbital reconstruction, histological and histomorphometric analysis were performed after implantation., Results: BCB presented reticular porous structure. GFP-BMSCs adhering to BCB appeared bright green fluorescence and grew vigorously. Infection and graft dislocation were not observed. In induced BMSCs/BCB group, CT and 3D reconstruction showed perfect orbital repair situation. Histological analysis indicated BCB was mostly biodegraded; newly formed bone and complete synostosis were observed. The percentage of newly formed bone was (57.12 ± 6.28) %. In contrast, more residual BCB, less newly formed bone and nonunion were observed in the noninduced BMSCs/BCB group. Slowly absorbed BCB enwrapped by fibrous connective tissue and a small amount of new bone occurred in BCB group. Fibrous connective tissue appeared in exclusive group., Conclusions: Antigen-free bovine cancellous bone that retains natural bone porous structure and moderate mechanical strength with elimination of antigen is the ideal carrier for mesenchymal stem cells in vitro. BCB combined with BMSCs is a promising composite for tissue engineering, and can effectively reconstruct the orbit rim defects in rats.

Background: An experimental study was done to assess the ability of the vegetal polymer miniplates and screws to repair defects of the orbital floor., Methods: An artificial standard-sized defect was created in the bony floor of right orbit of 45 albino rabbits. The animals were divided into three experimental groups: control group (G1) involving animals with orbital floor defect and no treatment; titanium group (G2) containing animals with orbital floor defect repaired by titanium miniplates and screws; vegetal polymer group (G3) composed of animals with similar orbital floor defects repaired by vegetal polymer miniplates and screws. Throughout the course of the experiment, the animals were clinically evaluated. At 15, 30 and 60 days after surgery, the animals were killed. They were X-rayed immediately after the floor defect and at the moment of sacrifice. Histological and morphometric evaluation of inflammatory reaction and bone healing was done. Data were statistically evaluated., Results: No implants were extruded. Bone consolidation was similar in G2 and G3 and better than in G1 group animals. Inflammatory reaction was most pronounced in animals of G3 15 days after surgery, and it subsided over time., Conclusion: Vegetal polymer miniplates and screws induces small inflammatory reaction and had the ability to stimulate bone growth with good integration in the orbital floor defect allowing to consider the vegetal polymer adequate option to treat orbital floor defects. Future studies involving long-term follow-up and biomechanical tests to evaluate material resistance to traction are needed., (© 2012 The Authors. Clinical and Experimental Ophthalmology © 2012 Royal Australian and New Zealand College of Ophthalmologists.)

The development of non-lethal weapons started in the 1960s. In France, they have been used by the police for about 10 years. We relate the cases of three French women, victims of stinger grenades, non-lethal weapons recently adopted by the French law enforcement to distract and disperse crowds. The three victims presented serious injuries requiring emergency surgical care. One lost her eye. Based on these cases, we discuss the lethal character of these weapons and propose measures to be taken to prevent their dramatic consequences. Although the danger is obviously less than for firearms, stinger grenades are nonetheless potentially lethal and cause serious physical injuries., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: Trauma-induced eye injuries are the leading cause of monocular blindness in the United States. Few studies to date have focused on ocular injuries in the trauma population. Our intent was to determine the annual percentage of ocular injury, types of injuries, and percentage with ocular injury-related procedures performed during the same hospitalization., Methods: This study was a retrospective analysis of 28,340 patient records included in the National Trauma Data Bank National Sample Program from 2003 to 2007. Patients with ocular injuries and related procedures were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedure codes and were subsequently grouped into categories of ocular injury using the criteria of the Barell body region injury diagnosis matrix. Weighted national estimates for the proportion of patients with ocular trauma were calculated based on the relative weights for patients in each facility within the sample universe. Weighted frequencies were expressed as a percentage of the total population of trauma admissions, with 95% confidence intervals calculated for precision., Results: During the time frame examined, 1.97% to 6.00% of annual trauma patient admissions included ocular injuries. The most common injuries were contusions or superficial injuries and then closed orbit fractures accounting for 0.95% to 2.48% and 0.58% to 2.37% of all injuries, respectively. Between 0.56% and 1.52% of annual trauma admission had both ocular trauma and related procedures during their hospitalization. Popular treatments were therapeutic procedures on eyelids, conjunctiva, and/or cornea occurring in 0.15% to 0.84% of all trauma patients. Facial fracture-related procedures were reported for between 0.16% and 0.65% of all trauma patient admissions., Conclusion: The National Trauma Data Bank National Sample Program can be used to create useful estimates of ocular injury characteristics among patients seen in the population seen in trauma centers, including types of ocular injury and related procedures performed during the same admission., Level of Evidence: Epidemiologic study, level V.

Background: Before undergoing repair of orbital fractures, most patients are worried about their postoperative appearance. Furthermore, there is an ongoing discussion in the literature about the influence of trauma and surgical approach to the inferior orbita on eyelid deformities., Methods: In this retrospective comparative study, we present an evaluation of a series of 311 postoperative results of orbital fractures on standardized photographs based on reference anthropometric data. Analysis included eye fissure width and height, lid sulcus height, upper lid height, upper and lower iris coverage, position of cornea to inferior palpebra, canthal tilt, scleral show, ectropion, and entropion. It was clearly differentiated between operated and contralateral eyelid type of fracture of the midface and whether a transconjunctival or a subciliary approach was used., Results: Surgery and the chosen approach presented significant effects on eye fissure index, lower iris coverage, scleral show, and ectropion. Different types of fractures affecting the orbita showed no influence on the investigated values., Conclusion: Not surprisingly, an association between surgery and lower lid retraction was found. The underlying osseous trauma did not show a significant influence on the presented measurements. Subciliary approaches increased the risk of lower lid retraction. The standard measurements described here are accurate and objective to evaluate postoperative results., Level of Evidence: Prognostic/epidemiologic study, level III.

The anatomical location of fractures following blunt cranio-orbital trauma is important for neurosurgeons and maxillofacial surgeons. In this study, 588 cranio-orbital fractures following blunt trauma were evaluated retrospectively with regard to the anatomical site and surgical treatment. Orbital cranial nerve injuries and the outcomes of the medical and/or surgical treatment are described. Distribution of the zygomatic complex and orbital fractures were as follows: zygomatic complex fractures (n:304), isolated orbital fractures (n:58), complex comminuted fractures (n:226). In 58 cases, 69 orbit fractures were found (11 bilateral and 47 unilateral fractures). The lateral wall was the most frequent fracture (n:63). The least frequent fracture was the roof of the orbit (n:11). The accompanying lesions were as follows: 89.65% of cases were associated with periorbital haematoma (n:52), 13.79% of cases with retrobulbar haemorrhage (n:8), 96.55% cases with periorbital soft tissue oedema (n:56), 53.45% cases with pneumocephalus (n:31), 8.62% cases with intra-parenchymal contusion (n:5), 6.89% cases with enophthalmia (n:4), 5.17% of cases with rhinorrhoea (n: 3), 5.17% cases with optic bulb injury and adnexial trauma (n:3), 32.76% cases with intra-orbital emphysema (n:19), and 20.69% with vision dysfunctions (n:12), of whom 2 had no optic nerve injury., (Copyright © 2011 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background and Purpose: The craniofacial skeleton remains not fully recognised as far as its mechanical resistance properties are concerned. Heretofore, the only available information on the mechanism of cranial bone fractures came from clinical observations, since the clinical evaluation in a living individual is practically impossible. It seems crucial to implement computer methods of virtual research into clinical practice. Such methods, which have long been used in the technical sciences, may either confirm or disprove previous observations. The aim of the study was to identify the areas of stress concentrations caused by external loads, which can lead to cranio-orbital fractures (COF), by the finite element method (FEM)., Material and Methods: For numerical analysis, a three-dimensional commercially available geometrical model of the skull was used which was imported into software of FEM. Computations were performed with ANSYS 12.1 Static Structural module. The loads were applied laterally to the frontal squama, the zygomatic process and partly to the upper orbital rim to locate dangerous concentration of stresses potentially resulting in COF., Results: Changes in the area of force application revealed differences in values, quality and the extent of the stress distribution. Depending on the area of force application the following parameters would change: the value and area of stresses characteristic of COF., Conclusion: The distribution of stresses obtained in this study allowed definition of both the locations most vulnerable to fracture and sites from which fractures may originate or propagate.

The aims of this study were to compare the degree of swelling of the medial rectus muscle (MR) in a recent fracture group, an old fracture group, and a normal group and to use this to differentiate old medial orbital wall fracture from recent fracture.We made measurements of the computed tomography images of 43 patients with a recent medial orbital wall fracture (the recent fracture group), 46 patients with depression of the medial wall and who were without a recent trauma history (the old fracture group), and 86 patients who were without any facial injury (the normal group). On the axial view, the width of the MR was measured bilaterally, and the width ratio to the contralateral side was calculated. On the coronal view, the height of the MR was measured bilaterally, and the height ratio to the contralateral side was calculated. The width-to-height ratio was also measured on the involved side.The width ratio of the recent fracture group was 1.42 ± 0.31, and it was significantly higher than that of the old fracture group (1.25 ± 0.15) or the normal group (1.00 ± 0.09). The width ratio of the old fracture group was also significantly higher than that of the normal group. The height ratio of the normal group (1.00 ± 0.04) was significantly higher than that of the recent fracture group (0.91 ± 0.15) or the old fracture group (0.86 ± 0.07). The height ratio of the recent fracture group was also significantly higher than that of the old fracture group (P = 0.043). The width-height ratio of the recent fracture group (0.63 ± 0.23) was significantly higher than that of the old fracture group (0.55 ± 0.09) or the normal group (0.37 ± 0.05). The height-to-width ratio of the old fracture group was also significantly higher than that of the normal group.We think the width ratio of the MR of the injured side to the MR of the contralateral side can be the better parameter to differentiate a recent fracture from an old fracture.

We report an autopsy case of a 42-year-old woman who, when discovered, had been dead in her apartment for approximately 1 week under circumstances involving treachery, assault and possible drug overdose. This case is unique as it involved two autopsies of the deceased by two different medical examiners who reached opposing conclusions. The first autopsy was performed about 10 days after death. The second autopsy was performed after an exhumation approximately 2 years after burial. Evidence collected at the crime scene included blood samples from which DNA was extracted and analysed, fingerprints and clothing containing dried body fluids. The conclusion of the first autopsy was accidental death due to cocaine toxicity; the conclusion of the second autopsy was death due to homicide given the totality of evidence. Suspects 1 and 2 were linked to the death of the victim by physical evidence and suspect 3 was linked by testimony. Suspect 1 received life in prison, and suspects 2 and 3 received 45 and 20 years in prison, respectively. This case indicates that cocaine toxicity is difficult to determine in putrefied tissue and that exhumations can be important in collecting forensic information. It further reveals that the combined findings of medical examiners, even though contradictory, are useful in determining the circumstances leading to death in criminal justice. Thus, this report demonstrates that such criminal circumstances require comparative forensic review and, in such cases, scientific conclusions can be difficult., (Published by Elsevier Ltd.)

Endoscopic transnasal reduction is a safe and effective technique for the treatment of blow-out fractures of the medial orbital wall. However, because this approach does not use rigid permanent material for reconstruction of the fractured medial orbital wall, some degree of herniation of the orbital contents may occur after the intraethmoidal packing material is removed. The purpose of this study was to evaluate the change in orbital volume in patients with medial orbital wall fractures treated through an endoscopic transnasal approach. This study was a prospective analysis that includes 20 patients who underwent endoscopic transnasal reduction of medial orbital wall fractures between April 2007 and December 2008. Computer-assisted orbital volume measurements were made using axial computed tomography. The mean (standard deviation [SD]) volume increase was 2.00 (0.92) cm(3) and the mean (SD) dimension of the fractured orbital wall was 2.76 (0.83) cm(2). After endoscopic surgery, an average (SD) volume decrease of 2.15 (0.91) cm(3) was achieved with ethmoid sinus packing. After removal of the packing materials, 1.14 (0.78) cm(3) increase of the orbital volume was observed. The dimension of the orbital wall fracture significantly correlated with the increased preoperative orbital volume (P = 0.002, r = 0.609); the preoperative increase in the orbital volume also significantly correlated with volume relapse after removal of the packing (P = 0.023, r = 0.452). These findings suggest that in broad orbital wall fractures, reconstruction of the orbital wall by rigid materials or prolongation of the packing period should be considered, because orbital volume can increase again after packing removal, and may thus lead to postoperative complications.

Purpose: To compare inferior orbital wall morphology between isolated inferior and medial orbital wall fracture patients., Methods: The morphologic properties of patients with isolated blow-out fractures involving the medial wall or inferior wall treated from August 2004 to August 2009 were reviewed. The cross-sectional area, thickness, gradient, and curvature of the inferior wall were measured via orbital CT in the opposite non-traumatized eye., Results: Patients with isolated inferior wall fractures (n = 77) and isolated medial wall fractures (n = 78) evidenced no differences in sex, age, etiology of trauma, laterality of trauma, and associated concomitant intraocular injuries. The cross-sectional area, thickness, and gradient of the inferior wall did not differ significantly between the 2 groups. However, the coefficient of curvature was significantly greater in patients with inferior wall fracture than in patients with medial wall fracture (0.016 ± 0.006 vs. 0.006 ± 0.002, respectively; p = 0.000)., Conclusion: Patients with more convex and steep inferior walls are more likely to incur isolated inferior wall fractures than isolated medial wall fractures., (Copyright © 2011 S. Karger AG, Basel.)

Fractures of the midface and internal orbit occur isolated or in combination with other injuries. Frequently, the patients are first seen in emergency rooms responsible for the coordination of initial diagnostic procedures, followed by the transfer to specialties for further treatment. It is, therefore, important for all colleagues in traumatology to understand the basic principles of injuries to the midface. Thus, the aim of this article is the description of the anatomy and the current classification systems in use, the related clinical symptoms, and the essential diagnostic measures to obtain precise information about the injury pattern. Issues for treatment will be illustrated and discussed in "Part 2" of this article.

Objective: To assess the vascularization of the laterally based pericranial flap and the feasibility of bony channel on the orbital lateral wall for transplantation of the flap, and apply this flap to treat traumatic enophthalmos., Methods: Two formalin preserved cadaver specimens were anatomized to observe the feasibility of pericranial flap transplantation through the bony channels on lateral orbital walls. Two fresh cadaver specimens were perfused with latex and ink respectively to observe the possible blood supply to laterally based pericranial flaps. Two patients with unilateral old orbital fracture were treated using this flap. The enophthalmos degrees were measured before and after operation to evaluate the effect of this therapy., Results: It was feasible to transplant the pericranial flap into orbit through the bony channel on lateral orbital wall, reaching the medial wall and orbital floor. Vascular perfusion did not reveal that the laterally based pericranial flap over the supra temporal line was vascularized by any axial vessel. The ink perfusion of one side showed that the middle temporal artery extended deeply under the deep temporal fascia, but didn't cross the supra temporal line. The subgaleal vascular plexus was observed obviously in the superficial layer of pericranial flap. The enophthalmos degrees of the two patients were respectively 5.35 mm and 6.86 mm prior to operation. They both showed desirable outcomes postoperation (<2 mm)., Conclusion: It is feasible to transfer the laterally based pericranial flap into orbit through the lateral orbital wall channel. The laterally based pericranial flap is possibly vascularized by the subgaleal vascular plexus. The primary treatment of traumatic enophthalmos using the laterally based pericranial flap is satisfactory.

A 46-year-old woman presented after blunt facial trauma for evaluation of bilateral orbital floor fractures, which were confirmed by clinical and radiographic examination. In addition, findings of right traumatic mydriasis and left traumatic ptosis were seen. On close investigation, miosis was noted on the side of the traumatic ptosis. Therefore, a workup for Horner syndrome was obtained, including neuro-ophthalmic consultation and magnetic resonance angiography of the neck. The magnetic resonance angiography showed an internal carotid pseudoaneurysm, an uncommon but potentially fatal complication of blunt carotid injury. The authors describe an interesting case where a life-threatening diagnosis was nearly masked by more common, benign pathology.