Grand Ward Round

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Grand Ward Round

• Case Presentation Mr QBZ

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History

• 17 Malay boy
• Allegedly assaulted on 31 May 2008
• Awoke to find himself in hospital
• Admittted under Neurosurgeons for head injury
• C/O binocular vertical diplopia during admission
• Referred as blue letter and first seen by us on 2
  June 2008
• Otherwise well with no nausea or vomiting

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Examination
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• R mild Enophthalmos
• R gross Hypotropia

-4
0
0
0
0
EOM
0
0
-3.5
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CT ORBITS

• Fracture involving the infero-medial wall of the
  right orbit posteriorly. Also Fracture of the
  medial wall of the right maxillary antrum seen
• Surrounding soft tissue swelling and prolapse of
  a small amount of retrobulbar fat into the roof
  of the maxillary sinus
• No significant prolapse of the R inferior rectus
  is seen, however it appears slightly swollen with
  surrounding fat stranding suggesting a contusion

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Diagnosis

• Right orbital floor fracture
• With entrapment of orbital contents
• White-eyed blowout fracture

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MANAGEMENT

• Underwent R Orbital Floor Fracture Repair with
  Osteomesh implant on 2 Jun 2008 1930 hrs in EOT
  (2 days post initial injury)
• Intraop findings
• Posterior fracture 28 mm from orbital rim
• 5 mm x 5mm in size
• Entrapment of orbital contents- relieved during
  op

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• Postop
• G Preforte Q1H RE
• G Cravit Q3H RE
• PO Prednisilone 60mg OM

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3 June 2006 ( POD 1)

• LHT 40?
• R Hypotropia ? due to R Inferior rectus
• Direct injury/ fibrosis
• Entrapment

0
-4
0
0
0
0
-3
0
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Postop CT Orbits

• Previously noted blowout fracture had been
  reduced
• The inferior rectus muscle is enlarged, with
  inflammatory change in adjacent fat
• No evidence of entrapment
• Findings suggest residual muscle swelling, edema
  and inflammation

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13 Jun 2008 (POD 11)

• Subjectively mild diplopia in primary gaze
• LHT 6 ?- Improved
• HERTELs

113
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17
-2
0
EOM
0
0
0
0
-3
0
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Orbital Blowout Fractures and the White-eyed
Blowout fracture
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Orbital Blowout Fractures

• More common in males
• Usually between the ages of 21 to 30 years
• Result from an impact injury to the globe and
  eyelid
• The object is usually
• Large enough not to perforate the globe
• And small enough not to fracture the orbital rim
• E.g. fist, tennis ball, door knob

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Mechanism of Injury

• 2 theories
• The fracture results from sudden increase in
  intraorbital pressure
• The fracture is the result of buckling forces
  which are transmitted to the orbital bones by a
  transient deformity of the orbital rim
• .

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• Under these circumstances, fractures of the
  inferior orbital wall are most common because of
  a combination of factors, namely
• the thinness of the maxillary roof,
• presence of the infraorbital canal,
• and the curvature of the floor

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Pertinent Signs Symptoms

• Restricted ocular movements and Diplopia
• Enophthalmos, resulting from
• Escape of orbital fat
• Enlargement of bony orbital volume
• Muscle entrapment causing a backward pull on the
  globe
• Infraorbital nerve hypoesthesia
• Numbness of the gums and skin of mid-face

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Investigations

• CT Orbits is gold standard
• But critical to obtain coronal views
• Might be difficult to obtain in patients with
  cervical spine injuries
• As coronal imaging requires hyper-extention of
  the neck
• In these cases, should be able to reconstruct
  coronal vies from axial images

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General Rules of Management

• Conservative Rx
• Suitable for
• Patients without significant enophthalmos
• A lack of marked hypoglobus
• Absence of entrapped muscle or tissue
• Fracture less than 50 of floor
• Lack of diplopia

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• In this group of patients, treat with
• IV or PO Antibiotics
• A short course of PO Prednisilone may also
  benefit in reducing edema of the orbit and
  muscle, and may allow more thorough assessment
  later on
• Discourage nose blowing to avoid creating or
  worsening orbital emphysema
• Nasal decongestants can also be used

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• Surgical Management
• Indications of surgery
• Diplopia especially in the primary position
• which does not improve after posttraumatic edema
  resolves
• Large floor fractures (gt50)
• Which may result in progressive enophthalmos
• Significant globe dystopia
• Hypoglobus or enophthalmos (gt2mm)

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• Generally accepted ophthalmic guidelines suggest
  surgical intervention within 2 weeks of injury
• This 2 week window allows for some resolution of
  tissue edema and hemorrhage

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• Important to bear in mind that these general
  guidelines are suitable and can be applied to the
  management of adult orbital floor fractures
• However for such fractures in the paediatric
  population, the evaluation and management
  differs from that of the adult

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White-Eyed Blowout Fractures (WEBOF)

• Young patients
• Less than or equal to 18 years of age
• Significant trauma history
• But little clinical signs of soft tissue injury
• Extraocular movements are restricted in up and
  down-gaze
• Giving rise to marked diplopia
• Often pain on attempted vertical gaze
• May complain of nausea and vomitting

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• Lane et al (2007)
• Compared signs and symptoms of 16 patients with
  WEBOF
• Versus 14 control patients with with large
  classic blowout fractures

Lane et al. Orbit, 200726
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• CT scanning
• Reveals either a small crack along the floor with
  little or no bony displacement
• Or a small trap door defect (i.e., the bony
  orbital floor was attached or hinged at one
  edge), with a tear drop tissue herniation into
  the maxillary sinus

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Example 1

• Coronal CT Orbits
• Arrow points to a small soft tissue opacity
  within a narrow break in the orbital floor
• Note that the inferior rectus is missing-
• the muscle is in effect tightly tethered and
  distorted within the confines of the fracture

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Pathophysiology of Orbital Fractures in Adults
versus Children
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Adults

• In adults (gt18 years of age)
• The bones are more mature, brittle and less
  flexible
• When a blow is sustained to the periocular
  region, the floor more commonly buckles, and
  breaks in several areas
• And a portion of the floor blows out into the
  antrum, rather than staying hinged and springing
  back

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Children

• Conversely, children have softer, less calcified
  and more flexible bone
• When a similar blow is sustained to the region
• The floor is more likely to bend, crack, and form
  a flexible trapdoor that springs downwards
  initially
• As the blow is finished, the floor returns to its
  normal position
• Entrapping tissue in the process

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• Radiographically, if a considerable amount of
  tissue is entrapped, it will show up as a tear
  drop tissue herniation on CT scan
• However if little tissue is entrapped, the floor
  will only appear to have a small crack
• The trap door returning to its normal anatomic
  position impinges the herniated tissue
• Potentially reduces blood flow to the muscle and
  the perimuscular tissue

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Smith et al (1984)

• First demonstrated that small orbital fractures
  were more likely to incarcerate extraocular
  muscle than large fractures
• And this may lead to compartment syndrome (as
  described by Volkman)
• Producing muscle ischaemia, fibrosis and
  restricted motility
• If this Volkman syndrome was not relieved
  surgically, diplopia seemed to be persistent
• They advocated early surgical release of
  entrapped muscles to prevent permanent damage and
  diplopia

Smith et al, Plast Reconstr Surg. 198474
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• Hence waiting 2 to 3 weeks in this group of
  patients may be detrimental to the patients
  recovery
• As the ischaemic process is prolonged, and could
  lead to fibrosis to the muscular and perimuscular
  tissue

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• Instead early repair (within days), returns the
  herniated tissue to its normal position, and
  relieves any compartment syndrome
• Moreover a 2 week watch and wait period is not
  necessary in this group because the patients have
  little or no sign of soft tissue trauma
• Thus allowing a thorough clinical assessment

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• Jordan et al (1998)
• Reported on 20 individuals with characteristics
  of white-eyed blowout fracture
• All patients were under 18 years of age
• With history of significant blows to the
  periocular area
• On clinical examination, they exhibited little
  signs of soft tissue injury
• Little ecchymosis, lid swelling, ptosis or
  chemosis

Jordan et al. Ophthal Plast and Recon Surg. 1998
14(6)
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• There were significant complaints of diplopia in
  all cases
• With motility restrictions in up and down-gaze in
  all patients
• CT scanning typically showed a small crack on the
  orbital floor
• Or trap door like defect with little bony
  displacement

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• The time of injury to the time of surgery ranged
  from 48 hours to 40 days
• Some of the patients were managed according to
  the 2 week watch and wait grace period Whereas
  other underwent early surgery within days

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• Of the 20 patients, 6 (30) underwent surgery
  within 5 days
• In 5 (83) of these 6 patients, symptoms resolved
  between 3 to 6 weeks after surgery
• In 1 patient, symptoms resolved slowly over 1
  year
• In no patients was there felt to be permanent
  restriction

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• In the other 14 (70) patients
• Surgery was performed between 5 to 40 days
  (average 14.2 days)
• Symptoms resolved in 3 (21) of these patients
  within 4 weeks
• In the other 11
• Symptoms resolved over 4 to 10 months in 8 (57)
  patients
• However 3 (21) patients had continued
  restriction by 12 months

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• The authors concluded that WEBOF patients having
  surgery
• At 2 to 3 weeks tended to have slower resolution
  of symptoms (over months), and some had permanent
  restriction
• Instead early surgery- within days of injury may
  be able to prevent ischaemic contracture of the
  entrapped muscle and persistent diplopia

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• However they acknowledged that with little
  clinical sign of soft tissue injury (white eye),
  the potential severity of the clinical problem is
  usually not appreciated
• And these patients may by default simply be
  observed

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Summary

• The evaluation and management of orbital floor
  fractures differs between adults and children
• In adults a 2 week wait and watch period is
  acceptable and appropriate
• However in children, we need to be wary of WEBOF,
  and its management should be fracture repair with
  release of entrapped muscle within 72 hours
• This affords this group of patients the best
  chance of full clinical recovery

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Recommendations

• In children/ teenagers who present with ocular
  trauma
• Ask about nausea and vomiting
• Ask about the presence and pattern of diplopia
• Undergo an extraocular motility examination
• If extraocular motility dysfunction is noted,
  then order a CT with axial and coronal views,
  along with brain imaging if indicated clinically

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Thank you