|Year : 1968 | Volume
| Issue : 4 | Page : 245-248
Orbital fracture due to camel bite - A case report
BN Consul, DP Sharma, RG Sharma
Department of Ophthalmology, S. M.S. Medical College and Hospital, Jaipur, India
|Date of Web Publication||24-Dec-2007|
B N Consul
Department of Ophthalmology, S. M.S. Medical College and Hospital, Jaipur
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Consul B N, Sharma D P, Sharma R G. Orbital fracture due to camel bite - A case report. Indian J Ophthalmol 1968;16:245-8
|How to cite this URL:|
Consul B N, Sharma D P, Sharma R G. Orbital fracture due to camel bite - A case report. Indian J Ophthalmol [serial online] 1968 [cited 2020 Aug 9];16:245-8. Available from: http://www.ijo.in/text.asp?1968/16/4/245/37566
Fractures of the orbital floor can occur by two different mechanisms: (i) Backward displacement of the strong bone forming the orbital rim which results in fractures of thin bones. (ii) Increased internal orbital pressure caused by a blow of human list, a baseball, or a cricket ball (Converse and Smith, 1957) on the soft tissues of the orbit, producing fractures of the floor of the orbit without affecting the orbital rim, called 'blow out' fracture. Smith and Regan (1956) have reproduced this type of fracture experimentally on the cadaver.
Comminuted fracture of orbital rim and floor is a more serious type and arises from a force similar in nature and direction but of much greater magnitude. This fracture unlike the simple fracture of zygoma is usually attended with much greater immediate deformity and involves the orbital floor medially and posteriorly. There is herniation of orbital contents into the antrum (Lang, 1899) and involvement of extra-ocular muscles. The globe loses its support and tends to occupy a lower position. The lateral canthus may show evidence of lowering. Pfeiffer (1911) reviewed 126 cases of the fractures of the orbit and found that enophthalmos was present in 53 of his cases.
| Treatment|| |
The early recognition and repair of such fractures ensures maximum physical and functional recovery. The treatment aims at freeing the orbital contents from the fracture site and restoring the integrity of the bony floor. Various materials that have boon used to provide support to the orbital floor include synthetic substances such as teflon and methyl methacrylate stents, silicon rubber and rubber baloons (Quereau, 1956; Anderson, 1963; Lipshutz, 1963; Patterson, 1962). Metal jack screw, tantalum mesh (Anthony, 1957; Callahan, 1953) and metal balls are the other materials used. The use of antogenous, homogenous or processed bovine bone grafts (Converse and Smith, 1950; Anderson, 1965; Patterson, 1967) provide most physiological substitutes and have given higher percentage of success in these cases. Autogenous bone graft though requires additional surgery in the patient, is readily available and is attended with least possible reactions.
An interesting case of comminuted fracture of the orbit due to camel bite, came to us quite sometime after the injury and is being recorded for its unusual cause and response to the conventional surgical approach.
| Case report|| |
Ganga Ram, 40 years of age sustained face injury due to camel bite on 8-1-67 and was admitted in the surgical ward of this hospital on 9-1-67. He had a lacerated wound about 3 inches' long extending from right lateral canthus to the temporal region. There was marked drooping of the right upper lid. The wound was stitched by the general surgeon in that ward. The case was referred to us for ophthalmic check up on 22-1-67. On examination there was an irregular healed scar, three inches long and a little swelling in the right temporal region and along the lateral orbital wall. On palpation there was a little depression and crepitus, on the lateral wall of right orbit. There was a discharging wound (1/2 inch long) on the left side of the mandible one inch below the lip. The right upper lid was found swollen and drooping and could not be lifted voluntarily. On attempted closure there was a lagophthalmos of 2 mm. The palpebral fissure was oblique and slanting down towards the lateral canthus. Lateral canthus was displaced 12 mm below the medial canthus [Figure - 1]. Exophthalmometry revealed 4 mm anophthalmos of the right eye. The eye ball was displaced down by 5 mm [Figure - 2]. Movements of the eye ball were markedly restricted laterally and upwards; rest of the movements were normal. The eyeball had escaped injury. The fundus was normal and the vision 6/12. There was diplopia in almost all quadrants except on the inner side. It was more on abduction and elevation.
Hess charting showed the restriction of the fields belonging to the right inferior oblique and right lateral rectus.
Skiagram of the orbit and paranasal sinuses [Figure - 3] revealed fracture of the lateral orbital wall and hazyness of the right maxillary antrum with a depressed orbital floor fracture and herniation of soft tissues into the antrum.
Blood cytology, the E.S.R. and the urine revealed nothing abnormal.
The conjunctival swab culture was sterile though the swab taken from the wound showed Staphylococcus and B. Pyocyaneous which showed sensitivity to chloromycetin.
Management:- (i) Repair of Orbital floor: The case was operated on 13-2-67, under general anaesthesia. The right orbital floor was exposed through lower lid by incising the skin, orbicularis oculi and periosteum to the inferior orbital margin. The orbital contents with the eye ball were lifted along with the periosteum. The orbital floor was visualised and multiple fractures of the floor were found, with herniation of orbital fat and inferior oblique muscle into the antrum. These structures were released from the antrum. A 2.5 x 1.5 x 0.5 cm piece of iliac bone was taken from the inner side of the right iliac crest by a separate incision over this region. The piece was cut to appropriate size and grafted on to the orbital floor with its broader end placed anteriorly. The periosteum was sutured with 5 'O' plain catgut and the wound closed in layers.
(ii) Repair of the lateral canthus: After a skin incision over the lateral canthus ligament the temporalis muscle was released at the site of the old scar from the skin and underlying bone. The lateral canthus was elevated by defining the lateral palpebral ligament and reattaching it a little above the lateral orbital tubercle. The wound was then closed in layers.
There was very little post operative reaction and at the time of discharge, there was anophthalmos of only 1 mm, depression of the eye ball was found to be fully corrected [Figure - 4] The movements of the eye ball were normal except slight restriction on the lateral side. Diplopia was present only in the right outer quadrant. The lateral canthus was 4 mm below the medial canthus showing a correction of 8 mm .
| Comments|| |
'Blow out' fractures are reported due to large blunt objects like human fist, cricket ball, base ball (Smith et al, 1957), the force of which is of such a magnitude which can fracture the firm orbital rim and the floor without damaging the eye ball. .
The orbital fracture in the present case is due to camel bite. Here the mechanism of fracture is the compression of the orbital rim between the two jaws of the camel without causing injury to the eye ball and thus resulting in a combined external and internal comminuted orbital fracture, with the dominant signs of external deformity of the orbital rim, depression of the lateral canthus, producing the deformed inter palpebral fissure, restricted movements, enophthalmos, and diplopia. The maxillary antrum was hazy due mostly to the blood and very little due to herniation of the orbital contents. The results are generally best when such cases are operated within 7 to 10 days of injury, but with us there was no other alternative except to take a late case and even then the results were fairly satisfactory. The patient was so satisfied with the results that for further improvement in his cosmatic appearance he did not like to submit himself for a second operation.
Orbital exposure may be made either from lower orbital rim or through Caldwell Luc anterior antrotomy. The best and permanant results are achieved by autogenous cartilaginous graft taken from the iliac crest and placing it over the orbital floor, through the inferior orbital margin.
| Summary|| |
A late case of orbital fracture due to camel bite is reported. The surgical repair of the orbital floor was done with autogenous bone graft from right iliac crest.
| References|| |
Anderson, R. A., and Teague, D. A. (1953): Blow out fractures of the orbital floor. Amer. J. Ophthal., 56, 4750.
Anderson, K. J., et al (1965): Processed heterogenous hone. A basic scientific study with preliminary clinical trials in humans. J.A.M.A.; 193: 377-380.
Anthony, D. 1-1. (1957) Diagnosis and surgical treatment of fractures of the orbit, Trans. Amer. Acad. Ophthal. Otolarvng. 56: 580-587.
Callahan, A. (195:3) Symposium: Malunited fractures of the zygoma. Bony depressions, particularly depressions of the floor of the orbit. Traps. Amer. Acad. Ophthal. Otolarvng. 57: 875.
Converse, T. N1. and Smith. B. (1950): Reconstruction of orbital floor by bone grafts. Arch. Ophthal. 44, (Chicago) 1.
Converse, J. M. and Smith, B. (1.957): Enophthalmos and diplopia in fractures of the orbital floor. Brit. J. of plastic surgery, 9, 265-274.
Lang, W. (1899): Trans. Onhthal. Soc. U.K., 9, 41.
Lipshutz, H. and Ardizone, R. A, (1963): The use of silicon rubber in the immediate reconstruction of the floor of the orbit. J. Trauma. 3: 563.
Patterson, R. W., and DePue, R. (1962): Blow out fractures of the orbit. Amer. J. Ophthal: 53, 841-845.
Patterson, R. W., Mc Coy, W. J. III and Benedict, W. H. (1967): The use of processed bovine bone in orbital floor fractures. Arch. of Ophthal., 78, 360-364.
Pfeiffer, R. L. (1941): Trans. Amer Ophthal. Soc., 39, 492.
Quereau, J. V. D., and Sounders, P. F. (1956): Teflon implant to elevate the eye in depressed fracture of the orbit. Arch. Ophthal., (Chicago) 55: 685.
Smith, B.: Converse, J. M. and Troutman, R. C. (1962): Plastic and reconstructive surgery of the eye and adnexa. Publisher, Butterworth and Co. Washington, 91, 104.
Smith, B. and Regan, W. F. (1956): Personal communication to Enopthalmos and diplopia in fractures of the orbital floor. B. J. of Plastic surgery., Vol. IX, 1957.
Smith, B. and Re-an, W. F. (1957): Blow out fracture of the orbit. American Jr. of Ophthal., 44, 733-739.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]