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Year : 1984  |  Volume : 32  |  Issue : 1  |  Page : 31-33

Impure blow out fracture of orbital floor

Government Rajaji Hospital, Madurai, India

Correspondence Address:
G Baskara Rajan
Govt. Rajaji Hospital, Madurai, (T.N.)
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Source of Support: None, Conflict of Interest: None

PMID: 6389333

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How to cite this article:
Rajan G B, Pugazhendi R. Impure blow out fracture of orbital floor. Indian J Ophthalmol 1984;32:31-3

How to cite this URL:
Rajan G B, Pugazhendi R. Impure blow out fracture of orbital floor. Indian J Ophthalmol [serial online] 1984 [cited 2023 Nov 30];32:31-3. Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?1984/32/1/31/27365

Blow out fracture is defined as fracture of the floor of orbit without involving the orbital rim. The term impure blow out fracture designates such a fracture when there is involvement of the orbital rim. The inferior orbital groove traverses the thin floor (0.5mm­1 mm) of the orbit and invites fracture[1]. Lang[2] and later King and Samuel[3] described blow out fracture with the probable mechanism of its 'production. Smith[4] demonstrated the mechanism in Cadavers and in skull. This is a report of impure blow out fracture with the classical clinical manifestations such as enophthalmos, limitation of elevation, infra orbital manifes­tations such as enophthalmos, limitation of elevation, infra orbital anaesthesia and additional features like photophobia any-' reversible error of refraction.

  Case report Top

Mr. C. aged 48 years came with the comp­laints of retraction of right eye with difficulty in facing the light. Three months prior, he had sustained an injury with fist over right side of his face and had developed black eye for which he was treated in the local hospital. Then he noticed a progressive enophthalmos of right eye and reported to us. On exam­ination, the right eye was enophthalmic and at a lower level than the left [Figure - 1]. Rest­riction of elevation, diplopia while looking upwards and infraorbital anaesthesia were also present.

Vision in right eye was 6/24, and in left eye 6/6. Retinoscopy value right eye was +4 Dsph and fundus was normal in both eyes. X­-ray sinuses by Water's view. revealed opacity in maxillary antrum with its lower border having a concavity upwards [Figure - 2]. In add­ition, there was also a fracture of inferior orbi­tal rim in the middle, without any displ­acement. To correct distressing symptoms and cosmetic disfigurement, surgery was per­formed.

Through a skin incision 3 mm below the lower lid margin, the skin and orbicularis muscle fibres were separated [Figure - 3]. Suture was passed through inferior rectus muscle to help in the elevation of the orbital contents as well for periodical duction test during surgery.

Periosteum was incised below the orbital rim. Periosteum was found to be intact and there was no entrapment of structures in between fractured bony fragments of the floor. A bone graft from iliac crest measuring 2X2.5X0.3 cms was carefully trimmed and inserted be­hind lower orbital margin to reconstitute the floor. The rim fracture was not corrected as the displacement was minimal. Periosteum was resutured and skin incision closed with 6`O'_ silk. Diplopia and photophobia disappeared with good cosmetic correction and invisible scar. Sutures were removed on eighth post operative day [Figure - 4]. Visual acuity improved to 6/6.

  Discussion Top

Objects with diameter more than 5 cms hit­ting the eye make orbit a closed cavity and blow out fracture occurs, there by eye, ball escapes injury. The term impure blow out fracture was suggested by Cramer, Tooze and Lerman (as quoted by Converse J.M. 1977[5]). The possible mechanism is the continuing momentum and pressure against the orbital contents by the fractured fragments of the rim, leading to a super imposed blow out fracture. In our case the injury with fist could have caused this. Once fracture occurs, gravity causes displacement of floor and orbital con­tents into maxillary sinus. The amount of dis­placement of the orbital contents depends upon the size of the maxillary antrum, the extent of the fracture and duration after injury at the time of examination[6]. There can be no enophthalmos as in a series of 57 cases, non surgically managed by Puterman et al[7]. The diplopia in elevation can be due to entr­apment of the inferior rectus and oblique muscles in the fractured fragments[8]. In this case there was an intact periosteum and there was no entrapment of the muscle. So the mechanism for the diplopia and limitation of elevation, is most likely, stretching of the inferior rectus and inferior oblique muscles by the sagging eye ball and orbital contents, which were originally supported by the intact orbital floor. This fact is supported by the observation that the diplopia and restriction of movements were reverses following the sur­gical correction. The reversibility of photo­phobia also is likely to be due to sympathetic irritation caused by stretching of the sympa­thetic nerve fibres producing mydriasis[9].

The hypermetropic type of refractive error could have been caused by the anter-pos­terior compression of the globe within the maxillary antrum. In the management of blow out fracture surgical and non surgical approaches are advocated by different authors[10]. The commonest indication for sur­gical intervention is cosmetically unacc­eptable enophthalmos and a distressing diplopia[11]. In our case. gross enophthalmos, limitation of elevation leading to diplopia and photophobia with defective vision were all corrected by surgical intervention.

  Summary Top

A case of impure blow out fracture with the classical features successfully treated by sur­gery is reported.

  Acknowledgement Top

We express our gratitude to Prof. S. Thiyagarajan for his encouragement to pre­sent this material. We are thankful to Dean, Government Rajaji Hospital, Madurai for permission to publish this material.

  References Top

Reeth, M.J. and Tsujimura K 1966, Amer J. Ophalmal. 62:79.  Back to cited text no. 1
Whyte, D.K 1968, Brit J. Opghthalmol 52:721.  Back to cited text no. 2
Milauskas A.T. and Fueger G.F., 1966, Amer J. Ophthalmol 62:670.  Back to cited text no. 3
Smith, B and Regan, W, 1971, Amer J. Ophthalmol 44:733  Back to cited text no. 4
Converse J.M. 1977, Reconstructive plastic surgery Vol. 2 published by Saunders Co. p. 752 to 775.  Back to cited text no. 5
Anderson RD. and Teague D.A : 1963, Amei J. Ophthalmol 56:46.  Back to cited text no. 6
Putterman AM. Stevens T. and Urist M.J. 1974, Amer J. Ophthalmol 77:232.  Back to cited text no. 7
Paton D. and and Goldberg M.F. 1976, Manag­ement of ocular injuries. P. 59-92. W.B. Saunders. Co.  Back to cited text no. 8
SorsbyA 1972, Modern Ophthalmology Vol. 4 p. 987 Published by Butterworths.  Back to cited text no. 9
Brockhurst RJ. 1974, Controversy in Ophthal­mology p. 401:415.  Back to cited text no. 10
Emery J.M. Von Noorden G.K and Schlerni­tzauer D.A Amer J. Ophthalmol 74:299.  Back to cited text no. 11


  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]


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