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| CASE REPORT |
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| Year : 1984 | Volume
: 32
| Issue : 1 | Page : 31-33 |
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Impure blow out fracture of orbital floor
G Baskara Rajan, R Pugazhendi
Government Rajaji Hospital, Madurai, India
Correspondence Address:
G Baskara Rajan
Govt. Rajaji Hospital, Madurai, (T.N.)
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 6389333 
How to cite this article:
Rajan G B, Pugazhendi R. Impure blow out fracture of orbital floor. Indian J Ophthalmol 1984;32:31-3 |
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 | |  |
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 | | |
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 | | |
A case of impure blow out fracture with the classical features successfully treated by surgery is reported.
| Acknowledgement | | |
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 | | |
| 1. | Reeth, M.J. and Tsujimura K 1966, Amer J. Ophalmal. 62:79.  |
| 2. | Whyte, D.K 1968, Brit J. Opghthalmol 52:721. |
| 3. | Milauskas A.T. and Fueger G.F., 1966, Amer J. Ophthalmol 62:670. |
| 4. | Smith, B and Regan, W, 1971, Amer J. Ophthalmol 44:733 |
| 5. | Converse J.M. 1977, Reconstructive plastic surgery Vol. 2 published by Saunders Co. p. 752 to 775. |
| 6. | Anderson RD. and Teague D.A : 1963, Amei J. Ophthalmol 56:46. |
| 7. | Putterman AM. Stevens T. and Urist M.J. 1974, Amer J. Ophthalmol 77:232. |
| 8. | Paton D. and and Goldberg M.F. 1976, Management of ocular injuries. P. 59-92. W.B. Saunders. Co. |
| 9. | SorsbyA 1972, Modern Ophthalmology Vol. 4 p. 987 Published by Butterworths. |
| 10. | Brockhurst RJ. 1974, Controversy in Ophthalmology p. 401:415. |
| 11. | Emery J.M. Von Noorden G.K and Schlernitzauer D.A Amer J. Ophthalmol 74:299. |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
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