Grand Ward Round Case Presentation: Mr QBZ
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Transcript of Grand Ward Round Case Presentation: Mr QBZ
Grand Ward Round
Case Presentation: Mr QBZ
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
Examination
R L
VA 6/7.5 6/7.5
IOP 12 12
PUPILS NO RAPD/ RR
CONJ White
CORNEA Clear
AC DQ
DISC 0.3 0.3
RETINA Flat Flat
• R mild Enophthalmos
• R gross Hypotropia
0 0
-3.5
-4 0
0
0 0 EOM
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
Diagnosis
• Right orbital floor fracture
• With entrapment of orbital contents
• “White-eyed blowout fracture”
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
• Postop– G Preforte Q1H RE– G Cravit Q3H RE– PO Prednisilone 60mg OM
3 June 2006 ( POD 1)
• LHT 40Δ
• R Hypotropia ? due to R Inferior rectus:– Direct injury/ fibrosis– Entrapment
0 0
-3
-4
0 0
0
0
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
13 Jun 2008 (POD 11)
• Subjectively: mild diplopia in primary gaze
• LHT 6 Δ- Improved
• HERTEL’s: 113
16 17
-2
-3
0 0
0
0
0 0EOM
Orbital Blowout Fractures and the White-eyed Blowout fracture
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
Mechanism of Injury
2 theories:1. The fracture results from sudden increase in
intraorbital pressure
2. The fracture is the result of buckling forces which are transmitted to the orbital bones by a transient deformity of the orbital rim
.
• 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
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
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
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
• 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
Surgical Management
• Indications of surgery– Diplopia especially in the primary position
• which does not improve after posttraumatic edema resolves
– Large floor fractures (>50%)• Which may result in progressive enophthalmos
– Significant globe dystopia• Hypoglobus or enophthalmos (>2mm)
• 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
• 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
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
• 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, 2007;26
• 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
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
Pathophysiology of Orbital Fractures in Adults versus
Children
Adults
• In adults (>18 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
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
• 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
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. 1984;74
• Hence waiting 2 to 3 weeks in this group of patients may be detrimental to the patient’s recovery – As the ischaemic process is prolonged, and
could lead to fibrosis to the muscular and perimuscular tissue
• 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
• 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)
• 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
• 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
• 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
• 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
• The authors concluded that WEBOF patients having surgery: 1. At 2 to 3 weeks tended to have slower
resolution of symptoms (over months), and some had permanent restriction
2. Instead early surgery- within days of injury may be able to prevent ischaemic contracture of the entrapped muscle and persistent diplopia
• 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
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
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
Thank you