AMERICAN JOURNAL OF OPHTHALMOLOGY

VOLUME 4 4 DECEMBER, 1957 NUMBER 6

BLOW-OUT FRACTURE OF T H E ORBIT*

M E C H A N I S M A N D CORRECTION OF INTERNAL ORBITAL FRACTURE

BYRON S M I T H , M . D . , A N D W I L L I A M F . R E G A N , JR., M . D .
New York

The term "blow-out" fracture refers to tan Eye, Ear, and T h r o a t Hospital with
fracture of the orbital floor caused by a sud­ "blow-out" fracture of the orbital floor stim­
den increase in intraorbital pressure. This ulated our interest in the mechanism of pro­
type of fracture occurs when a smooth con­ duction of this type of fracture. O u r skep­
vex object with sufficient force behind it hits ticism regarding direct bone transmission as
the front of the orbit and forces the soft a primary vector of the fracturing force is
orbital contents backward without rupturing based on experimental fracture of the orbital
the eyeball. Blows from fists and many va­ floor in the cadaver. T h e case history and
rieties of spheres, of the diameter of base­ method of experiment follow:
balls, are the most frequent causes of this
type of fracture. C A S E HISTORY

Several theories have been presented as M. N., a man aged 29 years, was admitted to
the Manhattan Eye, Ear, and Throat Hospital on
to why fracture of the orbital floor can oc­ July 29, 1956, two hours after having been struck
cur without concomitant fracture of the or­ in the right eye by a hurling ball.
bital rim. Pfeiffer holds that the force of the Severe swelling of the right upper lid, right
lower lid, and marked subconjunctival edema and
orbital contents against the floor causes frac­ hemorrhage were conspicuous. The right pupil re­
ture. LeForte, Lagrange, and others believe acted sluggishly to light. There was no abrasion
that the force is transmitted by bone con­ of the cornea nor tear of the iris sphincter. Ele­
duction through the rigid orbital rim directly vation of the right eye was limited in all fields of
upward gaze and was also limited with forced
to the thin orbital floor. T h e fracture line duction. Marked diplopia was present in all right
is consistent with the L e F o r t e I I "line of fields and in the primary position. A small hyphema
weakness." at the base of the anterior chamber was observed.
Funduscopic examination was difficult because
Pfeiffer's view, in our opinion, best ex­ of the hazy media. Commotio retinae was noted
plains the mechanism of internal fracture in the injured eye with a reduction of the visual
acuity to 20/10. Vision of the uninjured eye was
without fracture of the rim and we, there­ 20/20. Tonometric tension was 40 mm. Hg, O.D.,
fore, employ the term "blow-out" or hy­ and 20 mm. Hg, O.S.
draulic fracture. The force of a convex ob­ A small horizontal laceration of the skin ex­
ject at the orbital entrance displaces the tended along the lower orbital margin near its mid­
point. The bony contour of the orbital margin
globe and other orbital tissues posteriorly and surface of the zygoma were intact. Exophthal-
with resultant fracture of the area of least mometry disclosed no evidence of ocular displace­
resistance, the orbital floor. Downward dis­ ment.
X-ray films of the right orbit, skull, and nose
placement of the orbital contents and en- showed no demonstrable fracture of the nasal bones.
ophthalmos follow. An increase of soft tissue density in the right
The appearance of a patient at Manhat- orbit and a small amount of emphysema in the
upper aspect of the right orbit were apparent.
There was a depressed fracture of the floor of
* From Manhattan Eye, Ear, and Throat Hos­ the right orbit; one fragment was depressed about
pital and the Society for Rehabilitation of the 10 mm. (fig. 1). Measurements of the optic fora­
Facially Disfigured. men were normal. The cranial vault and sella
733
734 BYRON SMITH AND WILLIAM F. REGAN, JR.

Fig. 1 (Smith and Regan). Preoperative Waters view shows depressed fracture of the orbital floor with
comminuted displaced fragments of bone in the clouded right antrum.

turcica were normal. X-ray films demonstrated Degenerated fat globules floated out as the hema­
moderate clouding of the right ethmoids and right toma within the antrum was evacuated. Exposure
antrum. of the orbital floor through the original wound,
On August 3, 1956, muscle measurement showed coincident with digital pressure through the lower
that exotropia secondary to limitation in right wound, demonstrated a rent in the mucous mem­
ocular elevation was responsible for constant di­ brane of the antral roof. An intranasal antrotomy
plopia. Diplopia was present in all fields of gaze below the inferior turbinate was performed for
(fig. 2). the purpose of subsequent drainage.
By August 8th, secondary infection of the lacera­ A graft of cortical bone three to four mm. in
tion and edema had sufficiently subsided to permit thickness was removed from the internal surface of
surgical exploration and treatment. The following the right ilium. The graft was shaped to fit beyond
procedure was performed under general anesthesia. the edges of the orbital floor defect and was wired
A skin incision 2.5 mm. in length parallel to the into position through drill holes in the graft and
right lower orbital margin was extended through in the lower orbital margin. The orbicularis mus­
the skin, subcutaneous tissues, and periosteum. The cle and subcutaneous tissues were closed with
orbital rim was intact. Dissection was carried pos­ 6-0 chromic catgut sutures. The skin was closed
teriorly until a defect measuring IS by 25 mm. was with 5-0 silk sutures. The Caldwell-Luc incision
exposed. The anterior margin of the bony defect was closed with 4-0 chromic catgut. The right
was situated about six mm. within the lower antrum was packed through the antrotomy with
orbital margin. Numerous thin fragments of bone vaseline packing. An interpalpebral suture was
and the lower orbital contents were displaced into placed to prevent opening of the right eye beneath
the antrum. The wound was packed with gauze a moderate pressure dressing. The wound over
sponges for hemostasis while a Caldwell-Luc ap­ the ilium was closed in layers and a small rubber
proach to the antrum was made through the right drain inserted.
canine fossa. The anterior antrotomy was en­ The postoperative course was uneventful. The
larged sufficiently to admit the examiner's finger. pressure dressing was removed in four days, the
 BLOW-OUT FRACTURE OF THE ORBIT 735

8/3/56 Pre-Qp.

It 20 LH 1Λ rtó
Xt 16 LH 2 χ 16
X 12 χ 32 LH Tr.
Diplopia in Hight lateral and upper fields
8/22/56 Poat-Qp

Χ 9 LH 12 Χ8
Χ4
Χ2
Stereopsis in all fields.
Fig. 2 (Smith and Regan). Cardinal fields preoperatively and postoperatively.

antral packing on the eighth postoperative day. hammer. A cracking sound was interpreted
An X-ray film taken on September 7, 1956,
showed the bone graft in its proper position. as fracturing bone. A n exploratory incision
Residual clouding of the right antrum was present through the skin at the infraorbital margin
(fig. 1). and blunt dissection exposed a depressed
Diplopia had disappeared at the first postopera­ comminuted fracture of the floor of the or­
tive dressing. Exophthalmometric measurements
were recorded as equal on both sides. bit. Exenteration of the orbit revealed the
Muscle balance at discharge on August 22, 1956, fracture in its entirety (fig. 4 ) . There was
showed a small exophoria in all fields, a left also a comminuted undisplaced fracture in­
hyperphoria up and right with stereopsis in all
fields (fig. 2). Follow-up visits revealed no hyper­ volving the lamina of the ethmoid bone. N o
phoria in any field of gaze and no evidence of fracture of the orbital rim or zygomatic
enophthalmos or change in the width of the palpe­ arch was observed. This duplicated almost
bral fissure. These findings were unchanged as of
October 2, 1956. Postoperative X-ray films (fig. 3) exactly the injury sustained by our patient.
demonstrate restoration at the level of the orbital In a second experiment, the opposite orbit
floor. The position of the thin bone graft in the
orbit may be seen. of the cadaver was exenterated. T h e soft tis­
sue of the rim was excised to allow direct
M E T H O D S A N D R E S U L T S OF E X P E R I M E N T
contact between the bony orbital circumfer­
A blow-out fracture of the orbital floor ence and the surface of the hurling ball. Re­
was produced in a human cadaver by dupli­ peated blows of similar force with the ham­
cating a force similar to the one observed in mer failed to fracture the floor or the rim
the preceding case history. The hypotony of the orbit. W h e n the striking force was
of the cadaver globe was increased to nor­ sufficiently increased, the orbital floor and
mal finger tension by intravitreous injection the orbital rim collapsed simultaneously.
of 1.0 ml. of normal saline. A hurling ball This strengthened our belief that these frac­
was placed over the closed lids of the cadaver tures are caused by increased intraorbital
orbit and the ball was struck sharply with a pressure, rather than bone transmission.
 736 BYRON SMITH AND WILLIAM F. REGAN, JR.

Fig. 3 (Smith and Regan). Postoperative Waters view with autogenous ihac bone graft in place.
Antral clouding may persist for several weeks.

COMMENT laceration and abrasion of the lids with

The contour and thin dimensions of the ecchymosis and edema. Chemosis and sub­
orbital floor and lamina papyracea in contact conjunctival hemorrhage occur promptly.
with air spaces invite fracture. Emphysema is the surest indication of frac­
The orbital floor, for nearly its entire ex­ ture into the nasal sinuses. Commonly, rup­
tent, roofs the maxillary sinus with bone of ture of the sphincter, iritis, hyphema, com­
from 0.5 to 1.0 mm. in thickness. This bone motio retinae, and transient secondary glau­
may be even thinner at the inferior orbital coma are seen.
groove and canal. Behind the globe the or­ In fracture of the orbital floor, with or
bital floor bulges upward presenting a thin without fracture of the orbital rim, as soon
convex surface which receives the brunt of as vision in the injured eye is restored,
the force transmitted by the eye. Once frac­ diplopia is observed by the patient, provided
ture occurs, gravity alone causes displace­ that binocular single vision existed prior to
ment of the orbital floor and orbital contents injury. If the natural ostium of the antrum
into the maxillary sinus. T h e amount of dis­ is present, blood in the nasal cavity or post­
placement is dependent upon the size of the nasal discharge may be observed and naso-
antrum and the extent of the fracture pharyngoscopy may confirm the source. E n -
(fig. 5 ) . ophthalmos and narrowing of the palpebral
fissure are noticeable when orbital edema
DIAGNOSIS AND TREATMENT subsides. At this time orbital fat degenera­
Clinically, "blow-out" fractures may show tion and orbital fibrosis have advanced. Dur-
 BLOW-OUT FRACTURE OF THE ORBIT 737

Fig. 4 (Smith and Regan). Photograph of the experimental "blow-out" fracture of the orbital floor with
the orbital rim intact and fragments of the orbital floor depressed into the antrum.

ing this stage diplopia may be reduced or dense clouding of the homolateral antrum.
disappear. Fragments of the thin orbital floor may or
Oculorotary excursions, by screen and may not be recognized in the radiographic
comitance studies, are variable. Usually a shadows. Especially valuable are the Cald­
restriction of depression occurs, as well as well and W a t e r s views of the sinuses. Lam-
elevation of the injured eye. According to inography is of little value in demonstrat­
our findings and interpretations this pattern ing shadows of the small thin fragments.
is due to herniation and incarceration of T h e orbital rim and zygomatic arch show
the inferior rectus and the inferior oblique n o evidence of fracture. I n other words, the
muscle and their surrounding tissues into X-ray film may show nothing more than
the fracture. cloudiness of the antrum or ethmoid sinuses
Absence of elasticity in the injured, im­ or both. If the X - r a y films do not demon­
pounded inferior rectus restricts rotation in strate a fracture in the presence of this
the field of action of its antagonist, the su­ symptom complex, it is advisable to repeat
perior rectus. Since the point of greatest the films. Absence of X - r a y findings of a
damage is closer to the origin of the in­ specifically demonstrable fracture, however,
ferior oblique than that of the inferior do not preclude the presence of a "blow-out"
rectus, less evidence of underaction is de­ fracture when antral clouding is shown.
monstrable in inferior oblique function. In the presence of characteristic clinical
X-ray films projected in the various or­ manifestations of "blow-out" fracture of
bital and sinus views characteristically show the orbit we advocate surgical exploration.
738 BYRON SMITH AND WILLIAM F. REGAN, JR.

more radical oral approach, the typical

Caldwell-Luc anterior antrotomy is done
through the canine fossa. T h e osteotomy is
enlarged sufficiently to admit the palpating
finger of the surgeon. By expert instrumen­
tation the antral roof may also be viewed
through this approach. Before closure of
\ this wound it is advisable to do an intranasal
Hurlincj bull antrotomy as a precautionary measure.
In the treatment of early orbital fractures
we have been disappointed with some of the
results obtained from reduction and support
by antral packing. W e have come to believe
that some type of permanent orbital floor
fixation is superior to reliance on the tempo­
rary support attainable by antral packing.
Of the numerous devices and materials avail­
able we are inclined to conclude that autog­
enous living tissue is superior to other ma­
_ .Periorbital terials. Since bone becomes consolidnted and
Fractured Ψ \ fat
floor of orbit · cartilage does not, our preference is auto­
genous iliac bone. T o replace the commin­
Fig. 5 (Smith and Regan). (A) The normal rela­ uted orbital floor, a thin plate of cortical
tion of the orbit is shown. ( B ) External pressure bone taken from the inner aspect of the iliac
forcing a blow-out fracture of the orbital floor with
incarceration of the inferior oblique and inferior crest has proved most satisfactory. T h e
rectus. small, separated comminuted fragments of
orbital floor within the antrum should be
The time for exploration may be delayed as removed. Small fragments attached to orbital
much as a week. Beyond seven to 1 0 days tissues should be elevated and placed in con­
irreversible degeneration and fixation of tis­ tact with the upper aspect of the graft. T h e
sues diminish the probabilities of maximal graft itself may be wedged into the fracture
surgical restoration. site. If it is then still mobile, a wire fixation
U n d e r general anesthesia a traction test suture may be placed in the graft and orbital
of the inferior rectus may show restriction rim.
of passive ocular elevation. T h e exploratory
incision may be made by either of two meth­ DISCUSSION

ods: ( 1 ) orbital; ( 2 ) oral or transsinus. Small, blunt objects of a diameter less

Orbital exposure is made by incising the than that of the bony orbit tend to rupture
skin and underlying tissues superficial and the globe, leaving the floor of the orbit in­
parallel to the middle one third of the lower tact. Driven golf balls were the cause of
orbital rim. T h e periosteum is then incised rupture of the globe in three cases seen at
and elevated to expose the orbital floor. A Manhattan E y e , E a r , a n d T h r o a t Hospital.
nasal speculum introduced into the incision W e believe that objects with a diameter
has been found of value in exposing the larger than that of the bony orbit, such as a
depths of the wound. If the ocular exposure baseball, fail to rupture the globe because
is used and a fracture is not revealed, no part of the force is absorbed by the orbital
harm is done and completed healing leaves rim. While the force is not great enough to
little or no scar along natural lid folds. fracture the heavy orbital rim, the soft tis­
If the surgeon should decide upon the sues pressed into the orbital cavity penetrate
 BLOW-OUT FRACTURE OF THE ORBIT 739

the fragile orbital floor. T h e fluid mallea­ through a skin incision at the inferior orbital
bility of the contents of the globe helps pre­ rim.
vent rupture of the globe. Several cases of late enophthalmos, which
O u r investigation of blunt injury to the in retrospect would seem to be due to "blow­
orbit leads us to believe that internal fracture out" fractures, have been seen in this clinic.
of the orbit is more frequent than is common­ These late cases are far more difficult to
ly suspected, probably because the intact zy­ correct.
gomatic contour tends to exclude the diagno­
sis of fracture. Orbital floor fracture may be SUMMARY

observed in the absence of gross local signs A discussion of internal orbital fractures
although supraorbital and infraorbital produced by hydraulic action of the orbital
edema and ecchymosis with Berlin's edema contents is presented. Experimental evidence
are usually seen. T h e initial oculorotary for the mechanism of such fractures is de­
signs may be obscured by swelling. T h e post­ scribed. A surgical means of correction and
traumatic X-ray findings of antral clouding restoration by immediate autogenous bone
lead one to suspect the presence of "blow­ grafting is outlined. Difficulty in early diag­
out" fracture. If definite diagnosis of inter­ nosis is emphasized. E a r l y surgical treatment
nal fracture can be made, immediate surgery tends to prevent later permanent deformity.
in the form of autogenous iliac bone graft A n illustrative case is presented.
to the orbital floor is indicated. In doubtful
cases the orbital floor should be explored 210 East 64th Street (21).

REFERENCES
Converse, J. M.: Plastic operations for repair of the orbit following trauma. Arch. Ophth., 31:323,
1944.
Converse, J. M., and Smith, B. C.: Reconstruction of the orbital floor by bone grafts. Arch. Ophth.,
44:1, 1950.
: Enophthalmos and diplopia in fractures of the orbital floor. Brit. J. Plast. Surg., 41:265, 1957.
Devoe, A. G.: Fractures of the orbital floor. Tr. Am. Ophth. Soc., 54:502, 1956.
Lagrange, F.: Les Fractures de I'Orbite. Paris, Masson & Cie, 1917.
LeForte: XIII Cong. Internat Med., 23:275, 1901. (Duke-Elder, W. S.: Textbook of Ophthalmology,
St. Louis, Mosby, 1954, v. 6.)
Pfeiffer, R.: Traumatic enophthalmos. Arch. Ophth., 30:718, 1943.

A SIMPLIFIED METHOD FOR LOCALIZATION O F INTRAOCULAR

AND INTRAORBITAL FOREIGN BODIES*

WOLFGANG A . L I E B , M . D . , A N D HERBERT W I E S I N G E R , M . D .
Richmond, Virginia

Numerous methods for the localization of have the disadvantage of necessitating spe­
intraocular foreign bodies are known. cialized equipment and trained personnel.
A m o n g those the direct methods of Com­ T h e objective of this paper is to acquaint the
berg^ and Pfeiffer,^ the geometric construc­ ophthalmologist with a simple and fast
tion method of Sweet,' and the bone-free method of localization which does not re­
method of Vogt* are the most accurate and quire any specialized equipment but yields
reliable ones. fair accuracy and dependability.
F o r the practicing ophthalmologist, these
METHOD
• From the Department of Ophthalmology
(Chairman; Dr. DuPont Guerry, III), Medical Posteroanterior a n d lateral skull X-ray
College of Virginia. films are required. A n y modern table X-ray