Blow-Out Fractures

BLOW-OUT FRACTURES

Q. 1 Computed tomography (CT) is useful in the formulation of a treatment plan of blow-out fractures because:
 A It is the only way to diagnose an orbital fracture.
 B Coexistent sinus disease can be evaluated.
 C Magnetic resonance imaging is superior to CT in the evaluation of orbital fractures.
 D CT can fairly accurately determine the size of the fracture and its relationship to the orbital soft tissues.
Q. 1 Computed tomography (CT) is useful in the formulation of a treatment plan of blow-out fractures because:
 A It is the only way to diagnose an orbital fracture.
 B Coexistent sinus disease can be evaluated.
 C Magnetic resonance imaging is superior to CT in the evaluation of orbital fractures.
 D CT can fairly accurately determine the size of the fracture and its relationship to the orbital soft tissues.
Ans. D

Explanation:

CT can fairly accurately determine the size of the fracture and its relationship to the orbital soft tissues. Computed tomography (CT) scanning has become an integral factor in the diagnosis and treatment of blow out fractures. CT provides excellent detail of the bones and the relationship with the extraocular muscles and orbital tissues. Coronal views can help distinguish whether the muscle itself is entrapped, which can be difficult to evaluate on clinical examination.


Q. 2

A teenager brought with blow out fracture of orbit. The fracture may involve mainly:

 A

Roof of the orbit

 B

Posterior wall of floor of orbit

 C

Medial wall of orbit

 D

Medial part of floor of orbit

Q. 2

A teenager brought with blow out fracture of orbit. The fracture may involve mainly:

 A

Roof of the orbit

 B

Posterior wall of floor of orbit

 C

Medial wall of orbit

 D

Medial part of floor of orbit

Ans. D

Explanation:

Blowout fractures mainly involve orbital floor and medial wall. When an external force is applied to the globe, intraorbital pressure increases to the point that one or more of the thin-walled bones of the orbit “blow-out” or fracture. The most common bone fractured is the maxillary bone which comprises the floor of the orbit. The orbital contents can be significantly displaced inferiorly after orbital blowout fracture.

Ref: Shirakbari A.A., Hall M. (2011). Chapter 23. Maxillofacial & Neck Trauma. In R.L. Humphries, C. Stone (Eds), CURRENT Diagnosis & Treatment Emergency Medicine, 7e.

Q. 3

“Blow out” fracture of orbit involve:

 A

Floor

 B

Medial wall

 C

Lateral wall

 D

a and b

Q. 3

“Blow out” fracture of orbit involve:

 A

Floor

 B

Medial wall

 C

Lateral wall

 D

a and b

Ans. D

Explanation:

A > B i.e. Floor > Medial wall

Blow out fracture most frequently involves the floor of orbit along the thin bone covering the infraorbital canal (i.e. posteromedial wall of floor)Q. Occasionaly the medial wallQ may also be fractured. After h/o trauma from relatively large often rounded object (e.g. tennis ball, first) patient presents with periorbital oedema and blood extravasation in & around orbit, emphysema of eyelid, parasthesia & anaesthesia of infraorbital nerve, I/L epistaxis, proptosis, enopthalmos, diplopia (with forced duction test) Q. Water’s (nose-chin) view show hanging drop or tear drop sign Q

Blow Out Fracture

Occur when a blunt (non penetrating) force applied to anterior periorbital region compresses the orbital contents & causes a sudden increase in intraorbital pressure. This force is transmitted outward to the weakest orbital segment along with bone fragment & orbital content (eg fat). Severe ocular injury is rare as this is a nature’s way of protecting globe. It generally occurs after trauma to orbit by a large round object eg cricket ball or human fist.

These are isolated comminuted fractures of orbital floor (most common) & medial wallQ. Although lamina papyracea is truly thinner than the orbital floor, it is actually buttressed by perpendicular elements of ethmoid sinus bony lattice and therefore fractures less often than orbital floor. Orbital emphysema is most common in medial wall fractures.

Clinical features

  • Periorbital oedema and blood extravasation in and around the orbit (such as subconjunctival ecchymosis)
  • Emphysema of eyelid (mostly with medial wall fractures and made worse by blowing of nose)
  • Parasthesia & anaesthesia in the distribution of infraorbital nerve (lower lid, cheek, side of nose, upper lip & upper teeth)
  • Ipsilateral epistaxis
  • Proptosis due to orbital oedema
  • Enopthalmos after about 10 days as the oedema decreases, the eyeball sinks backward & inferiorly. It is due to

– Enlargement or orbit

Escape (herniation) of orbital fat into maxillary sinus Q

– Backward traction due to entrapped inferior rectus

  • Diplopia Q in both up & down gaze (double diplopia)
  • The presence of muscle restriction Q can be confirmed by a ‘positive forced duction test’ Q
  • Restriction movements occur due to entrapment of inferior rectus & inferior obliqueQ
  • Severe ocular damage is rare as this is a nature’s way of protecting globe. 
Management
  • Water’s view show hanging drop or tear drop sign Q (hanging opacity of superior maxillary antrum)
  • Surgery (optimal time is after 10-14 days of injury) is indicated in

– Persistent diplopia

– Enopthalmos > 3 mm

– Fracture with large herniation of tissue into the antrum

– Incarceration of tissue in the fracture with resulting globe retraction and increased applanation tension on attempted upward gaze

* Pure blow out fractures are not associated with orbital rim involvement. Impure b.o.f. are associated with fractures of middle third of face.



Q. 4

A boy presents with diplopia and restriction of eye movements following blunt trauma to his eye. X-ray reveals blow out fracture of orbit. Which part of orbit is most likely damaged:

 A

Superior wall

 B

Inferior wall

 C

Lateral wall

 D

Medial wall

Q. 4

A boy presents with diplopia and restriction of eye movements following blunt trauma to his eye. X-ray reveals blow out fracture of orbit. Which part of orbit is most likely damaged:

 A

Superior wall

 B

Inferior wall

 C

Lateral wall

 D

Medial wall

Ans. B

Explanation:

B i.e. Inferior wall

Blow out fracture mainly involve orbital floor (inferior wall) & medial wall Q. It presents with hanging drop or tear drop sign Q.

Quiz In Between


Q. 5

Blow out # orbit is characterized by:

 A

Diplopia

 B

“Tear drop: sign

 C

Forced duction test

 D

All

Q. 5

Blow out # orbit is characterized by:

 A

Diplopia

 B

“Tear drop: sign

 C

Forced duction test

 D

All

Ans. D

Explanation:

A i.e. Diplopia; B i.e. Tear drop sign; C i.e. Forced duction test

Blow out fracture is fracture of orbital floor or medial wall Q. It presents with emphysema of lid, subconjunctival ecchymosis, diplopia & forced duction test Q (due to entrapment of muscle), epistaxis, proptosis, enopthalmos & parasthesia in distribution of inferior alveolar nerve. X ray shows tear drop or hanging drop sign Q


Q. 6

Blow-out fracture of orbit is characterized by all except:

 A

Diplopia

 B

‘Tear drop” sign

 C

Positive forced duction test

 D

Exophthalmos

Q. 6

Blow-out fracture of orbit is characterized by all except:

 A

Diplopia

 B

‘Tear drop” sign

 C

Positive forced duction test

 D

Exophthalmos

Ans. D

Explanation:

Ans. Exophthalmos


Q. 7

Blow out fracture of the orbit, most commonly leads to fracture of:

 A

Posteromedial floor of orbit

 B

Medial wall of orbit

 C

Lateral wall of orbit

 D

Roof of orbit

Q. 7

Blow out fracture of the orbit, most commonly leads to fracture of:

 A

Posteromedial floor of orbit

 B

Medial wall of orbit

 C

Lateral wall of orbit

 D

Roof of orbit

Ans. A

Explanation:

Ans. Posteromedial floor of orbit


Q. 8

Orbital blow-out fracture involves:         

AIIMS 09; FMGE 10; MP 10; JIPMER 11; Bihar 11; PGI 11

 A

Lateral wall and floor of orbit

 B

Medial wall and floor or orbit

 C

Lateral wall and roof or orbit

 D

Medial wall and roof or orbit

Q. 8

Orbital blow-out fracture involves:         

AIIMS 09; FMGE 10; MP 10; JIPMER 11; Bihar 11; PGI 11

 A

Lateral wall and floor of orbit

 B

Medial wall and floor or orbit

 C

Lateral wall and roof or orbit

 D

Medial wall and roof or orbit

Ans. B

Explanation:

Ans. Medial wall and floor or orbit

Quiz In Between



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