Blow out fracture of orbit involves fracture of orbital floor without fracture of infraorbital rim. This injury is common from frontal blow to orbit. Frontal blow to orbit causes increased intraorbitaltension causing fracture of floor of the orbit (weak point) with prolapse of orbital content into the maxillary sinus cavity. This causes enophthalmos and diplopia. Infraorbital rim is not involved in pure blow out fracture, it is also involved then it should be considered as an impure blow out fracture [3]. Entrapment of inferior rectus muscle between the fracture fragments will causediplopia in these patients. This article discusses a novel endoscopic internal reduction of fractured fragments. Main advantage of endoscopic approach is the lack of facial skin incision. It iscosmetically acceptable.

Thaigarajan, Balasubramanian

Ulaganathan, Venkatesan

English

Otolaryngology online journal

ISSN: 2250-0359                                                                                      Volume 3 Issue 1.5  2013
Blow out fracture A Novel Management Modality
1Balasubramanian Thiagarajan    
2Venkatesan Ulaganathan
1Stanley Medical College     
 2Meenakshi Medical College
Abstract:
Blow out fracture of orbit involves fracture of orbital floor without fracture of infraorbital rim. This 
injury is common from frontal blow to orbit. Frontal blow to orbit causes increased intraorbital 
tension causing fracture of floor of the orbit (weak point) with prolapse of orbital content into the 
maxillary sinus cavity. This causes enophthalmos and diplopia. Infraorbital rim is not involved in 
pure blow out fracture, it is also involved then it should be considered as an impure blow out 
fracture [3]. Entrapment of inferior rectus muscle between the fracture fragments will cause 
diplopia in these patients. This article discusses a novel endoscopic internal reduction of fractured 
fragments. Main advantage of endoscopic approach is the lack of facial skin incision. It is 
cosmetically acceptable.
Introduction:
Orbital floor fractures were first described by MacKenzie in Paris in 1884 [1]. Smith was the first to 
describe entrapment of inferior rectus between the fracture fragments. He was also the first to coin 
the term “Blow out fracture” [2]. Blow out fracture causes an increase in the intraorbital volume, 
this causes enopthalmos. Entrapment of inferior rectus muscle causes diplopia. These patients 
usually report to an opthalmologist since orbital signs and symptoms are predominant. Shere etal in 
their study conclude that nearly 14% of blow out fractures are caused by contact sports in a military 
population [4].
Case report:
30 years old male patient came with complaints of:
1. Swelling right eye – 1 day duration
2. Double vision – 1 day duration
3. Bleeding from right nose – 1 day duration
History of injury on being struck by a cricket ball +
He gave no history of loss of consiousness.
On examination:
Swelling over upper and lower eyelids on the right side +
Enopthalmos right eye +
Ocular movements restricted on right gaze
Diplopia +Forced duction test +
CT scan nose and paranasal sinuses:
Showed evidence of blow out fracture right orbit. Tear drop sign could be seen.
Management:
Reduction was performed via Caldwel Luc approach under endoscopic guidance. 4 mm 30 degree 
nasal endoscope was used for this purpose. Trap door fractures can usually be reduced without 
resorting to prosthesis. Since this patient had a trap door fracture it could be easily reduced under 
endoscopic guidance. The reduced fracture fragment was stabilized by inflating the balloon of 
foley's catheter introduced into the maxillary sinus via inferior meatal antrostomy. Foley's catheter 
is left in place for a period of 2 weeks for union to occur.
Clinical photograph of a patient with blow out fracture right orbit
CT scan paranasal sinuses showing blow out fracture and the classical tear drop signPicture showing sublabial incision for caldwel luc surgery
Blow out fracture is seen being reduced via the opening made over the canine fossa area under 
endoscopic guidance.Foley's catheter seen inside the antrum
Balloon of foley's catheter seen inflated inside the antrumDiscussion:
Orbital blow out fracture is commonly caused by blunt trauma to the orbit. This is commonly seen 
in persons involved in contact sports like boxing, foot ball, rugby etc [5].
Two theories attempt to explain this injury phenomenon:
1. Buckling theory
2. Hydraulic theory
Buckling theory:
This theory proposed that if a force strikes at any part of the orbital rim, these forces gets 
transeferred to the paper thin weak walls of the orbit (i.e. floor and medial wall) via rippling effect 
causing them to distort and eventually to fracture. This mechanism was first described by Lefort [3].
Hydraulic theory [6]:
This theory was proposed by Pfeiffer in 1943. This theory believes that for blow out fracture to 
occur the blow should be received by the eye ball and the force should be transmitted to the walls of 
the orbit via hydraulic effect. So according to this theory for blow out fracture to occur the eye ball 
should sustain direct blow pushing it into the orbit.
Water House [7] in 1999 did a detailed study of these two mechanisms by applying force to the 
cadaveric orbit. He infact used fresh unfixed cadavers for the investigation. He described two types 
of fractures:
Type I: A small fracture confined to the floor of the orbit (actually mid medial floor) with 
herniation of orbital contents in to the maxillary sinus. This fracture was produced when force was 
applied directly to the globe (Hydraulic theory).
Type II: A large fracture involving the floor and medial wall with herniation of orbital contents. 
This type of fracture was caused by force applied to the orbital rim (Buckling theory).
Initial signs and symptoms of blow out fracture include:
1. Immediate swelling of the eye
2. Tenderness over involved orbit
3. Pain and difficulty with eye movements
4. Double vision
5. Enopthalmos
6. Numbness / tingling over lower eyelid, nose, upper lip [8]
Complications of blow out fracture:
1. Herniation of orbital fat into maxillary sinus [9]
2. Orbital emphysema [10]
3. Bleeding into maxillary sinus
4. Entrapment / rupture of ocular muscles
5. Ischaemic muscle contractures [11]
6. Cellulitis
7. Diplopia
Timing for surgical intervention:
This is highly controversial. Some of the authors prefer a waiting period of atleast 2 weeks for the 
oedema to resolve before proceeding with surgical reduction of the fracture. Early intervention is 
indicated only in white eyed blow out fracture which is common in children. In children the bones 
are flexible and does not break easily but bends. Significant amounts of orbital tissue may get entrapped in between the fractured fragments causing a compromise in their blood supply. This 
condition is known as the white eyed blow out fracture. These patients should under go immediate 
reduction. Surgery is indicated if the eye has recessed by more than 2 mm into the ortbit, ocular 
movements restricted, persistence of diplopia.
Advantages of endoscopic approach:[12]
1. Accurate fracture visualization
2. Incisions are small
3. Facial incisions can be avoided
4. Minimal soft tissue dissection
5. Hospital stay minimized
6. Cosmetically acceptable
References:
1. Ng P, Chu C, Young N, Soo M. Imaging of orbital floor fractures. Australas Radiol. Aug 
1996;40(3):264-8
2. Smith B, Regan WF Jr. Blow-out fracture of the orbit; mechanism and correction of internal 
orbital fracture.Am J Ophthalmol. Dec 1957;44(6):733-9
3. http://www.drtbalu.com/blow_out.html
4. Shere JL, Boole JR, Holtel MR, Amoroso PJ. An analysis of 3599 midfacial and 1141 orbital 
blowout fractures among 4426 United States Army Soldiers, 1980-2000. Otolaryngol Head Neck 
Surg. 2004;130:164-170.
5. Burm JS, Chung CH, Oh SJ. Pure orbital blowout fracture: new concepts and importance of 
medial orbital blowout fracture. Plast Reconstr Surg. 1999;103:1839-1849.
6. Rhee JS, Kilde J, Yoganadan N, Pintar F. Orbital blowout fractures: experimental evidence for 
the pure hydraulic theory. Arch Facial Plast Surg. 2002;4:98-101.
7. Waterhouse N, Lyne J, Urdang M, Garey L. An investigation into the mechanism of orbital 
blowout fractures. Br J Plast Surg. 1999;52:607-612.
8. Moore KL. Clinically Oriented Anatomy. 3rd ed. Baltimore, MD: Williams & Wilkins; 1992.
9. Gilbard SM. Management of orbital blowout fractures: the prognostic significance of computed 
tomography. Adv Ophthalmic Plast Reconstr Surg. 1987;6:269-280
10. Kaiser PK, Friedman NJ, Pineda R. The Massachusetts Eye and Ear Infirmary Illustrated 
Manual of Opthalmology. 2nd ed. Philadelphia, PA: Saunders; 2004
11. Lisman RD, Smith BC, Rodgers R. Volkmann’s ischemic contractures and blowout fractures. 
Adv Ophthalmic Plast Reconstr Surg. 1987;7:117-131.
12. Ikeda K, Suzuki H, Oshima T, Takasaka T. Endoscopic endonasal repair of orbital floor fracture. 
Arch Otolaryngol Head Neck Surg. Jan 1999;125(1):59-63.

An analysis of 3599 midfacial and 1141 orbital blowout fractures among 4426 United States Army Soldiers, 1980-2000. Otolaryngol Head Neck Surg.

An investigation into the mechanism of orbital blowout fractures.

Blow-out fracture of the orbit; mechanism and correction of internal orbital fracture.Am

Clinically Oriented Anatomy. 3rd ed.

Endoscopic endonasal repair of orbital floor fracture. Arch Otolaryngol Head Neck Surg.

Imaging of orbital floor fractures. Australas Radiol.

Management of orbital blowout fractures: the prognostic significance of computed tomography. Adv Ophthalmic Plast Reconstr Surg.

Orbital blowout fractures: experimental evidence for the pure hydraulic theory. Arch Facial Plast Surg.

Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture. Plast Reconstr Surg.

Volkmann’s ischemic contractures and blowout fractures. Adv Ophthalmic Plast Reconstr Surg.

Blow out fracture A Novel Management Modality

http://jorl.net/index.php/jorl/article/view/Blowout_frac

Blow out fracture A Novel Management Modality

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