MODERN APPROACHES TO SURGICAL TREATMENT OF INFERIOR ORBITAL WALL FRACTURES

Аннотация

This study presents a summary of our clinical experience in the surgical rehabilitation of patients with inferior orbital wall fractures. A comprehensive clinical and radiological examination was conducted both preoperatively and postoperatively in 14 patients diagnosed with orbital floor injuries. These fractures were observed both in isolated cases and in combination with zygomatic-orbital complex fractures. Analysis of the cases revealed that isolated inferior orbital wall fractures accounted for 57.14% of the total, with the predominant patient group being young males (78.57%). During surgical treatment, a transantral approach was utilized in all cases, providing optimal access to the inferior orbital wall. In instances where the orbital floor fracture was associated with a zygomatic-orbital complex injury, not only was the orbital floor repositioned, but the zygomatic complex was also stabilized at three standard anatomical fixation points. In cases of isolated injury, characteristic of the so-called pure “blow-out” fracture, the technique of bone-plastic antrotomy was employed as a variation of the transantral approach, allowing for the prevention of a defect in the anterior wall of the maxillary sinus. For osteosynthesis, titanium materials were used in all clinical cases, including F-shaped miniplates or individually contoured titanium meshes, particularly in cases of significant bone defects. As a result of the surgical intervention, all patients achieved restoration of both functional and aesthetic parameters disrupted by the trauma. Long-term outcomes demonstrated complete recovery of binocular vision and the absence of enophthalmos, confirming the high efficacy of the proposed approach. Выпуск журнала №-21 Часть–1_ Март –2025 33 MODERN EDUCATION AND DEVELOPMENT Keywords: orbital floor fractures, zygomatic-orbital fractures, transantral approach, bone-plastic antrotomy. Relevance. Historically, the first description of an inferior orbital wall fracture was provided by MacKenzie in Paris in 1844. The term blow-out fractures entered medical practice in 1957 when Smith and Regan presented a clinical description of an inferior orbital wall fracture with interposition of the inferior rectus extraocular muscle and restriction of ocular motility. It is generally accepted that the mechanisms underlying blow-out fractures are associated with the impact of a blunt object on the anterior parts of the orbit. The most common traumatic agents include punches, elbows, or sports equipment (such as balls). In this case, the force is transmitted from the orbital rim and the eyeball to the inferior orbital wall, leading to its damage at the thinnest site, most often in the medial zone near the infraorbital canal. As a result of a sharp increase in intraorbital pressure, the bony structure is destroyed, accompanied by prolapse of soft tissues into the lumen of the maxillary sinus. In some cases, interposition of the inferior rectus or inferior oblique extraocular muscle occurs along the fracture line, which, along with edema of the surrounding tissues, causes restriction of ocular motility and, as a result, the development of diplopia. Isolated fractures of the medial orbital wall are significantly less common and, as a rule, are part of more complex injuries, particularly naso-orbito-ethmoidal complex trauma. The clinical picture of most patients with inferior orbital wall fractures includes decreased visual acuity, blepharoptosis, as well as the development of vertical or oblique diplopia, which is most pronounced when looking upward. Additionally, hypoesthesia in the infraorbital nerve distribution is noted, caused by its compression or injury. Characteristic signs also include periorbital hematoma and pronounced edema, accompanied by pain. In the early days following trauma, the presence of enophthalmos may remain unnoticed due to significant swelling of the Выпуск журнала №-21 Часть–1_ Март –2025 34 MODERN EDUCATION AND DEVELOPMENT surrounding tissues, which can also restrict ocular movement, creating a false impression of extraocular muscle interposition in the fracture zone. The treatment strategy is determined by the time elapsed since the injury and continues to be a subject of discussion among researchers. Most authors agree that the optimal window for surgical intervention is up to 14 days, as later surgery is associated with the risk of developing fibrotic changes and persistent deformities due to contractures of soft tissues. In some cases, before performing surgery, physicians prefer to wait several days, during which edema and hematoma significantly subside, allowing for a more accurate assessment of enophthalmos severity and the functional state of the extraocular muscles. If interposition of the inferior rectus muscle is detected during this period, an urgent surgical intervention is performed, preferably within the first 7 days, to prevent residual muscle dysfunction. One of the key diagnostic meth