This paper examines whether early, rather than late, surgical repair results in better motility outcomes for a particular subgroup of orbital floor blowout fractures. The authors divide floor fractures into types A and B, depending on whether or not the degree of soft tissue involvement is in proportion to the level of bone fragment displacement. They found in an earlier study that those that had soft tissue displacement out of proportion to the bone disruption, which they labelled type B, were at greater risk of final reduced motility. They attributed this to constriction of the soft tissue and ongoing ischaemic injury until the fracture is repaired. This paper develops this hypothesis to see if early surgery can improve the final motility in type B fractures. Twenty-five patients were included and it was found that those that had surgery within seven days had better final motility with larger fields of binocular single vision than those who were operated on later. It has long been appreciated that urgent surgery is indicated for trapdoor orbital floor fractures in children who may have oculo-vagal signs and ischaemia of prolapsed tissue. This paper expands on this theme to include all age groups, and emphasises the importance of recognising on the CT scan when the degree of soft tissue involvement is out of proportion to the bone fragment displacement. The authors have shown that early intervention in these patients will result in better long-term ocular motility. There may be some difficulty in deciding whether a particular fracture is type A or B, and the study is let down by containing a mixture of prospective and retrospective data. There is no mention of how the timing of surgery was decided, which may be a source of bias. Despite these drawbacks, the paper makes a convincing argument with statistically significant results despite relatively small numbers.

Surgical timing and postoperative ocular motility in type B orbital blowout fractures.
Liao JC, Elmalem VI, Wells TS, Harris GJ.
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James Hsuan

Aintree University Hospital, Liverpool, UK.

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