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A
BSTRACT
Orbital contusion trauma is characterized by particular severity, a high risk of blindness, the possibility of
the development of purulent-inflammatory complications, and functional and cosmetic defects [1]. The
multiple nature of traumatic injuries necessitates the use of accurate topical diagnosis and treatment
planning. The study of traumatic lesions of the orbit is relevant.
K
EYWORDS
Contusion injury, orbit, fractures.
Journal
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p/fmspj
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Research Article
CLASSIFICATION, CLINIC AND DIAGNOSIS OF ORBITAL
FRACTURES (LITERATURE REV)
Submission Date:
February 19, 2022,
Accepted Date:
March 04, 2022,
Published Date:
March 14, 2022
Crossref doi:
https://doi.org/10.37547/medical-fmspj-02-03-03
Z.A.Gafurov
Assistant Of The Department Of Disease And Trauma Of The Oral And Maxillofacial Area
Tashkent Dental Medical Institute, Uzbekistan
Sh. Y. Abdullaev
Doctor Of Medicine, Professor, Head Of The Department Of Diseases And Trauma Of The Oral And
Maxillofacial Area Tashkent Dental Medical Institute, Uzbekistan
D.Z. Yusupova
Ph.D. Assistant Of The Department Of Maxillofacial Disease And Trauma Tashkent Dental Medical Institute,
Uzbekistan
J.H.Nishanov
Resident Physician At The Maxillofacial Surgery Department Tashkent Dental Medical Institute, Uzbekistan
Volume 02 Issue 03-2022
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I
NTRODUCTION
Orbital contusion trauma accounts for 36 to 64%
of all injuries to the facial skeleton involving the
visual organ and its accessory organs [1, 2]. About
85% of all orbital injuries requiring inpatient
treatment are bone wall integrity disorders [3].
According to epidemiological studies, in Russia,
there is an absolute prevalence of domestic
(64.5%) orbital injuries over criminal (21.7%)
and occupational (15.5%) injuries [1, 4]. This
pattern is not so much due to a decrease in the
number of criminal and occupational orbital
injuries per se, as to the fact that in many cases
they are reported by the patient as domestic [5].
Many authors have noted an increase in orbital
transport injuries in the last 5 years, from 4.9% in
2007 to 12.8% in 2010, due to an increase in the
number of vehicles, high road speeds, and alcohol
consumption behind the wheel [2, 6, 7].Orbital
injuries are often the result of sports activities [3].
According to the data of employees of
ophthalmology department of Perm medical
institute in 10 years (2000 - 2010) the sports
traumatism accounts for 9 - 11 % of fractures of
bones of the medial zone of facial skeleton [8].
The bones of the middle zone of the facial
skeleton are also involved in the formation of the
orbit, so injuries to this zone are reflected in the
nature of damage to the bony walls of the orbit.
Fractures of the midface are associated with
orbital fractures in 80% of cases [4], with isolated
fractures of the lower orbital wall being the most
common, accounting for 6-12% [9]. In 29 - 37% of
patients, fractures of two orbital walls are
identified. Fractures of three orbital walls were
reported in 12 - 18 % of patients and all four walls
in 3 - 7 % of patients. In the structure of all orbital
diseases in peacetime, according to the Military
Medical Academy of St. Petersburg (MMA St.
Petersburg), orbital damage ranges from 2% to
8% [4], and in children it is 0.9% [10]. In children,
fractures of the bony walls of the orbit in blunt
trauma account for 23% of all facial injuries. Of all
orbital fractures encountered in pediatric
practice, 25 to 70% are linear fractures of the
inferior wall without displacement of the
fragments, a trap fracture with impingement of
the inferior rectus muscle [3, 11]. Orbital trauma
is combined with injuries of ENT organs in 92 %,
maxillofacial region in 47 %, skull and brain
bones in 45 %, other organs in 11 % of cases,
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according to data of the Military Academy of St.
Petersburg. In 65-66% of cases, orbital trauma is
combined with contusions of the eyeball and its
accessory organs [4, 12]. The ophthalmology
literature distinguishes between orbital soft
tissue contusion without orbital fracture and with
fracture (13). Most cases of orbital contusion
injury are unilateral, with bilateral injury
occurring less frequently. In terms of incidence,
orbital bone wall fractures in orbital contusions
are one of the most common midface injuries and
account for 31% [3]; in children, 23% of all left
skeletal injuries [10]. Orbital contusions without
fracture occur in 78% of all orbital injuries (13).
The social significance of orbital trauma is
determined by the young working age of the
patients, with a bimodal distribution of orbital
contusions with peak frequency at the ages of 16-
21 and 39-55 years, reduced adaptation to
working life with diplopia in 89%, resulting in
significant economic losses [6, 14].
A significant difference was found in the gender
distribution of orbital trauma, with three quarters
of the victims being men [3].
The possibility of seasonality in the incidence of
orbital trauma was also investigated. For
example, it has been noted that the number of
orbital bone wall fractures increases sharply
between April and October; according to other
data, this occurs between July and September [2].
In an analysis of the population of orbital trauma
victims, 42% of cases were found to be under the
influence of alcohol at the time of injury.
Classification of orbital trauma. According to
Gundorova's classification (2009), orbital
trauma is divided into domestic, transport,
criminal, occupational, sports, agricultural,
man-made, and pediatric [1].
In the literature, the only complete
classification of orbital fractures is proposed
by Nikolaenko V.P. (2009), according to which
the most common types of orbital fractures,
which may occur in isolation or in various
combinations with other facial injuries, are
identified.- "Blast and depressed fractures of
the inferior wall of the orbit;
Explosive and depressed fractures of the inner
wall of the orbit;
Fractures of the zyco-orbital complex;
Le Fort I, II, III* fractures of the upper jaw;
Nasoethmoid fractures;
"Blasted" and depressed fractures of the
upper orbital wall;
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Fronto-basal
fractures
(including
supraorbital, glabellar, and isolated fractures
of the superior orbital margin);
Fractures of the orbital apex, including
concomitant damage to the optic nerve canal;
Local fractures caused by sharp objects
inserted into the orbit.
*Top jaw fractures account for 2-5% of all
facial bone fractures. The most common
classification of maxillofacial fractures is
LeFort (1901). It distinguishes between three
main fracture types (3).
Inferior (LeFort-I; transverse). Its line runs in
the horizontal plane. Starting at the edge of
the sternal foramen on both sides, it runs to
the back above the level of the floor of the
maxillary sinus and passes through the
tubercle and the lower third of the pterygoid
process of the sphenoid bone.
Medial (Lefort-II; suborbital).
Its line runs through the junction of the frontal
process of the maxilla with the nasal part of
the frontal bone and the nasal bones
(nasolabial suture), then runs down the
medial and lower walls of the eye socket,
crosses the bone along the suborbital margin
and reaches the pterygoid process of the
sphenoid bone. The cervical bone with the
crenoid plate is often injured.Upper
(Lephorus-III; subbasal). Its line runs through
the nasolabial suture, along the inner and
outer walls of the eye socket, up to the upper
part of the pterygoid process and the div of
the sphenoid bone. At the same time the
zygomatic process of the temporal bone and
the nasal septum are broken vertically. This
causes the facial bones to separate from the
skull bones. The orbit is affected by subbasal
and suborbital fractures. Traumatic fractures
of the upper jaw are bilateral according to
LeFort classification, and their lines run
symmetrically. The typical location of fracture
lines is rare, more often the fracture line is
atypical or asymmetrical [13].Scientific
papers focus on the inferior wall, as it is the
most
frequently
injured
in
orbital
trauma.According to the classification of A. С.
Kiselev (2006) identified types of 'blast'
fractures of the lower orbital wall:
Small splintering, when the lower orbital wall
is "scattered" into a large number of small
fractures and is practically absent in a certain
area, depending on the fracture;
Large splintering, consisting of one or two
large fractures that sink into the cavity of the
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maxillary sinus together with the tissues of
the eye cavity;
The fractures do not lose their connection
with the bone and tend to return to their
original position, impinging on the ocular
tissues that are wedged between them.
In addition, Prof. V. P. Ippolitova (2004)
developed a classification of post-traumatic
deformities of the midface based on the clinical
and radiological picture of zygomatic-orbital
complex (SOC) injuries. M. Khitrina (2007) based
on her classification, developed a working
scheme for fractures of the zygomaticorbital
complex (SOC), features:
Excludes the term "fracture of the zygomatic
bone" as the fracture lines are always localized
outside the zygomatic bone with involvement of
the orbital margins and walls.
Considers the multiple fractures of the MRL and
highlights the localisation of the maximal
displacement and diastasis, which facilitates the
choice of surgical treatment.
5 fracture groups:
1.
Fractures of the SSS with maximal fragment
displacement and diastasis along the inferior
orbital margin.
2.
Fractures of the CEA with maximal
displacement of the fragments and diastasis
along the zygomatic suture.
3.
Multiple SDS fractures without pronounced
diastasis between the fragments.
4.
Fractures of the ETS combined with fractures,
orbital floor defect.
5.
Fractures of the zygomatic arch [15].
According to the working classification of
Gorbunova E. Д. (2006) fractures of the lower
orbital wall in children according to clinical and
radiological signs: presence and terms of
disappearance of diplopia, limitation of eyeball
mobility, transverse size of the through defect,
magnitude of displacement of the lower orbital
wall towards the maxillary sinus, presence of CT
signs of orbital soft tissue impingement in the
fracture area.
1.
CT - signs of fracture with transverse size of
the penetrating defect up to 0.5 cm and
minimal displacement of the lower orbital
wall up to 0.2 cm, without signs of orbital soft
tissues impingement in the fracture zone.
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Clinical signs (diplopia, limitation of mobility)
disappear on the 2nd - 5th day.
2.
CT - signs of fracture with transversal
dimension of the penetrating defect more
than 0,5 cm and displacement of the lower
orbital wall more than 0,2 cm, without signs of
impingement of orbital soft tissues in the
fracture zone. Clinical signs (diplopia,
limitation of mobility of the eyeball) disappear
on the 7th to 10th day.
3.
CT - signs of a fracture with impingement of
the orbital contents and its prolapse into the
maxillary sinus. The clinical signs (disruption
of
ocular
mobility,
double
vision,
enophthalmos,
including
progressive
enophthalmos) remain unchanged [10].
Definition and mechanism of orbital contusion
injury. An orbital contusion is a closed, non-
dermal injury resulting from blunt force
(contusion, compression) to the bony walls of the
orbit and its contents [1].
Blunt orbital trauma is caused by a blow in which
the injuring object is in motion: a blow with a fist,
leg, stick, log, puck, ball, swing; or in which the
subject remains motionless: a fall to the ground
from a height (from a tree, bicycle), a traffic
accident [11, 13]. A detailed assessment of the
mechanism of orbital trauma in a contusion is
helpful in making the diagnosis. For example, if
the blunt solid object is smaller than the orbital
inlet, the patient may develop a subconjunctival
scleral tear without damage to the orbital bone
walls. If the size of the damaging object is larger
than the orbital inlet, there are two possibilities:
with the impact of an agent with relatively low
velocity and low kinetic energy, an "explosive"
fracture of the orbital wall (lower or inner); with
a strong impact, a combined fracture (lower
ocular margin and the orbital floor or inner wall;
upper ocular margin and inner wall, the orbital
roof) [1]. If the impacting object is large and has
high kinetic energy, it causes not only a fracture
of the "bone ring" of the orbit, but also of other
facial bones, up to and including the formation of
panfacial fractures [3].
The type of injury in orbital contusions is
determined by the condition of the eyeball and
the anatomical features of the orbital structure. If
the outer membranes of the eye are incomplete,
e.g. after keratotomy or scleromalacia, the eye
"capsule" is torn and this "saves" from a fracture.
The normal eyeball in a contusion does not
rupture with a blunt flat blow, but deforms and
shifts deep into the orbit, compressing its
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contents and sharply increasing intraorbital
pressure, which causes the weakest lower wall of
the orbit to push into the maxillary sinus [3, 15,
16].
The anatomic structure of the lower orbital wall -
thin periosteum, honeycomb structure of the
cancellous substance, and topographic location -
nodal position in the system of natural bone
connections of the orbit result in a high incidence
of isolated and combined fractures in 87.3 %. Less
common are isolated and combined external,
upper, and internal wall fractures in 15.8% [1, 9].
Takizawa et al. (1998) demonstrated from
experiments
and
subsequent
computer
simulations that the contour (profile) of the
orbital walls plays an important role. In
particular, an arch-shaped orbital roof is much
more resistant to deformation than a nearly flat
bottom, which deforms and breaks more easily.
The inner wall of the orbit is even thinner, but the
lattice labyrinth cells reinforce it at the back like
buttresses, so more mechanical energy is
required to fracture the medial wall than to
fracture the orbital floor [3, 13]. The reflex
contraction of the orbital circular muscle and the
presence of a large air cavity beneath the orbit
also contribute to more frequent damage to the
lower
orbital
wall
(17).
It
is
the
underdevelopment of the maxillary sinus and the
continued growth of the orbit that accounts for
the rarity of orbital floor fractures in children
under 7-8 years of age [3,18].
In 'straight' fractures the zygomatic bone is
injured and 'breaks out' along the joints
connecting it to the frontal, temporal and
maxillary bones. The entire force of the impact
falls on the edges of the orbit, causing them to
fracture or terminate in the formation of fractures
in the trauma area, or spread inward along the
walls. Such a fracture is accompanied by almost
complete loss of the lower orbital wall [ 19 ].
The clinical presentation of orbital trauma in
contusion in the acute period is determined by
the localization of the fracture of the orbital bone
wall. Symptoms of fracture of the lower orbital
wall are well described: oedema, eyelid
haematoma, hypophthalmos, bulbar conjunctiva
chemosis, downward displacement of the eyeball
(hypophthalmos), limitation of active and passive
eye movements, impaired sensitivity in the zone
of innervation of the suborbital nerve [1, 3].
Symptoms of fracture of the inner wall of the orbit
are not as clear as those of the lower wall:
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emphysema of the eyelids, conjunctiva, unilateral
nasal bleeding. In the case of a fracture of the
inner wall of the orbit, enophthalmos with
impingement of the internal rectus muscle in the
fracture zone has been observed [9, 20]. In this
type of fracture, the medial ligament of the
eyelids, the lacrimal ducts and the lacrimal sac
can also be damaged [1].In fracture of the upper
orbital wall, along with a severe general state of
the patient, eyeball movement disorders, upper
orbital slot syndrome, pulsating exophthalmos,
anisocoria due to impaired pupillary innervation,
optic nerve damage in the bone canal, opto-nerve
path, lycvoria, "glasses symptom" are common [1,
21]. Symptoms of fracture of the external wall of
the orbit, which includes the zygomatic complex
(facial asymmetry, disruption of the contour of
the zygomatic bone, limitation of lateral and
downward movements of the lower jaw when
opening the mouth). There is also displacement of
the eyeball, limitation of active and passive
movements, and damage to the external
commissure of the eyelid [1, 13].The complexity
of the clinical examination of patients with orbital
trauma is due, on the one hand, to the uniformity
of clinical symptoms in various orbital and optic
nerve injuries, on the other hand, to the
inaccessibility of the orbit for examination and
limited known examination techniques, and the
difficulty
of
differential
diagnosis
with
intracranial and optic tract injuries [3].Clinical
Examination This explains the importance of the
radiological diagnosis stage, which aims to clarify
and confirm the clinical diagnosis, develop an
optimal treatment strategy and determine the
prognosis of orbital trauma [1, 22].
The diagnosis of orbital trauma in contusion is
difficult due to the need to use various
instrumental methods to examine the orbit (3).
Radiological diagnosis is the leading method for
examining the orbit. The diagnosis of traumatic
injuries to the orbital bone structures begins with
traditional cranial radiography in straight, lateral
and anterior semiaxial projections, or orbital
radiography in 2 projections. In case of suspicion
of injuries of the posterior wall of the orbit, optic
nerve canal, frontal, metacarpal bone, the
targeted X-ray of the orbital region is carried out
by the method of O. According to different
authors, many time-consuming radiological
examinations are not very informative and often
mislead the doctor and significantly delay the
diagnosis. The probability of error (missed X-ray
fracture diagnosed by subsequent coronary
computed tomography) is 10 - 13% for an inferior
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wall fracture and 20 - 27% for an inferior wall
fracture. However, radiography is 100% effective
in diagnosing a fracture of the upper and outer
orbital wall [3, 10, 22, 23, 24]. Therefore, at
present, X-rays of the skull and orbital cavity in
frontal, lateral and anterior semiaxial views are
used only at the admission stage as a screening
method. When analysing the radiographs
obtained, attention is mainly paid to indirect signs
of orbital damage: darkening of the orbit due to
marked swelling of the eyelids and retrobulbar
tissue in the area of damage, air in the upper parts
of the orbit.
It can diagnose gross fractures of the orbital wall,
large bone fragments, and haemosinus by
obscuring the sinus cavity adjacent to the fracture
area [22].The disadvantages are that it is not
possible to assess changes and the interposition
of the soft tissues of the orbit with the bone
structures (impingement, shape changes, muscle
tears), and to determine the extent of the fracture
towards the orbital apex and the width over the
entire length. In radiography there is projection
layering of bones, so it is impossible to get an idea
of small fractures with small fragments or
fractures of thin bones, comminuted fractures
without significant displacement, establish the
presence of bone fragment penetration into the
skull cavity, sinus cavities. X-rays cannot be used
to assess and decide if surgical intervention is
necessary [6, 10, 23].
Conventional radiography can be limited to the
determination of an extensive orbital fracture
with an appropriate clinical picture. If the
traditional radiological examination is positive
and the radiologist gives a negative opinion and
the clinician's suspicions remain, the patient is
referred to a computed tomography (CT) scan for
a detailed diagnosis of the features of orbital
contusions (19). Emergency CT scanning is
becoming the reality of our time as the method of
choice. Although the optimal time for CT scanning
is considered to be a delayed period after orbital
trauma (soft tissue swelling reduction) [3, 25].
The advantages of CT scanning are its ability to
differentiate tissues of different density due to
high resolution (to define the condition of orbital
bone structures, eye cavity and orbital contents),
noninvasiveness, small time and financial
expenses. Furthermore, CT scanning data can
clearly visualize small and combined (several
walls) fractures, estimate the size and position of
bone fragments, diagnose complications of
contusion trauma such as retrobulbar and
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subperiosteal
hematoma,
hemorrhage
in
subchain optic nerve space, extraocular muscles,
and diagnose the condition of mucosa of
accessory sinuses (signs of hemorrhage and
inflammation) [3, 10].
A significant disadvantage of CT scanning,
especially multiple scanning, is the radiation load
on the lens [3, 26].
For a complete analysis of lesions of the orbital
bone and its contents, the examination is
performed in two planes at 1.25 mm increments.
Coronal (frontal) tomograms are more
informative when analysing deformities, defects
of the lower and upper walls of the orbit, orbital
herniation into the maxillary sinus or cerebral
herniation into the orbit, tears and extraocular
muscle-bone fusion sites. Axial slices better
visualize fractures of the medial and lateral walls
of the orbit, optic nerve and optic nerve canal, and
the shape of the straight extraocular muscles [26,
27]. When analyzing CT data in unilateral
fractures, attention is paid to the symmetry of the
shape and volume of the orbit, the position of the
eyeballs and extraocular muscles, the condition of
the optic nerve and its bone canal, and the
presence of foreign bodies [1, 28]. In normal cases
the eyeball occupies a central position in the orbit,
its displacement close to any wall shows the
impingement of the corresponding muscle in the
fracture zone. The shadows of straight muscles
are normally 0.1-0.3 cm away from the bone
walls. If there is no X-ray-negative stripe between
the muscle and bone, scar fusion or impingement
of the muscle and bone is suspected [3, 10, 26].
Minor comminuted fractures are characteristic of
"blast" fractures of the orbit with damage to the
thin bones of the labyrinth or the lower orbital
wall.
Fractures in the form of a fracture are usually
found in 'blast' fractures (lower wall fracture) and
fractures of the frontal bone (upper wall
fracture). The CT scan helps to identify secondary
involvement of the inferior and inner rectus
muscles near the displacement of bone fragments
in blast fractures of the orbital wall, differentiates
the causes of diplopia due to muscle impingement
and muscle haematoma development, and helps
to identify parabulbar soft tissue prolapsed into
the sinuses adjacent to the orbit [1, 27, 28].
Coronary imaging may be impeded by the
patient's poor general condition, the presence of
an intubation tube in the trachea (its image
overlays the orbital contours), or trauma to the
neck preventing hyperextension. In these cases,
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spiral
computed
tomography
(SCT)
or
multidetector spiral computed tomography
(MSCT) are indispensable. They are characterized
by high diagnostic informativeness, high scanning
speed, possibility of imaging orbits in bone and
soft tissue modes, creating 3D and multiplanar
reformations based on multiple slices - high
frequency scanning. In addition, overextension of
the neck is no longer necessary to obtain coronal
slices [29, 30].Many authors claim that CT and
MSCT techniques will eliminate the need for
magnetic resonance imaging (MRI) in patients
with orbital trauma. However, the use of these
techniques in the diagnosis of orbital contusion
injury has been reported in the literature by a few
authors [31].
In addition, a method of noninvasive low dose (2
mSv) functional MSCT (fMSCT) of extraocular
muscles in orbital trauma was developed by the
staff of the Sechenov First Moscow State Medical
University Department of Radiation Diagnostics.
The study is performed in dynamic scanning
mode according to the program of bone and soft
tissue reconstruction with a slice thickness of 0.5
mm in axial projection, followed by obtaining
multiplanar
and
three-dimensional
reconstructions
with
simultaneous
eye
movement in a certain sequence. When fMSCT is
performed in the presence of functional muscle
activity, extraocular muscle fixation in the
fracture zone can be detected. In the absence of
movement and contractility of a muscle, paralysis
of nerves involved in muscle innervation can be
confirmed or muscle detachment from the eyeball
from the vertex of the orbit can be diagnosed [32].
These include the presence of a pacemaker, metal
implants, permanent makeup and tattoos (which
create artifacts and impede the interpretation of
images), claustrophobia, pregnancy and lactation,
and uncontrolled movements of the patient
during the examination. MRI can be used to assess
the anatomico-topographical relationship of the
orbital structures to the sinuses and brain [ 1,31
].
Ultrasound
(ultrasound;
two-dimensional
imaging system) of the orbit and eyeball
structures for orbital contusions, allows you to
see a cross-section of the eye in a given scanning
plane with its structural changes. Ultrasound can
assess the shape, size, clarity of contours,
structure, echogenicity of eyeballs, as well as the
location and size of the main intraocular
structures: cornea, anterior chamber, iris, ciliary
div, lens, vitreous div, retina, vasculature;
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condition of optic nerve area, retrobulbar space,
extraocular muscles [32, 33].
In recent years, ultrasound diagnosis of orbital
fractures in contusive orbital trauma has been
actively introduced [34]. The main arguments are
economic feasibility, widespread availability of
ultrasound equipment, also the absence of
radiation exposure and the possibility of long-
term investigation. The use of ultrasound to
diagnose fractures of the lower edge and anterior
parts of the orbital floor proved to be the most
justified; the method was proposed by Medvedev
Y.A. and Konyakhin A.F. (2007). The principle of
the method consists in drawing on the patient's
face the scheme of the location of ultrasound
probes to study the bone tissue throughout the
fracture line on the injured side and the same
amount of bone tissue on the undamaged side,
taking into account the complex topography and
anatomico-topographic structure of the midface
bones.Based on this method, it is determined that
the rate of ultrasound signal transmission is
slower on the injured side compared to the
healthy side, in the dynamics the line of injury
approaches the indicators of the healthy side.
Dynamic studies provide data on the course of
reparative processes along the fracture line,
enable timely transition to functional treatment,
assess a particular method of fixation of bone
fragments, and reduce the number of radiological
studies [35].
In conclusion, the incidence of blunt orbital
trauma among all injuries to the facial skeleton
involving the visual organ and its accessory
organs ranges from 36 to 64%. In the early stages,
the uniformity of clinical symptoms does not
allow a precise topical diagnosis to be made.
Different diagnostic methods (X-ray, CT, MSCT,
fMSCT, MRI, ultrasound) are currently used to
diagnose the localization of the orbital injury site.
However, the published literature does not
provide clear indications for the use of each of
these methods. To systematize and build an
effective, targeted algorithm for the examination
of patients with blunt orbital trauma is the task of
our further research.
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