儿童Trapdoor眼眶骨折14例临床分析

Clinical analysis on pediatric orbital trapdoor fractures

目的通过分析儿童Trapdoor眼眶骨折的临床资料，探讨儿童Trapdoor眼眶骨折的临床表现和治疗效果。方法对2008年1月至2015年1月在深圳市眼科医院确诊为儿童Trapdoor眼眶骨折的14例（14只眼）患儿的临床资料进行回顾性分析。结果14例Trapdoor眼眶骨折的主要临床表现为垂直复视伴患眼上转受限（6／14），垂直复视伴患眼上转及下转受限（8／14），眼心反射（6／14），急性眼压升高（2／14）。单纯上转受限者牵拉试验5只眼弱阳性、1只眼阳性，上下转均受限者牵拉试验7只眼强阳性、1只眼弱阳性。CT表现为眶下壁眼球赤道后方眶下神经管内侧窄隙样骨折（14／14），下直肌箝闭于骨折处（7／14），下直肌肿胀、向骨折端旋转移位（6／14）。从受伤到就诊时间为4—30d，13例行眼眶骨折复位术，1例保守治疗治愈，手术距外伤时间为7—31d。6例单纯上转受限的患者复视完全消失、眼球运动恢复正常。7例上下转均受限的患者中，1例复视痊愈、3例部分好转、3例无明显好转。结论儿童患者出现垂直方向眼球运动障碍、眼心反射、急性眼压升高却没有眼球受伤表现时，通常为Trapdoor眼眶骨折。眼球上下转均受限伴牵拉试验强阳性是急诊手术的适应证，牵拉试验阳性或弱阳性者如果数天内眼球运动障碍无明显好转，则需尽早手术治疗。仅上转运动受限者较上下转运动均受限者预后好。

Objective To explore the clinical manifestation and therapeutic efficacy of orbital trapdoor fracture in children by analyzing the clinical data of children with orbital trapdoor fracture. Methods Fourteen cases （14 eyes） with pediatric orbital trapdoor fracture were reviewed and ana- lyzed from January 2008 to January 2015 in Shenzhen Eye Hospital. Results The common clinical manifestations of 14 cases with orbital trapdoor fracture were vertical diplopia with limitation of up-gaze （6/14）, vertical diplopia with limitation of up-gaze and down-gaze （8/14）, oculocardiac reflex （6/14）, acute intraocular pressure rising （2/14）. In 6 patients with limitation of up-gaze, forced duction test were positive for 1 and weak positive for 5, in 8 patients with limitation of up-gaze and down-gaze, 7 were strongly positive, and 1 weakly positive. The common CT image demonstration included a slit fracture along the inside of infraorbital groove in the orbital floor located posterior to the equator of the globe （14/14）, incarceration of the inferior rectus muscle in the fracture （7/14）, the swollen inferior rectus muscle rotated and displaced into the fracture （6/14）. The intervals from injury to presentation were 4-30 days. Thirteen cases underwent surgery, 1 case cured after conservative treatment. The intervals from injury to surgery were 7-30 days. Six cases with limitation of up-gaze obtained good restoration of ocular mobility and correction of diplopia. Of 7 cases with limitation of up-gaze and down-gaze, 1 case obtained good restoration of ocular mobility and correction of diplopia, 3 cases had residual diplopia at extremes of up-gaze and restricted superduction, 3 patients had no obvious improvement in ocular mobility and diplopia. Conclusions Pediatric patients with vertical diplopia and severe limitation of vertical-gaze, oculocardiac reflex, and acute intraocular pressure rising without eyeball injury often have trapdoor fracture in the orbital floor. Strongly positive forced duct＇ion test and severe limitation of up-gaze and down-gaze is the indication for emergency surgery. Positive or weak positive forced duction test and severe limitation of ocular motility persistence for several days is the indication for early operation. Patients with pure limitation of up-gaze obtained favorable results than patients with both limitations of up-gaze and down-gaze.