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Mechanism of Orbital Blowout Fracture I Stress Coat Test Keio J. Med. 23: 71-75, 1974 MECHANISM OF ORBITAL BLOWOUT FRACTURE I STRESS COAT TEST SADAO TAJIMA, TOYOMI FUJINO and TOSHIO OSHIRO Department of Plastic and Reconstructive Surgery, School of Medicine, Keio University , Tokyo, Japan (Received for publication February 23, 1974) ABSTRACT Orbital blowout fracture in facial fractures is the most difficult to handle and mechanism of the fracture is unknown. Only one experimental proof is made by Smith, who insists of the theory of increased hydraulic pressure in the orbital contents as a causative factor. Our clinical cases do not always present such an evidence. In order to clarify the mechanism, the serial tests were designed. The first test is stress coat test, which suggests that stress concentration is quantitatively focused along the suture lines of the orbital walls and the infraorbital canal. The phenomenon is notch effect. The term "blowout fracture" is commonly used despite the fact that many clinicians still do not have an accurate concept of this disorder. Probably the most accurate and concise definition was presented in 1944 by King' in one of the first description of blowout fracture of the orbital floor. He said "I would like to add one other type of fracture of great importance, which is not infre quent. In this there is a downward displacement of part of the orbital floor, unassociated with any damage to the margin of the orbit surrounding the facial bones. The cause of such a fracture is difficult to visualize." At present time, mechanism of the orbital blowout fracture is classified into two categories, mostly based on the clinical experiences. I. the hydraulic force of the orbital contents against the floor causes a blowout type fracture. This views are supported by. Pfeiffer,2 King, Smith3 and Con verse .4 II. Le Fort5 and McCoys think that the force is transmitted by bone conduction through the orbital margin directly to the orbital floor. There is only one experimental explanation of mechanism of blowout 71 72 Sadao Tajima et al fracture in the literatures, done by Smith utilizing a human cadaver. He con cluded that the force of a convex object at the orbital entrance displaced the globe and other orbital tissues posteriorly with the resultant fracture of the area of least resistance, the orbital floor. In other words, blowout fracture is caused by the increased hydraulic pressure rather than by bone transmission. This is an accepted theory as mechanism of blowout fracture. However, our clinical experiences on blowout fracture did not always presnet such an evidence of the increased hydraulic pressure. Therefore, we planned to clarify experimentally what the real causative factor of blowout fracture is. As the first step, stress coat test was done. Fig. 1 Relationship between strain sensibility of stress coat and stress. Mechanism of Orbital Blowout Fracture , Stress Coat Test 73 MATERIALS Stress coat is the trade name of a brittle lacquer method of strain determi nation in any structure subjected to static or dynamic forces . Stress coat is consisted of lime rosin 100 grams, titan white 20 grams , dioctyl phthalate 0-8 ml, benzol 0-50 ml, triol 100-150 ml and xylol 5 ml. Figure 1 shows the relationship between strain sensibility of stress coat and stress. TECHNIQUES Four human dried skull were used. The surface of the human dried skulls was polished smoothly with a fine sandpaper and dried with ether prior to the test. Half an hour later, stress coat was sprayed uniformly (0.1 mm in thickness) with a spray gun on the surface of the orbit and the surrounding facial bones. At the same time, the calibration strip of duralmin, 2 x 20 x 200 mm, was coated. The calibration strip was used in order to mantain the same characteristics for the dried skull. The dried skull and calibration strips were allowed to dry at 70° C for 6 hours, when the most sensible condition for stress coat test was found. This is found by weighing 500 grams of weight at the end of calibration strip (Fig. 1). A dynamic impact by a hammer was given on the infraorbital rim on the Frankfurt line above the infraorbital foramen. RESULTS Figure 2 reveals that the stress lines are mainly concentrated along the suture lines of the orbital walls and the infraorbital canal. The suture lines are notched and the infraorbital canal is thinn, where the maximum intensity of stress will concentrate. This phenonemon is the notch effect. DISCUSSION Fracture of the bone means, in physiological terms, the destruction phenone mon of the solid body and concerns with stress and strain quantitatively. According to Gurdjian,7 dry bone, while having different strength and stiffness characteristics than living bone, may be used for the determination of paths of strain under dynamic impact, and area of weakness may thus be determined. Deformations of the skull may be more extensive at some distance from the point of the blow than they are in the region of the blow. This qualitative 74 Sadao Tajima et al Mechanism of Orbital Blowout Fracture , Stress Coat Test 75 uniformity in stress seems to be more helpful in clarification of mechanism of blowout fracture. SUMMARY Stress coat test suggests that the maximum stress concentration is quanti tatively focused along the suture lines of the orbital walls and the infraorbital canal, and those areas are determined to be weak. The phenonemon is the notch effect. The part of the study was supported by the grant of Japan Automobile Research Institute. REFERENCES 1. King, E. F.: Fractures of the orbit. Trans. Ophth. Soc. U.K. 64: 134-1J9, 1944 2. Pfeiffer, R. L.: Traumatic enophthalmos. Arch. Ophth. 30: 718-726, 1943 3. Smith, B. and Regan, W. F. Jr.: Blowout fractures of the orbit; mechanism and correction of internal orbital fracture. Amer. J. Ophth. 44: 733-739, 1957 4. Converse, J. M. and Smith, B.: Enophthalmos and diplopia in fracture of the orbital floor. Brit. J. Plast. Surg. 9: 265-274, 1957 5. Le Fort, R.: Etude experimentale sur les fractures de la machoire superieure. Rev. de chir, 23: 208, 360, 479, 1901 6. McCoy, F. J., Chandler, R. A. Magnan, C. G., Moore, J. R. and Siemsen, G.: An analysis of facial fractures and their complications. Plast. Reconst. Surg. 29: 381-391, 1962 7. Gurdjian, E. S. and Lissner, H. R.: Deformations of the skull in head injury. A study with the "Stress coat" techniques. Surg. Gyn. Obst. 81: 679-687, 1945 Fig. 2 Stress lines caused by dynamic impact by a hammer. (a) stress lines along the infraorbital rim and infraorbital canal, extending to the lacrimomaxillary suture line. (b) stress lines along the zygomaticomaxillary suture line, extend ing down to the infraorbital canal and up to the ethomoideomaxillary suture line and sphenozygomatical suture line. (c) stress lines along the zygomati comaxillary suture line, extending to the infraorbital canal, ethomoideomaxil lary suture line and sphenofrontal suture line. (d) stress line along the infraorbital rim, extending to the infraorbital canal and up to the ethomoideo maxillary suture line..
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