Blind canalicular marsupialization in complete punctal absence as part of a systematic approach for classification and treatment of lacrimal system obstructions

The procedure of choice for epiphora caused by bipunctal and canalicular obstruction is conjunctivodacryocystorhinostomy. Despite its high success rate, it may result in multiple complications, such as extrusion, migration, and secondary obstruction. The author describes a simple alternative procedure to conjunctivodacryocystorhinostomy for patients with epiphora caused by bipunctal and proximal canaliculus complete occlusion and a systematic approach to treat lacrimal system obstructions. Ten instances of bipunctal and proximal canaliculus absence in five consecutive patients, caused in four patients by ocular surface disorders (topical drug toxicity, herpetic keratoconjunctivitis, and trachoma), were treated by blunt dissection of the presumed lower punctal site under a surgical microscope. The punctal site was determined by several landmarks, the peaked medial lid margin, a dimple at that site, or an area of relative avascularity. The canaliculus was exposed and expanded to create a pocket. After the procedure, the lacrimal drainage system was found patent in nine of the 10 procedures. After one additional procedure, irrigation of the lacrimal drainage system revealed a nasolacrimal duct obstruction that was treated with dacryocystorhinostomy and silicone tube insertion. After these procedures, an objective resolution of the epiphora was noted in all patients. Epiphora resulting from lack of punctal and proximal canaliculus caused by ocular surface diseases may be treated with blind exposure and marsupialization of the proximal canaliculus instead of conjunctivodacryocystorhinostomy. If, in addition, the nasolacrimal duct is obstructed, a dacryocystorhinostomy may be performed. If this proposed procedure fails, the patient can still undergo conjunctivodacryocystorhinostomy or other procedures. The procedure may be part of a systematic approach to treat lacrimal drainage obstructions that is based on an association between the location and the cause of the obstruction.     

Septomaxilla of nonmammalian synapsids: soft-tissue correlates and a new functional interpretation. DELETE

The function of the septomaxilla of nonmammalian synapsids has long been problematic. Distinctive features of this bone, including a prominent intranarial process and a septomaxillary canal and foramen, are characteristic of pelycosaurs and nonmammalian therapsids, but are lost in their mammalian descendants. Numerous contradictory reconstructions have been proposed for the soft anatomy associated with the septomaxilla of nonmammalian synapsids. This review supports the following conclusions: 1) No particular correlation exists between the septomaxilla and the vomeronasal organ (VNO), and the most likely location for the VNO is on the dorsal surface of the palatal process of the vomer; 2) The most likely occupant of the septomaxillary canal is the nasolacrimal duct, which opened either anterior or medial to the intranarial process, near the opening of the VNO duct; and 3) The occupant of the septomaxillary foramen remains uncertain. These conclusions suggest that the functional significance of the septomaxilla in the nonmammalian synapsids is tied to that of the nasolacrimal duct. The association of this duct and the VNO in these animals resembles the condition in Recent amphibians and lepidosaurs, in which the nasolacrimal duct supplies orbital fluids to the VNO, apparently to enhance vomeronasal function. The peculiar shape of the synapsid septomaxilla may have served to collect vomeronasal odor molecules. The changes of the septomaxilla in early mammals, and its nearly complete loss in extant mammals, are probably correlated with a dissociation of the nasolacrimal duct and VNO, and functional changes in both structures.     

Incorporation of titanium mesh in orbital and midface reconstruction

Several authors have demonstrated the safety and effectiveness of titanium in orbital reconstruction. One question posed by clinicians is what happens to large pieces of titanium in communication with the paranasal sinuses or nasal-oral-pharyngeal area. This question becomes increasingly relevant as titanium is used to reconstruct extensive defects for which the destruction of bony architecture requires the placement of mesh in proximity to these areas. The objective of this study was to examine the gross and histologic soft-tissue response to large segments of titanium mesh in the setting of orbital and midface reconstruction, particularly when exposed to the nasal-oral-pharyngeal area and paranasal sinuses. In this study, large segments of titanium mesh were used in eight patients to reconstruct orbital and midface defects, with direct communication between the mesh and nasal-oral-pharyngeal area and paranasal sinuses. Four patients had suffered self-inflicted gunshot wounds; as a result, much of their midface was missing, including the inferior and medial orbital floor, maxilla, nose, naso-orbital-ethmoid complex, and hard palate. Extensive sheets of titanium mesh were used to reconstruct their medial and inferior orbital walls, nasal bridge, and maxilla. In the fifth patient, titanium mesh was used to reconstruct the maxilla after resection of a squamous cell carcinoma of the nasolacrimal duct. In the sixth and seventh patients, mesh was used to reconstruct the nasal bridge after severely comminuted nasal fractures resulted in the loss of bone and mucosa. Finally, the eighth patient had titanium mesh used to replace cocaine-induced bone loss involving the left medial orbital floor and wall and part of the maxilla. On gross examination by either endoscopy or direct inspection, all eight patients had rapid soft-tissue incorporation of the titanium mesh. Initial examination typically revealed budding of soft tissue through mesh interstices, followed by progressive incorporation. One patient's mesh was covered in only 15 days. Two patients underwent biopsies of this newly formed soft tissue. One had biopsies performed at 3, 15, and 31 months after the original operation. Biopsy examination at 3 months revealed incorporation of the titanium with fibrous soft tissue covered by ciliated respiratory epithelium, goblet cells, and squamous epithelium with metaplasia. In addition, the dense, acute inflammation present at 3 months evolved into mild, chronic inflammation at 31 months. The second patient had a single biopsy 4 months after secondary orbital reconstruction for delayed enophthalmos. Biopsy examination revealed a fibrous soft-tissue sheath lined by squamous epithelium with metaplasia. Again, mild chronic inflammation was present within the soft tissue. This study provides evidence of titanium's compatibility with soft tissue. The mesh underwent progressive incorporation with soft tissue that was then resurfaced by indigenous cells, including respiratory epithelia and goblet cells. This phenomenon occurred despite communication with the nasal-oral-pharyngeal area and paranasal sinuses.     

Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment

The medial canthal tendon and the fragment of bone on which it inserts ("central" fragment) are the critical factors in the diagnosis and treatment of nasoethmoid orbital fractures. The status of the tendon, the tendon-bearing bone segment, and the fracture pattern define a clinically useful classification system. Three patterns of fracture are appreciated: type I--single-segment central fragment; type II--comminuted central fragment with fractures remaining external to the medial canthal tendon insertion; and type III--comminuted central fragment with fractures extending into bone bearing the canthal insertion. Injuries are further classified as unilateral and bilateral and by their extension into other anatomic areas. The fracture pattern determines exposure and fixation. Inferior approaches alone are advised for unilateral single-segment injuries that are nondisplaced superiorly. Superior and inferior approaches are required for displaced unilateral single-segment injuries, for bilateral single-segment injuries, and for all comminuted fractures. Complete interfragment wiring of all segments is stabilized by junctional rigid fixation. All comminuted fractures require transnasal wiring of the bones of the medial orbital rim (medial canthal tendon-bearing or "central" bone fragment). If the fracture does not extend through the canthal insertion, the canthus should not be detached to accomplish the reduction.     

Complex maxillary fractures: role of buttress reconstruction and immediate bone grafts

Between 1978 and 1984, 558 patients with complex facial fractures have been treated. One hundred and seventy-one of these patients have had complex Le Fort fractures of the maxilla. In this group of patients, the importance of direct anatomic reconstruction of the anterior maxillary buttresses has been assessed. Complete exposure of the injured buttresses will facilitate assessment of the exact fracture pattern. Direct fixation of the medial and lateral maxillary buttresses on each side, in combination with immediate bone-graft reinforcement or replacement of comminuted or missing buttresses, will facilitate the reconstruction of even the most severely injured maxilla in one stage. This approach is combined with similar reconstructive techniques in other areas of the craniofacial skeleton. Associated mandibular fractures are managed with rigid internal fixation utilizing A-O techniques. The use of these techniques dramatically facilitates airway management and simplifies the treatment of the edentulous patient, the patient with bilateral condylar neck fractures, and those patients with sagittal splitting of the maxilla and palate. The use of both internal craniofacial suspension wires and external craniofacial suspension devices has become largely unnecessary, and reconstruction of even the most complex injuries in one stage with minimal complications and secondary deformities is made possible.     

Endoscopic transnasal approach for the treatment of medial orbital blow-out fracture: a technique for controlling the fractured wall with a balloon catheter and Merocel

The authors repaired a medial blow-out fracture by using an endoscopic transnasal technique with a balloon catheter and Merocel packing in 17 subjects. The follow-up periods were from 6 weeks to 2 years, and averaged 6 months. The length of the operation was 50 minutes on average. The enophthalmos was corrected in seven of the eight patients. Supporting material for the fractured medial orbital wall was kept in place for 1 to 3 weeks. The mean volume of balloon inflation was 2 cc. The result was satisfactory. No complications resulted from the transnasal endoscopic technique. This endoscopic transnasal approach allows for a better aesthetic result because it eliminates external scarring and permits a direct approach to the medial orbital wall and has a superior visualization. A balloon catheter was used to support the fractured medial orbital fracture, which was adapted, ballooned, and then visualized using a radiopaque dye (Visipaque) in 11 cases. A postoperative computed tomographic scan revealed that this is a very useful method for controlling the status of the reduced orbital wall and eliminates the possibility of complications resulting from infection. A resected uncinate process was used as a bone graft material to repair the large defect in five cases. This method provides several advantages including a mucoperiosteal attached bone graft, working in the same operative field, and cost-effective surgical time. A transnasal endoscopic technique for medial orbital fracture is also very useful for releasing entrapment of the medial rectus muscle, because it directly pushes against the fractured wall and gives good exposure of the medial orbital wall.     

Endoscopic endonasal reconstruction of blowout fractures of the medial orbital walls

High-resolution endoscopes and the advent of endoscopic instruments for sinus surgery currently provide surgeons with excellent endonasal visualization and access to the medial orbital walls. The purpose of this study was to demonstrate the reduction of medial orbital wall fractures through an endonasal endoscopic approach that allows the repair of the medial orbital wall fractures without an external incision. This study was a retrospective analysis of 16 patients who underwent surgical repair of medial orbital wall fractures from March of 1997 to May of 1998. The 11 male and five female patients ranged in age from 16 to 54 years (mean, 30.5 years). These patients had undergone primary reduction of medial orbital wall fractures and were observed for at least 12 months after surgery. There were no intraoperative or postoperative complications. Fifteen of 16 patients showed a complete improvement of their symptoms. One patient showed persistent diplopia, which was well managed by prisms. Endoscopic reduction of medial orbital wall fracture using an endonasal approach seems to produce good results and definite cosmetic advantages.     

Bipedicle strap flaps in reconstruction of longitudinal dorsal skin defects of the digits

Dorsal skin defects in which the loss of integument is longitudinal in shape are not uncommon after injury by rotating machinery and by glass shearing along the length of the digit. This shape of defect is difficult to reconstruct with commonly used flaps but lends itself to reconstruction by the use of longitudinal bipedicle strap flaps moved across the dorsum of the finger from lateral to medial. A variant of this traditional technique was used in the reconstruction of 28 dorsal digital defects. The incidence of these defects and the need for this reconstructive technique were analyzed by a review of 1077 patients with dorsal digital injuries treated in a 6-year period between 1989 and 1995. Approximately 20 percent of all dorsal digital injuries requiring flap reconstruction were suitable for reconstruction with bipedicle strap flaps.     

A biodegradable polymer as a cytokine delivery system for inducing bone formation

Bone morphogenetic proteins (BMPs) that have the potential to elicit new bone in vivo have been used in a tissue-engineering approach for the repair of bone injuries and bone defects. Although it is now possible to generate large amounts of recombinant human (rh) BMPs for medical use, the major challenge remains in the development of optimal local delivery systems for these proteins. Here we describe the development of a synthetic biodegradable polymer, poly-d,l-lactic acid-p-dioxanone-polyethylene glycol block copolymer (PLA-DX-PEG). This polymer exhibits promising degradation characteristics for BMP delivery systems and good biocompatibility under test conditions. PLA-DX-PEG/rhBMP-2 composite implants induced ectopic new bone formation effectively when tested in vivo, and can repair large bone defects orthotopically. This polymeric delivery system represents an advance in the technology for the enhancement of bone repair.     

Pure orbital blowout fracture: new concepts and importance of medial orbital blowout fracture.

Pure orbital blowout fracture first occurs at the weakest point of the orbital wall. Although the medial orbital wall theoretically should be involved more frequently than the orbital floor, the orbital floor has been reported as the most common site of pure orbital blowout fractures. A total of 82 orbits in 76 patients with pure orbital blowout fracture were evaluated with computed tomographic scans taken on all patients with any suspicious clinical evidence, including nasal fracture. Isolated medial wall fracture was most common (55 percent), followed by medial and inferior wall fracture (27 percent). The most common facial fracture associated with medial wall fracture was nasal fracture (51 percent), not inferior wall fracture (33 percent). This finding suggests that the force causing nasal fracture is an important causative factor of pure medial wall fracture as the buckling force from the medial orbital rim. Of patients with medial wall fractures, 25 percent had diplopia and 40 percent had enophthalmos. On plain radiographs, diagnostic signs were found in 79 percent of medial wall fractures and in 95 percent of inferior wall fractures. On computed tomographic scans, late enophthalmos was expected in 76 percent of medial wall fractures. Therefore, the medial orbital blowout fracture may be an important cause of late enophthalmos, because it has a high incidence of occurrence, a low diagnostic rate, and a high severity of defect. Among the causes of limitation of ocular motility, muscle traction of the connective septa and direct muscle injury were found frequently, but true incarceration of the muscle was extremely rare in all fractures. The medial and inferior orbital walls are clearly demarcated by the bony buttress, which is an important structure supporting these orbital walls. Its buttress was closely correlated with the fracture of these orbital walls. Most orbital blowout fractures without collapse of the bony buttress had a trapdoor fracture with or without small fragments of punched-out fracture.     

妇科手术造成泌尿系统损伤的原因及预防

目的：分析妇科手术致泌尿系统损伤的原因,并为预防提供理论依据,以改善患者的预后。方法：对我院2003年6月-2010年10月进行妇科手术治疗的13801例患者进行回顾性统计,分析出现泌尿系统损伤患者的相关资料,探讨其泌尿系统损伤情况,归纳影响妇科手术损伤泌尿系统的危险因素。结果：13801例患者共确诊122例术后泌尿系统损伤,损伤率0．88％;多因素分析显示,手术方式、盆腔粘连、导尿管阻塞及手术操作是影响妇科手术泌尿系统损伤的独立危险因素,有统计学意5C（P〈0．05）。结论：妇科手术致泌尿系统损伤的原因主要有手术方式的选择,患者出现盆腔粘连,导尿管受到阻塞及手术操作不当等。绝大部分损伤可在术前、术中得到避免,而对于术后出现泌尿系统损伤的患者,应进行及时有效的处理,以保证患者生活质量,改善预后。     

Spinal injuries due to front-end bale loaders.

Of 22 patients admitted to Plains Health Centre, Regina, from January 1979 to April 1986 with spinal injuries due to farming accidents, 7 had injuries related to tractor-mounted front-end bale loaders. In contrast, none of the 12 patients admitted with farm-related spinal injuries from 1974 through 1978 had injuries related to bale loaders. All seven injuries occurred when a front-end loader was used to move a large, round hay bale. In each case when the loader arms were raised past the horizontal plane the bale rolled back onto the unprotected tractor operator. There were five thoracic injuries, one cervical injury and one lumbar injury. All seven bony injuries healed. Four of the patients had permanent neurologic sequelae; two of the four had paraplegia. All seven patients suffered disability that impaired work performance; all five farmers suffered some loss of income. None of these injuries would have occurred if available safety equipment had been in place.     

Circulating sensory peptide levels within 24 h of human bone fracture.

We designed this study to examine the circulatory levels of wound modulatory peptides [substance P (SP), calcitonin gene related peptide (CGRP] in patients with muscle injuries with bone fractures and within 24 h of the injury. The peripheral plasma levels of these sensory nerve peptides were measured on hospital admission (OA) and 24 h post-injury (PI), using ELISA technique. Mean (s.d) ng/liter of CGRP was higher in patients OA (270 +/- 199), and PI (205 +/- 176); than the controls (3 +/- 81) P < 0.05. Substance P also increased in the patients OA: 101 +/- 50; PI: 46 +/- 3 than controls [8 +/- 9] P < 0.001. Elastase (predictor of posttraumatic complication) was examined and there was no significant differences between patients and control samples (P = NS). This study shows that sensory nerve peptides are increased in bone fracture related injuries up to 24 h after injury. An intact nociceptor system of primary afferent sensory nerves is important for the initiation of the inflammatory process and successful tissue repair as dysfunction of this system could be a contributing factor for a delayed wound healing.     

3. Current approaches to popliteal artery repair.

Trauma to the popliteal artery is potentially dangerous, and limb loss may result, especially with delayed diagnosis. Three anatomic factors contribute to the seriousness of the outcome: proximity of the artery to bone, superficial position of the artery and consequent lack of protection, and frequent associated injury to associated collateral blood vessels. Diagnosis of injury to the popliteal artery rests on suspicion and vigilance; the Doppler transcutaneous flow detector and angiography are often useful aids to diagnosis. Methods of treatment that have been used include arterial repair, grafting and fasciotomy, together with management of associated injuries. The bypass principle of vascular reconstruction may improve overall results.     

Endogenous BMP-7 is a critical molecular determinant of the reversibility of obstruction-induced renal injuries

Although obstructive uropathies are frequently correctable through surgery, the potential for permanent renal injury remains even following the successful correction of obstructions. Little is known about the intrinsic mechanisms that determine the reversibility of renal injuries. We and others found that exogenous bone morphogenic protein 7 (BMP-7) inhibits the pathogenesis of renal injury. Here, we examine the role of endogenous BMP-7 in the outcome of renal recovery following the correction of obstructive uropathies using a reversible murine model of ureteral obstruction. The role of BMP-7 was determined by examining the regulation of BMP-7 during renal recovery and by treating with either BMP-7-neutralizing antibodies or exogenous BMP-7. While BMP-7 is upregulated following the correction of obstructions that lead to reversible renal injury, the upregulation of BMP-7 is diminished following the correction of prolonged obstructions that lead to irreversible renal injury. The activation of the BMP-7 pathway is required for several processes that contribute to renal recovery including the suppression of transforming growth factor-β-dependent profibrotic pathways, the restoration of renal architecture, and the resolution of fibrotic changes in the kidney. Importantly, the therapeutic restoration of BMP-7 enhances renal recovery following the correction of prolonged obstructions that typically lead to irreversible renal injury. Together, these findings show that, while BMP-7 plays a critical role in the repair of obstruction-induced renal injuries, the potential for renal recovery from prolonged obstruction is diminished, in part, due to the dysregulation of BMP-7. Accordingly, renal recovery from obstructive uropathies may be optimized through timely intervention and adjuvant approaches to restore BMP-7 activity.     

Regeneration of the central nervous system-principles from brain regeneration in adult zebrafish

Poor recovery of neuronal functions is one of the most common healthcare challenges for patients with different types of brain injuries and/or neurodegenerative diseases. Therapeutic interventions face two major challenges: (1) How to generate neurons de novo to replenish the neuronal loss caused by injuries or neurodegeneration (restorative neurogenesis) and (2) How to prevent or limit the secondary tissue damage caused by long-term accumulation of glial cells, including microglia, at injury site (glial scar). In contrast to mammals, zebrafish have extensive regenerative capacity in numerous vital organs, including the brain, thus making them a valuable model to improve the existing therapeutic approaches for human brain repair. In response to injuries to the central nervous system (CNS), zebrafish have developed specific mechanisms to promote the recovery of the lost tissue architecture and functionality of the damaged CNS. These mechanisms include the activation of a restorative neurogenic program in a specific set of glial cells (ependymoglia) and the resolution of both the glial scar and inflammation, thus enabling proper neuronal specification and survival. In this review, we discuss the cellular and molecular mechanisms underlying the regenerative ability in the adult zebrafish brain and conclude with the potential applicability of these mechanisms in repair of the mammalian CNS.     

The bare area of the upper conjunctiva: a closer look at the anatomy of transconjunctival upper blepharoplasty

Transconjunctival upper blepharoplasty is a novel technique for which the overall experience has been limited. The authors have used this technique in 42 patients for eyelid rejuvenation, with predictable results and low morbidity. The authors previously described the "bare" area in the medial upper conjunctiva, which was initially noted during their clinical series. This area serves as an anatomic window to access the medial upper eyelid fat pad with a high degree of safety. To clarify the anatomy of this approach, an anatomic study of the upper medial eyelid was performed on the orbits of 10 cadavers (20 orbits). The bare area was further elucidated during these dissections and its microscopic components described in detail. Its spatial relationship to the medial orbital wall and trochlea was also examined during this study. The authors hope that these findings will aid surgeons planning to use this technique.     

Neuroregenerative strategies in the brain: emerging significance of bone morphogenetic protein 7 (BMP7)

Every year thousands of people suffer from brain injuries and stroke, and develop motor, sensory, and cognitive problems as a result of neuronal loss in the brain. Unfortunately, the damaged brain has a limited ability to enact repair and current modes of treatment are not sufficient to offset the damage. An extensive list of growth factors, neurotrophic factors, cytokines, and drugs has been explored as potential therapies. However, only a limited number of them may actually have the potential to effectively offset the brain injury or stroke-related problems. One of the treatments considered for future brain repair is bone morphogenetic protein 7 (BMP7), a factor currently used in patients to treat non-neurological diseases. The clinical application of BMP7 is based on its neuroprotective role in stroke animal models. This paper reviews the current approaches considered for brain repair and discusses the novel convergent strategies by which BMP7 potentially can induce neuroregeneration.     

Prospects on clinical applications of electrical stimulation for nerve regeneration

Regenerative capability is limited in higher vertebrates but present in organ systems such as skin, liver, bone, and to some extent, the nervous system. Peripheral nerves in particular have a relatively high potential for regeneration following injury. However, delay in regrowth or growth, blockage, or misdirection at the injury site, and growth to inappropriate end organs may compromise successful regeneration, leading to poor clinical results. Recent studies indicate that low-intensity electrical stimulation is equivalent to various growth factors, offering avenues to improve these outcomes. We present a review of studies using electric and electromagnetic fields that provide evidence for the enhancement of regeneration following nerve injury. Electric and electromagnetic fields (EMFs) have been used to heal fracture non-unions. This technology emerged as a consequence of basic studies [Yasuda, 1953; Fukada and Yasuda, 1957] demonstrating the piezoelectric properties of (dry) bone. The principle for using electrical stimulation for bone healing originated from the work of Bassett and Becker [1962], who described asymmetric voltage waveforms from mechanically deformed live bone. These changes were presumed to occur in bone during normal physical activity as a result of mechanical forces, and it was postulated that these forces were linked to modifications in bone structure. Endogenous currents present in normal tissue and those that occur after injury were proposed to modify bone structure [Bassett, 1989]. These investigators proposed that tissue integrity and function could be restored by applying electrical and/or mechanical energy to the area of injury. They successfully applied electrical currents to nonhealing fractures (using surgically implanted electrodes or pulsed currents using surface electrodes) to aid endogenous currents in the healing process. A considerable technological improvement was made with the noninvasive application of EMFs [Bassett et al., 1974] to accelerate fracture repair. This newer technique allowed the treatment of hard tissues without the complications of invasive electrode insertion. In addition, soft tissue injuries were now accessible for treatment by electromagnetic fields. In this article, we will first define the basic problems encountered in nerve injury and regeneration, and then review both in vitro and in vivo studies on the use of electric and electromagnetic fields to stimulate the healing process.     

A current 10-year retrospective survey of 199 surgically treated orbital floor fractures in a nonurban tertiary care center.

This study characterizes the surgically treated patient population suffering from orbital floor fractures by use of current data from a large series consisting of 199 cases taken from a nonurban setting. Data were gathered through a retrospective chart review of patients surgically treated for orbital floor fractures at the University of Michigan Health System, collected over a 10-year period. Data regarding patient demographics, signs and symptoms of presentation, cause of injury, nature of injury, associated facial fractures, ocular injury, and associated nonfacial skeleton trauma were collected. In total, there were 199 cases of orbital floor fractures among 189 patients. Male patients outnumbered female patients by a 2:1 ratio and were found to engage in a wider range of behaviors that resulted in orbital floor fractures. Motor vehicle accidents were the leading cause of orbital floor fractures, followed by physical assault and sports-related mechanisms. The ratio of impure to pure orbital floor fracture was 3:1. The most common signs and symptoms associated with orbital floor fractures, in descending order, were periorbital ecchymosis, diplopia, subconjunctival hemorrhage, and enophthalmos. Associated facial fractures were found in 77.2 percent of patients, the most prevalent of which was the zygoma-malar fracture. Serious ocular injury occurred in 19.6 percent of patients, with globe rupture being the most prevalent, accounting for 40.5 percent of those injuries. There was a 38.1 percent occurrence of associated nonfacial skeletal trauma; skull fracture and intracranial injury were the most prevalent manifestations. Associated cervical-spine fractures were rare (0.5 percent). Statistical examination, using odds ratios and chi-squared analysis, demonstrated significant associations that have not previously been reported. Impure and pure orbital floor fractures revealed striking differences in several demographic aspects, including mechanism of injury, signs and symptoms of presentation, spectrum of associated trauma, and the severity of concomitant trauma.