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World J Otorhinolaryngol Head Neck Surg
World J Otorhinolaryngol Head Neck Surg
10.1002/(ISSN)2589-1081
WJO2
World Journal of Otorhinolaryngology - Head and Neck Surgery
2095-8811
2589-1081
John Wiley and Sons Inc. Hoboken

10.1002/wjo2.158
WJO2158
Research Paper
Research Paper
Isolated traumatic orbital floor fracture: An analysis of the National Trauma Data Bank
NTDB ANALYSIS OF TRAUMATIC ORBITAL FLOOR FRACTURES
DE RAVIN et al.
De Ravin Emma http://orcid.org/0000-0002-1076-1941
1 2
Xu Katherine 1 2
Fritz Christian http://orcid.org/0000-0002-3821-3859
1
Parhar Harman S. 1
Rajasekaran Karthik http://orcid.org/0000-0003-2148-1643
1 3 karthik.rajasekaran@pennmedicine.upenn.edu

1 Department of Otorhinolaryngology Head and Neck Surgery University of Pennsylvania Philadelphia Pennsylvania USA
2 Perelman School of Medicine at the University of Pennsylvania Philadelphia Pennsylvania USA
3 Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
* Correspondence Karthik Rajasekaran, Department of Otorhinolaryngology Head and Neck Surgery, 800 Walnut Street, 18th Floor, Philadelphia, PA 19107, USA.
Email: karthik.rajasekaran@pennmedicine.upenn.edu

08 1 2024
9 2024
10 3 10.1002/wjo2.v10.3 187192
06 3 2023
30 10 2023
© 2024 The Authors. World Journal of Otorhinolaryngology ‐ Head and Neck Surgery published by John Wiley & Sons, Ltd on behalf of Chinese Medical Association.
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

Abstract

Objectives

To date, no study provides a comprehensive analysis of traumatic orbital floor fractures across the United States. We aimed to characterize patient demographics, injury‐related variables, and operative management in this population.

Method

The National Trauma Data Bank was queried for open or closed orbital floor fractures from 2008 to 2016. Clinical data were extracted.

Results

Overall, 148,592 orbital floor fractures were identified, with 142,577 (95.9%) closed‐ and 6158 (4.1%) open‐type fractures. A total of 106,243 (71.5%) patients were male and the median patient age was 41 years. The majority of patients (79.2%) had abbreviated injury scale scores of ≤2, indicating minor/moderate injury. Fracture mechanism of injury (MOI) differed by gender, with the most frequent being unarmed fights in men (34.3%) and falls in women (14.0%). There were 29,600 patients (19.9%) with isolated orbital floor (I‐OF) fractures. The MOI most strongly associated with operative intervention of with I‐OF fractures were penetrating injuries caused by a firearm (odds ratio [OR]: 2.91; 95% confidence interval [CI]: 1.62–5.20) and cuttings/piercings (OR: 2.17; 95% CI: 1.29–3.65).

Conclusion

This large epidemiological study reveals that orbital floor fractures tend to present with minor or moderate injuries and are more likely to require operative intervention in setting of firearm or cut/pierce injuries.

Key points

Significant findings: Isolated orbital fractures due to penetrating firearm or cut/pierce injuries are more likely to require surgical repair, while those resulting from a fall or as a passenger in a motor vehicle accident are less likely to need surgical repair.

What this study adds: This is the first study to provide a comprehensive analysis of traumatic orbital floor fractures across the United States. We also present a secondary analysis of the predictors of surgical intervention in patients with isolated orbital floor fractures.

epidemiology
National Trauma Data Bank
orbital fracture
risk factors
trauma
None source-schema-version-number2.0
cover-dateSeptember 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:03.09.2024
De Ravin E , Xu K , Fritz C , Parhar HS , Rajasekaran K . Isolated traumatic orbital floor fracture: an analysis of the National Trauma Data Bank. World J Otorhinolaryngol Head Neck Surg. 2024;10 :187‐192. 10.1002/wjo2.158
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pmcINTRODUCTION

Orbital floor fractures can present in isolation (“blow‐out fracture”) or along with other fractures of the midface and zygomaticomaxillary complex (ZMC). Collectively these fractures are estimated to account for 25% of all traumatic facial fractures. 1 , 2 , 3 , 4 , 5 While many orbital fractures can be managed conservatively without surgical intervention, 11%–15% are associated with ophthalmological emergencies, requiring urgent operative intervention. 6 , 7 Of the seven facial bones comprising the orbit, those of the medial wall and floor are quite delicate and prone to fracture. 8 , 9 As such, large orbital floor fractures commonly present with herniation of orbital contents into the maxillary sinus, leading to associated enophthalmos and diplopia. 10 , 11 , 12 , 13 Small or hairline floor fractures can result in restriction of extraocular movement due to entrapment of the inferior rectus or adjacent periorbital soft tissue, as well as associated traumatic optic neuropathy, and diplopia. 10 , 11 , 12 , 13 The potential for these and other related consequences obviate the need for a comprehensive understanding of the epidemiology of orbital floor fractures, their workup, and their management.

Although the general principles of orbital trauma management are well established, prior clinical guidance is currently being re‐exaimined. 11 This is warranted given recent advancements in computed tomography imaging, 14 endoscopic sinus approaches, 15 and new data specifying surgical indications and optimal timing. 16 Despite this need for re‐examination, no large‐scale study has characterized the epidemiology and management of traumatic orbital floor fractures. To address this paucity in the literature,a systematic analysis of the National Trauma Data Bank (NTDB) was undertaken. We aimed to: (1) characterize clinical, demographic, and injury‐related variables in patients presenting with traumatic orbital floor fractures; (2) identify procedures performed and predictors of clinical outcomes in patients with isolated orbital floor (I‐OF) fractures.

MATERIALS AND METHODS

The NTDB is the largest nationwide incident‐based trauma repository. Created by the American College of Surgeons, it comprises more than 8 million records and pulls data from over 750 trauma centers across the United States. 17 For this study, the NTDB was queried for all adult patients presenting to an NTDB‐participating trauma center between 2008 and 2016. Data were extracted using the International Classification of Diseases, Ninth Revision (ICD9) diagnostic codes referring to “Fracture orbital floor, closed” (802.6) and “Fracture orbital floor, open” (802.7). Baseline patient characteristics were collected, including age, sex, race, and concomitant injuries on admission. Relevant clinical data were abstracted from each record: mechanism of injury (MOI), diagnoses, procedures performed, abbreviated injury scale (AIS) score, Glasgow Coma Scale (GCS) score, and trauma center level. We further analyzed the likelihood of surgical intervention by MOI in patients with I‐OF fractures. Such fractures were defined as involving only the orbital floor, without additional fractures of the internal orbital skeleton, nasal, maxilla, mandible, or other facial bone.

With regard to scoring, AIS is a consensus‐derived, global severity scoring system that classifies individual injuries by specific anatomical region on a 6‐point severity scale (1 = minor, 2 = moderate, 3 = serious, 4 = severe, 5 = critical, 6 = maximum). 18 According to the AIS dictionary, coding of all injuries to the facial region should begin at 2 points in severity (moderate). Those injuries involving the orbit, therefore, have a minimum AIS score of 2, by definition. Furthermore, GCS is a neurological assessment that objectively describes the extent of impaired consciousness. 19 This scale assesses patients on three aspects of responsiveness: eye‐opening, motor, and verbal responses. Scores range from 3 to 15, with a classification of traumatic brain injuries being reported as severe (GCS ≤ 8), moderate (GCS 9–12), or mild (GCS ≥ 13).

Consistent with nomenclature of fractures outside of the orbit, fractures of the orbital floor can be classified as open or closed. “Open” orbital floor fractures are those in which bone of the orbital skeleton protrudes though the skin or is visualized though a deep wound. “Closed” orbital floor fractures are limited to the internal orbital skeleton such that the skin remains intact with no externally visible bone. Both are considered “blow‐out” fractures.

Collected data were summarized via SAS (SAS Analytics Software) and Excel, and forest plots with risk ratios were generated in Stata version v15.1 (StataCorp). This study was deemed exempt by the Institutional Review Board of the University of Pennsylvania given the deidentified, publicly accessible data set utilized.

RESULTS

Baseline characteristics

Between 2008 and 2016, a total of 148,592 patients were admitted to trauma centers for orbital floor fracture injuries, including 142,577 (95.9%) open and 6158 (4.1%) closed fractures. A total of 106,243 (71.5%) patients were male and 100,300 (67.5%) patients were white. Median age was 41 years (interquartile range: 25–57 years). Patients most commonly presented to Level Ⅰ or Level Ⅱ trauma centers, representing 67.1% and 29.5% of cases, respectively, in which trauma center level was known. The majority of recorded AIS scores were ≤2 (n = 40,434; 79.3%), indicating minor (14,014) or moderate (26,420) injury. There were only 516 (1.0%) recorded incidents of severe, critical, or maximal/fatal injuries (AIS ≥ 4). Consistent with these relatively minor AIS scores, over 75% presented with GCS scores ≥13, suggestive of only mild head injury. Full cohort demographic information can be found in Table 1.

Table 1 Demographics and clinical presentation of patients with orbital floor fractures (n = 148,592).

Characteristic	Data	
Age [year, median (IQR)]	41 (25–57)	
Gender [n (%)]		
Male	106,283 (71.5)	
Female	42,158 (28.4)	
Unknown	151 (0.1)	
Race [n (%)]		
American Indian	1548 (1.0)	
Asian	2670 (1.8)	
Black or African‐American	22,699 (15.3)	
Native Hawaiian/Pacific Islander	337 (0.2)	
White	100,272 (67.5)	
Unknown/other	21,066 (14.2)	
Orbital fracture [n (%)]		
Open	142,577 (96.0)	
Closed	6158 (4.0)	
Trauma center level [n (%)]		
Ⅰ	61,083 (41.1)	
Ⅱ	26,843 (18.0)	
Ⅲ	2938 (2.0)	
Ⅳ	126 (0.1)	
N/A	57,602 (38.8)	
Common concomitant injuries [n (%)]		
Closed malar/maxillary fracture	69,251 (46.6)	
Closed nasal bone fracture	49,331 (33.2)	
Closed facial bone fracture	47,967 (32.3)	
AIS score [n (%)]		
1–2	40,434 (27.1)	
3–4	10,504 (7.1)	
5–6	81 (0.1)	
Unknown	97,573 (65.7)	
GCS score [n (%)]		
3	7282 (4.9)	
4–5	1590 (1.1)	
6–8	4471 (3.0)	
9–12	7124 (4.8)	
13–15	64,266 (43.2)	
Unknown	63,859 (43.0)	
Abbreviations: AIS, abbreviated injury score; GCS, Glasgow Coma Scale; IQR, interquartile range.

John Wiley & Sons, Ltd.

Mechanism of injury

When recorded (n = 49,871), the most common type of injury resulting in orbital floor fracture was assault (n = 28,942; 58.0%). Less common causes were falls and motor vehicle trauma (MVT) (25.9% and 16.1%, respectively) (Figure 1). Mechanisms of traumatic injury differed by gender. For men, the assault‐type MOIs were most frequent: unarmed fights/brawls (47.4%) and attacks via blunt/thrown object (22.8%). Falls were less frequent among male patients (14.1%). In contrast, the most common MOIs by far in women were falls (58.5%), followed by MVT (17.2%) and unarmed fights/brawls (17.1%).

Figure 1 Most common mechanisms of injury for orbital floor fracture by sex (n = 49,871). MVA, motor vehicle accident.

Outcomes among I‐OF fractures

Of all patients with orbital floor fractures, a total of 29,600 (19.9%) occurred in isolation without concomitant facial fractures. Only 512 (1.7%) of these I‐OF fractures required operative intervention during initial hospitalization. Penetrating injuries resulting in I‐OF fractures were significantly more likely to require surgical repair of the orbit than blunt force traumas (odds ratio [OR]: 2.54; 95% confidence interval [CI]: 1.69–3.84) (Figure 2). Of those penetrating injuries causing I‐OF fractures, the MOIs most strongly associated with operative intervention were firearm injuries (OR: 2.91; 95% CI: 1.62–5.20), cut/pierce injuries (OR: 2.17; 95% CI: 1.29–3.65), and injuries in which patients were struck by/against an object (OR: 1.94; 95% CI: 1.63–2.31). Patients significantly less likely to undergo operative repair while hospitalized were those who sustained I‐OF fractures due to a fall or as a passenger in a motor vehicle accident (MVA). Moreover, designated injury intent was also predictive of the need for operative repair in the setting of I‐OF fractures. Victims of assault were more likely to need surgery (OR: 1.64; 95% CI: 1.38–1.96), while unintentional or accidental I‐OF fractures were less so (OR: 0.62; 95% CI: 0.52–0.74).

Figure 2 Forest plot demonstrating risk ratio of operative intervention by a mechanism of injury for orbital floor fracture. CI, confidence interval; MVA, motor vehicle accident.

DISCUSSION

Orbital floor fractures are major contributors to the burden of facial fractures in the United States. 1 , 2 , 3 To date, however, there remain no uniform recommendations for surgical intervention on these fractures. 20 Using the NTDB, we conducted an analysis of all adult patients presenting with I‐OF fractures between 2008 and 2016.

The demographics in our study closely resemble the prior literature onnasal, 21 facial, 22 and orbital floor fractures 23 in regards to a relatively young patient age and strong male predilection. As such, the median sample age was 41 years and 71.5% of patients were male. It is known that facial fractures caused by assault tend to be most common among young males. 24 , 25 , 26 Although both the events and clinical manifestations surrounding orbital fractures can be diverse, the preponderance of assault cases in the NTDB sample may help explain the male over representation. Indeed, regardless of gender, the overall top MOI for orbital fractures was assault (58.0%). The majority of these assaults were observed in males (88.9%) (Figure 1). Similarly, a recent case series (n = 156) by Prabhu et al. 16 found the most common injury mechanism for I‐OF fracture to be assault, albeit at a lower reported prevalence (34.7%).

While orbital floor fractures are commonly seen in clinical practice, the mechanism of fracture is poorly understood. The two pathophysiological theories explaining these fractures are the hydraulic and buckling theory, which implicate trauma to the orbital rim and the globe, respectively. Under the hydraulic theory, a blow force to the globe in the setting of lower‐impact injuries is transmitted to the weaker orbital floor while leaving the ZMC intact. 16 , 27 Our results are congruent with this pattern of injury given that I‐OF fractures were most commonly caused by assault (low‐impact) and less frequently by MVA (high‐impact). Such fractures of the orbital floor occurring in isolation made up to 20% of all orbital fractures. This proportion is consistent with other recent reports. 5 , 26

With regards to surgical intervention, prior studies describe surgery as being more common among orbital fractures caused by MVA (35.0%) than those due to assault or fall (21.9% and 13.4%, respectively). 25 In contrast, we report that operative interventions on I‐OF fractures were most common in the assault category, which included injuries from firearms, cuttings/piercings, and those resulting from a strike by/against an object. These three MOIs were each statistically significant predictors of the need for surgical intervention (Figure 2).

Taken together, complex orbital fractures can be the result of significant trauma and thus frequently associated with serious injuries, including intracranial 28 , 29 , 30 , 31 and intraocular injury. 20 , 32 Conversely, we report that the majority of I‐OF fractures present with the mildest form of intracranial injury (GCS ≥ 13, 75.8%) and only minor/moderate regional injuries (AIS ≤ 2, 79.3%). Although the AIS dictionary specifies that coding of all injuries to the facial region should begin at 2 points in severity (moderate), this scoring rule was not routinely followed in clinical practice. A total of 14,014 orbital floor fracture injuries (9.4%) received an AIS score of 1. This indicates that either there is room for improvement in score reporting, or that a subset of these fractures tend to be perceived as relatively minor in severity based on the clinical experience of providers responding to such trauma calls.

A limitation of this report is that the NTDB includes only operations on indexed hospitalizations. The NTDB does not include follow‐up information on subsequent operative interventions undertaken on an outpatient basis. 33 For this reason, our results could underestimate the rate of operative intervention, some of which may occur more than a month after injury. 14 Likewise, we are unable to comment on long‐term functional or cosmetic complications. Another inherent weakness of NTDB is that it does not include outpatient evaluations, emergency department visits, and other non‐trauma activations. Injury severity may, therefore, be overestimated due to not capturing potentially less severe orbital floor fractures that do not warrant hospitalization. Nevertheless, this study does represent an important addition to the literature as it describes the epidemiology and risk factors associated with isolated fractures of the orbital floor in patients presenting to trauma centers across the country. Our findings are highly generalizable and potentially of interest to surgeons from a variety of subspecialties involved in the care of ocular trauma (i.e., emergency medicine, trauma surgery, ophthalmology, otolaryngology, and oral and maxillofacial surgery).

CONCLUSIONS

The present study is the largest epidemiological study on traumatic orbital floor fractures to date. Importantly, we report that I‐OF fractures tend to be conservatively managed, with only 1.7% requiring operative repair. We also demonstrate that patients presenting with assault‐type injuries (cut/pierce, firearm, or struck by/against an object) were significantly more likely to require operative intervention for I‐OF fractures. Individuals who sustained I‐OF fractures due to a fall or as a passenger in an MVA were significantly less likely to require operative repair. Careful consideration should be given to the mechanism of a patient's injury, in addition to the physical exam, in personalizing operative management of patients presenting with traumatic orbital floor fractures. Future multi‐institutional prospective studies should investigate long‐term functional and cosmetic outcomes not assessed in this report.

AUTHOR CONTRIBUTIONS

Emma De Ravin: Conceptualization (lead), methodology (lead), visualization (lead), writing—original draft preparation (lead), writing—reviewing and editing (lead); Katherine Xu: Data curation (lead), software (lead), conceptualization (equal), methodology (equal), writing—reviewing and editing (supporting); Christian Fritz: Writing—original draft preparation (lead), writing—reviewing and editing (supporting), investigation (supporting), conceptualization (supporting); Harman S. Parhar: Supervision (supporting), conceptualization (supporting), visualization (supporting), writing—reviewing and editing (supporting); Karthik Rajasekaran: Supervision (lead), conceptualization (lead), methodology (supporting), validation (lead), writing‐ reviewing and editing (lead).

CONFLICT OF INTEREST STATEMENT

Professor Karthik Rajasekaran is a member of World Journal of Otorhinolaryngology—Head & Neck Surgery (WJOHNS) editorial board and is not involved in the peer review process of this article. The authors declare no conflicts of interest.

ETHICS STATEMENT

This study was performed in compliance with the Helsinki Declaration.

ACKNOWLEDGMENTS

This research did not receive any specific grant from funding agencies in specific in the public, commercial, or not‐for‐profit sectors.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.
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REFERENCES

1 Erdmann D , Follmar KE , Debruijn M , et al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg. 2008;60 :398‐403.18362568
2 Scherer M , Sullivan WG , Smith Jr. DJ , Phillips LG , Robson MC . An analysis of 1,423 facial fractures in 788 patients at an urban trauma center. J Trauma. 1989;29 :388‐390.2648018
3 Kelley P , Crawford M , Higuera S , Hollier LH . Two hundred ninety‐four consecutive facial fractures in an urban trauma center: lessons learned. Plast Reconstr Surg. 2005;116 :42e‐49e.
4 Antoun JS , Lee KH . Sports‐related maxillofacial fractures over an 11‐year period. J Oral Maxillofac Surg. 2008;66 :504‐508.18280384
5 Hwang K , You SH , Sohn IA . Analysis of orbital bone fractures: a 12‐year study of 391 patients. J Craniofac Surg. 2009;20 :1218‐1223.19553835
6 Lee H , Jilani M , Frohman L , Baker S . CT of orbital trauma. Emerg Radiol. 2004;10 :168‐172.15290482
7 Mellema PA , Dewan MA , Lee MS , Smith SD , Harrison AR . Incidence of ocular injury in visually asymptomatic orbital fractures. Ophthalmic Plast Reconstr Surg. 2009;25 :306‐308.19617792
8 Green Jr. RP , Peters DR , Shore JW , Fanton JW , Davis H . Force necessary to fracture the orbital floor. Ophthalmic Plast Reconstr Surg. 1990;6 :211‐217.2268617
9 Rhee JS , Kilde J , Yoganadan N , Pintar F . Orbital blowout fractures: experimental evidence for the pure hydraulic theory. Arch Facial Plast Surg. 2002;4 :98‐101.12020203
10 Hawes MJ , Dortzbach RK . Surgery on orbital floor fractures. Ophthalmology. 1983;90 :1066‐1070.6646646
11 Boyette J , Pemberton J , Bonilla‐Velez J . Management of orbital fractures: challenges and solutions. Clin Ophthalmol. 2015;9 :2127‐2137.26604678
12 Chen CT , Huang F , Chen YR . Management of posttraumatic enophthalmos. Chang Gung Med J. 2006;29 :251‐261.16924886
13 Cobb ARM , Jeelani NO , Ayliffe PR . Orbital fractures in children. Br J Oral Maxillofac Surg. 2013;51 :41‐46.22497691
14 Shah HA , Shipchandler TZ , Sufyan AS , Nunery WR , Lee HBH . Use of fracture size and soft tissue herniation on computed tomography to predict diplopia in isolated orbital floor fractures. Am J Otolaryngol. 2013;34 :695‐698.23529135
15 Cheung K , Voineskos SH , Avram R , Sommer DD . A systematic review of the endoscopic management of orbital floor fractures. JAMA Facial Plastic Surgery. 2013;15 :126‐130.23370729
16 Prabhu SS , Hemal K , Runyan CM . Outcomes in orbital floor trauma: a comparison of isolated and zygomaticomaxillary‐associated fractures. J Craniofac Surg. 2021;32 :1487‐1490.33427777
17 Fantus RJ , FACS. Annual Report 2017: ICD‐10. The Bulletin. 2018. Accessed July 26, 2022. https://bulletin.facs.org/2018/01/annual-report-2017-icd-10/
18 Agency for Clinical Innovation . Abbreviated injury scale. Agency for Clinical Innovation. 2014. Accessed July 26, 2022. https://aci.health.nsw.gov.au/networks/institute-of-trauma-and-injury-management/data/injury-scoring/abbreviated_injury_scale
19 Teasdale G , Jennett B . Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2 :81‐84.4136544
20 Sigron GR , Barba M , Chammartin F , Msallem B , Berg BI , Thieringer FM . Functional and cosmetic outcome after reconstruction of isolated, unilateral orbital floor fractures (blow‐out fractures) with and without the support of 3D‐printed orbital anatomical models. J Clin Med. 2021;10 :3509.34441806
21 Pham TT , Lester E , Grigorian A , Roditi RE , Nahmias JT . National analysis of risk factors for nasal fractures and associated injuries in trauma. Craniomaxillofac Trauma Reconstr. 2019;12 :221‐227.31428247
22 Greathouse ST , Adkinson JM , Garza 3rd R , et al. Impact of injury mechanisms on patterns and management of facial fractures. J Craniofac Surg. 2015;26 :1529‐1533.26114516
23 Safi AF , Richter MT , Rothamel D , et al. Influence of the volume of soft tissue herniation on clinical symptoms of patients with orbital floor fractures. J Craniomaxillofac Surg. 2016;44 :1929‐1934.27756551
24 Donahue DJ , Smith K , Church E , Chadduck WM . Intracranial neurological injuries associated with orbital fracture. Pediatr Neurosurg. 1997;26 :261‐268.9440496
25 Kreidl KO , Kim DY , Mansour SE . Prevalence of significant intraocular sequelae in blunt orbital trauma. Am J Emerg Med. 2003;21 :525‐528.14655229
26 Chen X , Yao Y , Wang F , Liu T , Zhao X . A retrospective study of eyeball rupture in patients with or without orbital fracture. Medicine. 2017;96 :e7109.28614230
27 Koltai PJ , Amjad I , Meyer D , Feustel PJ . Orbital fractures in children. Arch Otolaryngol Head Neck Surg. 1995;121 :1375‐1379.7488366
28 Lee KH , Snape L , Steenberg LJ , Worthington J . Comparison between interpersonal violence and motor vehicle accidents in the aetiology of maxillofacial fractures. ANZ J Surg. 2007;77 :695‐698.17635287
29 Lee KH . Interpersonal violence and facial fractures. J Oral Maxillofac Surg. 2009;67 :1878‐1883.19686924
30 Chrcanovic BR . Factors influencing the incidence of maxillofacial fractures. Oral Maxillofac Surg. 2012;16 :3‐17.21656125
31 Tahernia A , Erdmann D , Follmar K , Mukundan S , Grimes J , Marcus JR . Clinical implications of orbital volume change in the management of isolated and zygomaticomaxillary complex‐associated orbital floor injuries. Plast Reconstr Surg. 2009;123 :968‐975.19319062
32 Manolidis S , Weeks BH , Kirby M , Scarlett M , Hollier L . Classification and surgical management of orbital fractures: experience with 111 orbital reconstructions. J Craniofac Surg. 2002;13 :726‐737.12457084
33 Nguyen A , Ho T , Czerwinski M . Safety of outpatient isolated orbital floor fracture repair. J Craniofac Surg. 2016;27 :1686‐1688.27464556
