Delayed immediate surgery for orbital floor fractures: Less can be more
Bibliographic record
Abstract
O rbital floor fractures are a not infrequent consequence of facial trauma.Common etiologies for these injuries include motor vehicle accidents (1,2) and violent altercations (3,4).The majority of these fractures are sustained by young male patients (5-7).Recognized clinical effects of orbital floor fractures include diplopia, impaired extraocular muscle motility, enophthalmos, hypoglobus and infraorbital dysthesia.In 1957, Smith (8) espoused early exploration and reconstruction of the orbital floor using bone graft implants.In 1971, Emery et al (9) documented the natural history of untreated orbital floor fractures.This was closely followed by a recommendation from Putterman (10) to delay surgery because there was no advantage to early surgery and, in many patients, the diplopia resolved as the swelling reduced.At Saint John Regional Hosptial, Saint John, New Brunswick, we have more than 50 surgeon-years of experience with delayed orbital floor fracture surgery.If a forced duction test is negative for true entrapment of the inferior rectus, we wait up to two weeks to see if diplopia resolves, or if symptomatic enophthalmos of more than 2 mm develops.We operate for the latter condition, or for diplopia that persists at two weeks.We have observed that diplopia resolves in most patients because it is caused by swelling.We also note that mild (less than 2 mm) enophthalmos is usually asymptomatic.Our observations are supported by previous studies examining nonoperatively managed patients (11,12).The purpose of the present article is to document our experience, which parallels that of Putterman.We believe that our approach has avoided unnecessary surgical and anesthetic risks for hundreds of patients, as well as unnecessary operating room time and costs. MethodsAfter ethics review board approval, a 10-year review (January 1999 to December 2008) of medical records, clinical notes, radiographs and computed tomography (CT) scans in patients with orbital floor fractures managed by one senior surgeon (DHL) at the Saint John Regional Hospital was performed.Data regarding patient demographics, fracture etiology, presenting signs and symptoms, and subsequent follow-up visits assessing resolution or persistence of ophthalmic dysfunction were collected.Inclusion criteria were patients 16 years of age or older with orbital floor fracture confirmed either by radiograph or CT.Patients were excluded from the study if they had bilateral orbital floor fractures, previous orbital fractures, pre-existing ophthalmic dysfunction, significant concomitant orbital/facial fractures, reinjury before current follow-up assessment, or an inability to appropriately undergo follow-up assessment.Once the appropriate patients were identified, they were contacted and either interviewed by telephone or invited to return to the hospital for formal clinical assessment.The clinical outcomes recorded originaL articLe
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.000 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.001 | 0.002 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.001 | 0.002 |
| Insufficient payload (model declined to judge) | 0.026 | 0.002 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".