Bilateral isolated blowout fracture due to airbag deployment

Burak Ozkan; Kadri Akinci; Cagri Ahmet Uysal; Nilgun Markal Ertas

doi:10.4103/tjps.tjps_21_20

CASE REPORT

Year : 2021 | Volume : 29 | Issue : 2 | Page : 131-133

Bilateral isolated blowout fracture due to airbag deployment

Burak Ozkan, Kadri Akinci, Cagri Ahmet Uysal, Nilgun Markal Ertas
Department of Plastic, Reconstructive and Aesthetic Surgery, Baskent University, Ankara, Turkey

Date of Submission	12-Mar-2020
Date of Acceptance	10-May-2020
Date of Web Publication	26-Mar-2021

Correspondence Address:
Dr. Burak Ozkan
Yukari Bahcelievler Mah 63. Sok16/17 Bahcelievler Cankaya, Ankara
Turkey

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_21_20

Abstract

The airbag is a lifesaver innovation in automobile industry, but the impact of airbag deployment may cause maxillofacial fractures. Airbag deployment in traffic accidents is a rare etiology of orbital fractures. Although there are reports about airbag-induced orbital fractures in the literature, isolated bilateral blowout fractures have not been published yet. We present a case of isolated bilateral blowout fracture due to airbag deployment in a traffic accident and its management in this study.

Keywords: Airbag deployment, blowout fracture, maxillofacial trauma

How to cite this article:
Ozkan B, Akinci K, Uysal CA, Ertas NM. Bilateral isolated blowout fracture due to airbag deployment. Turk J Plast Surg 2021;29:131-3

How to cite this URL:
Ozkan B, Akinci K, Uysal CA, Ertas NM. Bilateral isolated blowout fracture due to airbag deployment. Turk J Plast Surg [serial online] 2021 [cited 2021 Apr 22];29:131-3. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/2/131/312176

Introduction

Blowout fractures are often associated with complex zygomaticomaxillary fractures according to the energy volume of the blunt trauma. Blowout fractures occur due to blunt trauma to the orbital region. As a result of increased intraocular pressure, the orbital inferior bone wall breaks and periocular tissues herniate into the maxillary sinus. Isolated orbital floor fracture accounts for approximately one-third of orbital fractures. Airbag deployment is a rare condition among high-energy blunt trauma etiologies. Although there are reports about blowout fractures that accompany midface fractures, bilateral isolated blowout fractures due to airbag deployment have not been reported yet. In this study, we present an isolated bilateral blowout fracture due to airbag deployment.

Case Report

A 41-year-old male patient was admitted to the emergency department after a car accident. The patient was consulted with the plastic surgery team for periocular trauma history. It was learned that the patient did not wear a seat belt while traveling in the front seat of the car. The patient hit his face to the deployed airbag right after the car had crushed to another car. The patient was conscious, orientated, and cooperative. Physical examination revealed edema in the right periorbital region and hyphema in the left eye, ecchymosis in the lower eyelid medial, enophthalmos, and hypoesthesia in the left infraorbital region. The patient's eye movements and vision were normal, and there was no diplopia. Maxillofacial computed tomography showed isolated bilateral blowout fracture in which the bilateral periocular structures herniated into the maxillary sinus, larger in the left orbital floor [Figure 1]. The patient was started on anti-edema and anti-inflammatory treatment and was operated after 3 days. The subperiosteal plan was prepared from the orbital rim through a subciliary incision, and the fracture lines were reached by dissection. Herniated periocular tissues were rescued with gentle maneuvers. The inferior orbital wall was reconstructed with 1 cm × 1 cm-sized porous polyethylene (Medpor) sheet for the right orbital base and 3 cm × 1 cm porous polyethylene sheet for the left orbital base with endoscopic assistance [Figure 2] and [Video 1]. Personal protective equipment (PPE) materials were secured underneath the periosteum of the inferior orbital rim for the prevention of excursion and palpability. The ocular motility was evaluated as normal with the forced duction test. There were no early and late complications in the postoperative period. The patient's enophthalmos improved, and extraocular motility was normal. In the postoperative 6^th month, anesthesia in the left infraorbital region was improved and had a well-hidden scar [Figure 3]. Computed tomography showed nearly equal bilateral orbital volumes and no herniation of orbital tissues to maxillary sinus in the postoperative 1^st year [Figure 4].

Figure 1: Coronal computed tomography of bilateral isolated blowout fracture

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Figure 2: Videoendoscopic view of the porous polyethylene placement from subciliary approach

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Figure 3: Postoperative 6^th-month view of the patient. The patient has no restrictions in eye movements and has a very well hidden subciliary incision scar

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Figure 4: Coronal section of computed tomography of the patient in the postoperative 1^st year

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Discussion

Although car industries have been developing life-saving technologies, seat belts and airbags are still considered as the major driver and passenger protective innovations. Viano stated that seat belts and airbags prevent 46% of the fatalities in car accidents.^[1] Loo et al. showed that facial fractures and lacerations were significantly reduced in airbags used with worn seat belts than airbags alone.^[2] As a complementary to this study, Murphy et al. reported fewer facial fractures in airbags used with seat belts than seat belts alone.^[3] Besides their vital benefits, airbags have been shown to cause blunt trauma to facial skeleton such as orbital region.^[4] Blowout fractures are frequently seen consequence of blunt orbital traumas.

The mechanism of blowout fractures due to airbag deployment can be explained by three theories named hydraulic, buckling, and footprint. Hydraulic theory is breaking of orbital floor due to increased intraocular pressure after direct compression to orbit.^[5] Buckling theory is spreading the high energy from orbital rim to orbital components.^[6] Footprint theory is breaking of orbital floor due to intraorbital movement and crush of the globe after trauma.^[7] The mechanism of airbag-induced blowout fractures such as in our case might be combinations of these theories rather than one specific theory. Green et al. showed that the energy generated by airbag deployment pressure is more than the threshold required to break the facial skeleton.^[8] The speed of the car and the distance between the wheel and the passenger, properly worn seat belts, are the other factors that affect the terminal pressure on the face. Our patient did not wear a seat belt at the time of the accident, and as a consequence, the patient encountered much more increased face to airbag meeting energy. In this nonbelt case, airbag might prevent a mortal injury while causing orbital fractures. Because of this high-energy-related background, airbag-related orbital fractures are usually associated with zygomaticomaxillary and nasal fractures.^[9],[10] While isolated orbital floor fractures account for 22%–47% of orbital fractures,^[11] there are no reports about bilateral isolated blowout fracture after airbag deployment in the literature.

Although indications for repair are controversial, certain clinical findings require urgent surgery such as symptomatic diplopia due to compression of the extraocular muscles, limitation of upward gaze, pediatric trapdoor blowout fractures, and unresolved oculocardiac reflex. In most studies, emergency repair is defined as repair within 24–48 h and should be performed in patients with >2 mm early enophthalmos and orbital floor or medial wall defects larger than 2 cm². Our patient had significant herniation to maxillary sinus without any diplopia; thus, we planned an elective orbital floor reconstruction with porous polyethylene.

The orbital floor is reconstructed by various implant materials. Autologous grafts such as parietal bone, olecranon bone, nasal septum, and conchal cartilage are advantageous in terms of biocompatibility.^{[12],[13],[14]} Donor-site morbidity is the main limitation of autologous materials. Porous polyethylene and titanium mesh implants are widely used materials for orbital floor.^[15] Although they have implant-dependent complications such as extrusion and infection, these complications can be prevented with securing PPE under periosteum and sinusitis prophylaxis.^[16]

We preferred subciliary approach when the floor defect is larger defect 2 cm² for better implant placement. External videoendoscopy can be used likewise in our case for better visualization of posteriorly placed floor fractures and assistance in rescuing all the herniated periorbital tissues [Video 1]. Another benefit of external videoendoscopy is checking underneath the implant for detecting in case of re-herniation.

Conclusion

The airbags have been developed as passive protective products to protect drivers and passengers after the seatbelt and are designed to reduce the risk of serious injury during an accident. Although airbag-induced maxillofacial fractures have been reported in the literature, our case is important for the absence of pure bilateral blowout fractures in previous reports. It should be kept in mind that airbags are the etiology of blunt trauma to the face and fractures may occur in patients who hit their face after airbag deployment. We believe that seat belts must always be worn to reduce the impact energy of airbag deployment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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