What is the management for a lamina propria fracture?

Management of Lamina Papyracea Fracture

Immediate Recognition and Diagnosis

Endoscopic reduction under nasal endoscopy is the recommended treatment approach for lamina papyracea fractures, offering excellent outcomes with minimal complications. 1

Clinical Presentation to Assess

• Endophthalmos (sunken eye appearance) - present in all cases 1
• Blepharophimosis (narrowed palpebral fissure) - present in all cases 1
• Diplopia (double vision) - occurs in approximately 67% of cases 1
• Orbital emphysema or periorbital swelling may be present

Essential Imaging

• Horizontal and coronal CT of the orbit is mandatory to clearly visualize the lamina papyracea fracture 1
• Measure the degree and range of lamina papyracea displacement on CT films to guide surgical planning 1

Definitive Management: Endoscopic Reduction

Surgical Technique

The procedure is performed under local and topical anesthesia using the Meeserklinger's route of entry 1:

1. Sequential removal of anatomical structures:

   • Remove the uncinate process first 1
   • Remove the ethmoidal bulla 1
   • Remove ethmoidal cells successively 1

2. Fracture reduction:

   • Use a tonsil dissector to push the lamina papyracea outward 1
   • Replace the fractured bone to its anatomical position 1
   • Support the reduced fracture with iodoform gauze packing 1

3. Postoperative care:

   • Remove the iodoform gauze after 2-3 weeks 1

Expected Outcomes

Immediate Results

• Complete resolution of endophthalmos in all cases 1
• Complete resolution of diplopia in all cases 1
• No postoperative complications reported with this technique 1

Long-term Follow-up

• Endophthalmos remains stable within 2 mm with 0.5-2 years follow-up 1
• The degree of correction is maintained over time 1

Advantages of Endoscopic Approach

This technique offers multiple benefits over traditional open approaches 1:

• Short route of entry minimizes tissue trauma 1
• Simple performance with straightforward technique 1
• No facial scarring - entirely intranasal approach 1
• Excellent visualization of the fracture site under endoscopic guidance 1

Critical Pitfalls to Avoid

• Delaying CT imaging - horizontal and coronal views are essential and should not be omitted 1
• Premature gauze removal - maintain support for the full 2-3 week period to ensure adequate healing 1
• Inadequate fracture reduction - ensure complete outward displacement of the lamina papyracea to prevent persistent enophthalmos 1
• Missing associated orbital injuries - always assess for orbital floor involvement and extraocular muscle entrapment on CT 1