A 34-year-old patient playing tennis is hit by a ball at the level of the left orbit. On examination he presents significant palpebral hematoma, hyposphagmia, diplopia to superior vision with limitation of the upper version of the eyeball. What would you suspect?
This question has a small typo (one would say "tennis"), but personally I am a little more bothered by the error in the description of the scan. Specifically when they say "diplopia to superior vision with limitation of the superior version of the eyeball". Versions are bilateral conjugated movements of both eyes. That is, a version is composed of the sum of two ductions, since duction is the movement of only one eye. When you explore the versions, specifically the superior version or supraversion, both eyes rotate upward. At that time, you may encounter a limitation of the movement of one eye. In this case, when you scan the supraversion, you suspect or you detect a limitation in the movement of the left eye. And we would call this a limitation to the supraversion of that eye. It doesn't make sense to talk about limitation to the version of the eyeball, because the version is always of both eyeballs. Okay, it is understood, but it is an important misconception that should not be made by the person writing the question (who is supposed to be an expert on the subject), but well, as I do not think it is a reason to challenge the question, let's go on. It is about a patient who has received a blow. All four answers are fractures, so we have a pretty definite picture. The palpebral hematoma and hyposphagma (subconjunctival hemorrhage) does not give us the key data. What is important is that the eye that has received the blow does not go up, and therefore there is double vision in the superior gaze. It might be tempting to answer 3, thinking that because the superior rectus is trapped, it does not work and therefore the eye cannot go up. However, muscles trapped in a fracture do not automatically lose their muscular action. What happens is that they become trapped, they are "hooked", and cannot stretch. The problem is that the inferior wall has been broken, the inferior rectus has been trapped, and when the eye must look up, this inferior rectus cannot stretch as it should. It is not paralysis, but a restrictive problem. This question could also be answered by discarding. Options 2 and 4 can be ignored because they are too far away from the extraocular muscles to produce diplopia. And as for the walls of the orbit, the ones that break most frequently are the inferior and medial wall. The superior wall ruptures very rarely.
Fracture of the inferior wall of the floor of the orbit with trapping of the inferior rectus muscle.
Zygomatic arch fracture.
Fracture of the superior wall of the orbit with entrapment of the superior rectus muscle.
Dentoalveolar fracture.
And as for the walls of the orbit, the ones that break most frequently are the inferior and medial wall.
Options 2 and 4 can be ignored because they are too far away from the extraocular muscles to produce diplopia.
The superior wall ruptures very rarely.
Options 2 and 4 can be ignored because they are too far away from the extraocular muscles to produce diplopia.