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Orbital Fractures

Farhad Fazel, MD

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Topics for DiscussionOrbital anatomyTypes of fracturesSigns and symptomsManagement

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Bony OrbitSeven bones form the bony orbit

Maxilla Zygoma Lacrimal Ethmoid Palantine Sphenoid Frontal

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Anatomy

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Physical Exam Inspection Palpation Ophthalmologic exam

Vision Extraocular movements Forced ductions Exophthalmometry Internal exam

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Emergency Management

A - Airway

B - Breathing

C - Circulation / Hemorrhage

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Blowout Fractures of OrbitOriginally defined as orbital floor

fractures without fracture orbital rim, but with entrapment one or more soft tissue structures

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Blowout Fractures Blowout fractures now refer to fractures of

the: Orbital floor Medical wall Lateral wall Superior wall

“pure” blowout fractures – trapdoor rotation to bone fragments involving central area of bone

“impure” fracture – fracture line extends to orbital rim

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Physiology of Blowout FractureThe bony defect is filled with soft tissue

and fat from the orbitAlters support mechanisms for EOMEOM can become entrappedDirect muscle damage can result

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Common causes of orbital fracturesFallingAggressionSporting eventsMVAs

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Common physical signsPeriorbital eccyhmosis Impaired extraocular musclesHypoesthesia in V2 distribution Intraorbital emphysemaEnophthalmos and ptosis

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Common SymptomsDiplopiaPain with eye movement

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Injuries associated with blow out fractures Ruptured globe Retroorbital hemorrhage Vitreous hemorrhage Hyphema Anterior chamber angle recession Dislocated lens Secondary glaucoma Retinal detachment

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Treatment OptionsNonsurgicalSurgical

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Initial Management Ice affected area for 48 hours Elevation HOB Use of nasal decongestants Broad spectrum antibiotics like Augmentin Oral steroids to prevent fibrosis No ASA No nose blowing

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Absolute Indications for Surgical RepairDiplopiaEnophthalmos >2 mmLarge fracture

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Contraindications to surgeryHyphemaRetinal detachmentGlobe perforationOnly seeing eyeMedically unstable patient

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Timing of SurgeryUsually seven to ten days after trauma

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Surgical ApproachesTransconjunctival approachTranscutaneousSubciliaryTrasantral

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Surgical procedures for orbital floor fractures Incision Subtarsal dissection Skin-muscle flap Incision of maxilla Floor dissection Placement of Marlex mesh Periosteal closure Skin closure

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Orbital ImplantsUse of implants based on degree of

comminution and size of fractureVarious implant material used

Autogenous bone and cartilage Alloplastic material

Teflon Marlex PDS Etc.

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ConclusionsAssessment of orbital fractures is an

area that requires a high index of suspicion

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MRI

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Maxillary Fractures

Midfacial (LeFort)Fracture

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LeFort Type I

LeFort Type II

LeFort Type III

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Le Fort I - tooth bearing portion separated from upper maxilla

Le Fort II - fracture across orbital floor and nasal bridge (pyramidal fracture)

Le Fort III - fracture across frontozygomatic suture line, entire orbit and nasal bridge (craniofacial separation)

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Maxillary FracturesLeFort Fractures

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Maxillary FracturesExamination and Diagnosis

Epistaxis Ecchymosis (periorbital, conjunctival, and

scleral) Malocclusion With Anterior Open Bite Buccal Mucosa Hematoma Tear in Intraoral Soft Tissues Elongated, Retruded Appearance

“Donkey-Like” Facies CSF Leak in 25-50% of LeFort II and III

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Maxillary FracturesManagement

Intermaxillary FixationOpen Reduction

LeFort I Bilateral Buccal Sulcus Incisions

LeFort II and III Coronal and Lower Eyelid Incisions

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Maxillary FracturesManagement

Goals re-establish

midfacial height and projection

establish occlusal relationship

maintain integrity of nose and orbits

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Maxillary FracturesManagement

Rigid Internal Fixation Frontal Bone as a

Guide Mandibuar Ramus

Dictates Facial Height

Stabilize Vertical Buttresses

Bone Grafts If Necessary

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Naso-Orbital-Ethmoidal Fractures

Medial Orbital Wall Fracture

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Naso-Orbital-Ethmoidal FracturesClassification

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Naso-Orbital-Ethmoidal Fractures

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Naso-Orbital-Ethmoidal FracturesPhysical Exam

Flat noseSwollen medial canthal areaTelecanthus (12-20%)Lack of skeletal support on palpation of

noseCSF leakPositive eyelid traction test

Management Miniplate stabilisation

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Zygomatic fracture

Tripod Fracture

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Tripod FractureLateral rim Inferior rimZygomatic archLateral wall of maxillary sinuses

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Tripod Fracture

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Tripod Fracture

Sign and SymptomsCosmetic deformityGlobe displacementDiplopia trismus

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Tripod fracture

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Tripod fracture

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Intraorbital Foreign BodiesPlain film x-rayCT scanMRI(not in ferromagnetics)

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Forigin body

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Forigin body

FB managementVegetable matter must removedAnterior easy access must removed

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Orbital

Orbital HemorrhageTrauma or surgerySpontaneous

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Retrobulbar Hemorrhage(management)Canthatomy and cantholysis if nerve

compression ,altered arterial perfusion,hematic cyst.

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Orbital hemorrhage

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Canthotomy,cantholysis