Transcript Document
Orbital Fractures Farhad Fazel, MD 1 Topics for Discussion Orbital anatomy Types of fractures Signs and symptoms Management 2 Bony Orbit Seven bones form the bony orbit Maxilla Zygoma Lacrimal Ethmoid Palantine Sphenoid Frontal 3 Anatomy 4 Physical Exam Inspection Palpation Ophthalmologic exam Vision Extraocular movements Forced ductions Exophthalmometry Internal exam 5 Emergency Management A - Airway B - Breathing C - Circulation / Hemorrhage 6 Blowout Fractures of Orbit Originally defined as orbital floor fractures without fracture orbital rim, but with entrapment one or more soft tissue structures 7 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 8 Physiology of Blowout Fracture The bony defect is filled with soft tissue and fat from the orbit Alters support mechanisms for EOM EOM can become entrapped Direct muscle damage can result 9 Common causes of orbital fractures Falling Aggression Sporting events MVAs 10 Common physical signs Periorbital eccyhmosis Impaired extraocular muscles Hypoesthesia in V2 distribution Intraorbital emphysema Enophthalmos and ptosis 11 Common Symptoms Diplopia Pain with eye movement 12 Injuries associated with blow out fractures Ruptured globe Retroorbital hemorrhage Vitreous hemorrhage Hyphema Anterior chamber angle recession Dislocated lens Secondary glaucoma Retinal detachment 13 Treatment Options Nonsurgical Surgical 14 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 15 Absolute Indications for Surgical Repair Diplopia Enophthalmos Large >2 mm fracture 16 Contraindications to surgery Hyphema Retinal detachment Globe perforation Only seeing eye Medically unstable patient 17 Timing of Surgery Usually seven to ten days after trauma 18 Surgical Approaches Transconjunctival approach Transcutaneous Subciliary Trasantral 19 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 20 Orbital Implants Use of implants based on degree of comminution and size of fracture Various implant material used Autogenous bone and cartilage Alloplastic material Teflon Marlex PDS Etc. 21 Conclusions Assessment of orbital fractures is an area that requires a high index of suspicion 22 MRI 23 24 25 26 27 28 29 30 31 Maxillary Fractures Midfacial (LeFort)Fracture 32 LeFort Type I LeFort Type II LeFort Type III 33 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) 34 Maxillary Fractures LeFort Fractures 35 Maxillary Fractures Examination 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 36 Maxillary Fractures Management Intermaxillary Fixation Open Reduction LeFort Bilateral Buccal Sulcus Incisions LeFort I II and III Coronal and Lower Eyelid Incisions 37 Maxillary Fractures Management Goals re-establish midfacial height and projection establish occlusal relationship maintain integrity of nose and orbits 38 Maxillary Fractures Management Rigid Internal Fixation Frontal Bone as a Guide Mandibuar Ramus Dictates Facial Height Stabilize Vertical Buttresses Bone Grafts If Necessary 39 Naso-Orbital-Ethmoidal Fractures Medial Orbital Wall Fracture 40 41 Naso-Orbital-Ethmoidal Fractures Classification 42 Naso-Orbital-Ethmoidal Fractures 43 Naso-Orbital-Ethmoidal Fractures Physical Exam Flat nose Swollen medial canthal area Telecanthus (12-20%) Lack of skeletal support on palpation of nose CSF leak Positive eyelid traction test 44 Management Miniplate stabilisation 45 Zygomatic fracture Tripod Fracture 46 Tripod Fracture Lateral rim Inferior rim Zygomatic arch Lateral wall of maxillary sinuses 47 Tripod Fracture 48 Tripod Fracture 49 Sign and Symptoms Cosmetic deformity Globe displacement Diplopia trismus 50 Tripod fracture 51 Tripod fracture 52 53 54 55 Intraorbital Foreign Bodies Plain film x-ray CT scan MRI(not in ferromagnetics) 56 Forigin body 57 Forigin body 58 FB management Vegetable matter must removed Anterior easy access must removed 59 Orbital Hemorrhage Trauma or surgery Spontaneous 60 Retrobulbar Hemorrhage(management) Canthatomy and cantholysis if nerve compression ,altered arterial perfusion,hematic cyst. 61 Orbital hemorrhage 62 Canthotomy,cantholysis 63