Transcript Orbital-Fractures-1387

Orbital Fractures
Farhad Fazel, MD
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Topics for Discussion
 Orbital
anatomy
 Types of fractures
 Signs and symptoms
 Management
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Bony Orbit
 Seven
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 Orbit
 Originally
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:

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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
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
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Common causes of orbital
fractures
 Falling
 Aggression
 Sporting
events
 MVAs
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Common physical signs
 Periorbital
eccyhmosis
 Impaired extraocular muscles
 Hypoesthesia in V2 distribution
 Intraorbital emphysema
 Enophthalmos and ptosis
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Common Symptoms
 Diplopia
 Pain
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 Options
 Nonsurgical
 Surgical
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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 Repair
 Diplopia
 Enophthalmos
 Large
>2 mm
fracture
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Contraindications to surgery
 Hyphema
 Retinal
detachment
 Globe perforation
 Only seeing eye
 Medically unstable patient
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Timing of Surgery
 Usually
seven to ten days after trauma
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Surgical Approaches
 Transconjunctival
approach
 Transcutaneous
 Subciliary
 Trasantral
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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 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.

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Conclusions
 Assessment
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
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LeFort Type II
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LeFort Type III
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
Le Fort I - tooth bearing portion separated
from upper maxilla
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Le Fort II - fracture across orbital floor and
nasal bridge (pyramidal fracture)
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Le Fort III - fracture across frontozygomatic
suture line, entire orbit and nasal bridge
(craniofacial separation)
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Maxillary Fractures
LeFort Fractures
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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
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
“Donkey-Like” Facies
CSF Leak in 25-50% of LeFort II and III
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Maxillary Fractures
Management
 Intermaxillary
Fixation
 Open Reduction
 LeFort

Bilateral Buccal Sulcus Incisions
 LeFort

I
II and III
Coronal and Lower Eyelid Incisions
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Maxillary Fractures
Management

Goals
re-establish
midfacial height
and projection
 establish occlusal
relationship
 maintain integrity of
nose and orbits
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Maxillary Fractures
Management

Rigid Internal
Fixation
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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 Fractures
Classification
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Naso-Orbital-Ethmoidal
Fractures
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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
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Management
 Miniplate
stabilisation
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Zygomatic fracture
Tripod Fracture
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Tripod Fracture
 Lateral
rim
 Inferior rim
 Zygomatic arch
 Lateral wall of maxillary sinuses
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Tripod Fracture
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Tripod Fracture
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Sign and Symptoms
 Cosmetic
deformity
 Globe displacement
 Diplopia
 trismus
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Tripod fracture
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Tripod fracture
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Intraorbital Foreign Bodies
 Plain
film x-ray
 CT scan
 MRI(not in ferromagnetics)
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Forigin body
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Forigin body
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FB management
 Vegetable
matter must removed
 Anterior easy access must removed
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Orbital Hemorrhage
 Trauma
or surgery
 Spontaneous
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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
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