Orbital Fractures
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1 Orbital Fractures Farhad Fazel, MD
description
Orbital Fractures. Farhad Fazel, MD. Topics for Discussion. Orbital anatomy Types of fractures Signs and symptoms Management. Bony Orbit. Seven bones form the bony orbit Maxilla Zygoma Lacrimal Ethmoid Palantine Sphenoid Frontal. Anatomy. Physical Exam Inspection Palpation - PowerPoint PPT Presentation
Transcript of Orbital Fractures
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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
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
