Orbital fractures

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  • Ectropion – turing outward eyelid
  • Orbital fractures

    1. 1. Orbital Fractures 2
    2. 2. Topics for Discussion• Orbital anatomy• Types of fractures• Signs and symptoms• Management 3
    3. 3. Orbital Anatomy• The bony orbit refers to the shell of bone which surrounds and protects the eye.• The bony orbit is a pyramidal cavity with an elliptical base presenting anteriorly and the apex posteriorly 4
    4. 4. 5
    5. 5. Bony Orbit• Seven bones form the bony orbit – Maxilla – Zygoma – Lacrimal – Ethmoid – Palantine – Sphenoid – Frontal 6
    6. 6. 7
    7. 7. Superior Orbital Wall• Formed by: – Frontal bone – Lesser wing of sphenoid• Functions as: – Floor anterior fossa• Important structures: – Supraorbital notch which transmits the supraorbital nerve 8
    8. 8. Medial Orbital Wall• Formed by (from anterior to posterior): – Maxilla – Lacrimal bone – Ethmoid – Sphenoid• Important structures: – Lamina papyracea 9
    9. 9. Lamina Papyracea• Thin segment of the medial orbital wall• Separates the orbit from the ethmoid air cells 10
    10. 10. Lateral Orbital Wall• Formed by: – Zygomatic bone – Greater wing of sphenoid 11
    11. 11. Orbital Floor• Formed by: – Maxilla – Palatine• Important structures: – Infraorbital groove • Transverses floor from lateral to medial • Location of infraorbital nerve which supplies sensation to check and ipsilateral upper alveolus and teeth 12
    12. 12. Orbital Floor• Forms roof of maxillary sinus• Location of more blow out fractures due to inherent weakness of bone overlying maxillary sinus 13
    13. 13. Three important apertures at the apex of bony orbit • Optic canal • Superior orbital fissure • Inferior orbital fissure 14
    14. 14. Optic Canal• Contains: – Optic nerve – Ophthalmic artery• In Lesser wing of sphenoid 15
    15. 15. Superior Orbital Fissure• Separates lateral wall from roof• Transmits the following structures: – Oculomotor nerve (CN III) – Trochlear nerve (CN IV) – Abducens nerve (CN VI) – Ophthalmic division of trigeminal nerve • Lacrimal, frontal and nasociliary Branches – Ophthalmic vein – Sympathetics from cavernous sinus 16
    16. 16. 17
    17. 17. 18
    18. 18. Clinical Correlation• Superior orbital fissure syndrome – Ptosis – External Ophthalmoplegia ( III, IV &VI ) – Anaesthesia of cornea (Nasociliary) – Ipsilateral Numbness forehead, lateral orbital skin• Orbital Apex Syndrome – All of the above – Visual Loss 19
    19. 19. Inferior orbital Fissure• Connects to pterygopalantine fossa• Located between floor and lateral wall• Transmits: – Maxillary division Trigeminal nerve – Infra orbital Artery – Zygomatic Nerve – Sphenopalatine Ganglion Branches – Ophthalmic Vein Branches 20
    20. 20. Blowout Fractures of Orbit• Originally defined as orbital floor fractures without fracture orbital rim, but with entrapment one or more soft tissue structures 21
    21. 21. Blowout Fractures• Blowout fractures now refer to fractures of the: – Orbital floor – Medial 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 22
    22. 22. 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 23
    23. 23. Common causes of orbital fractures• Falling• Aggression• Sporting events• MVAs 24
    24. 24. 25
    25. 25. 26
    26. 26. Initial Evaluation• History – Time and mechanism of injury – Change in appearance of eye – State of vision immediately after injury • Immediate loss of vision – severe damage to retina • Loss of light perception - vascular occlusion or optic nerve compression • Initial good vision – compression optic neuropathy 27
    27. 27. Initial Evaluation• Physical Exam – Cranial nerve examination • EOM • Numbness check – Palpation orbital rim – Papillary function – Visual acuity – Fundus examine – Ophthalmologic evaluation 28
    28. 28. Visual Acuity• Light perception• Finger counting• Visual acuity 29
    29. 29. ConsultationDo not hesitate to obtain an ophthalmologic consultation 30
    30. 30. Common physical signs• Periorbital eccyhmosis• Impaired extraocular muscles• Hypoesthesia in V2 distribution• Intraorbital emphysema 31
    31. 31. Common Symptoms• Diplopia• Pain with eye movement 32
    32. 32. Radiographic Evaluation• CT scan of the orbits• Plain films not useful due to a high rate of false negatives and non-diagnostic studies 33
    33. 33. 34
    34. 34. 35
    35. 35. 36
    36. 36. Injuries associated with blow out fractures• Ruptured globe• Retroorbital hemorrhage• Vitreous hemorrhage• Hyphema• Dislocated lens• Secondary glaucoma• Retinal detachment 37
    37. 37. Treatment Options• Nonsurgical• Surgical 38
    38. 38. Initial Management• ABC• C-Spine• Analgesia• Nurse Head up• Ice affected area• Broad spectrum antibiotics• Steroids• No nose blowing 39
    39. 39. Indications for Surgery• Retrobulbar haematoma• Diplopia• Enophthalmos >2 mm• Substantial soft tissue herniation into maxillary sinus• Displaced fracture esp if palpable step at rim 40
    40. 40. Contraindications to surgery• Hyphema• Retinal detachment• Globe perforation• Only seeing eye• Medically unstable patient 41
    41. 41. Surgical Approaches• Transconjunctival approach• Transcutaneous• Subciliary 42
    42. 42. Factors to consider for surgery• Site• Location• Severity• What needs to be corrected 43
    43. 43. 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 44
    44. 44. Complications of Surgery• Ectropion• Lid retraction• Persistent diplopia• Malposition of eye• Hypoaesthesia of V2• Extrusion of orbital floor implant• BLINDNESS 45

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