Orbital Fractures

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  • Orbital Fractures

    1. 1. Orbital Fractures/Orbital Blowout Fractures Christina Gillespie, MD
    2. 2. Topics for Discussion <ul><li>Orbital anatomy </li></ul><ul><li>Types of fractures </li></ul><ul><li>Signs and symptoms </li></ul><ul><li>Management </li></ul>
    3. 3. Orbital Anatomy <ul><li>The bony orbit refers to the shell of bone which surrounds and protects the eye. </li></ul><ul><li>The bony orbit is a pyramidal cavity with an elliptical base presenting anteriorly and the apex posteriorly at 22 degrees lateral from the visual axis. </li></ul>
    4. 4. Bony Orbit <ul><li>Seven bones form the bony orbit </li></ul><ul><ul><li>Maxilla </li></ul></ul><ul><ul><li>Zygoma </li></ul></ul><ul><ul><li>Lacrimal </li></ul></ul><ul><ul><li>Ethmoid </li></ul></ul><ul><ul><li>Palantine </li></ul></ul><ul><ul><li>Sphenoid </li></ul></ul><ul><ul><li>Frontal </li></ul></ul>
    5. 5. Superior Orbital Wall <ul><li>Formed by: </li></ul><ul><ul><li>Frontal bone </li></ul></ul><ul><ul><li>Lesser wing of sphenoid </li></ul></ul><ul><li>Functions as: </li></ul><ul><ul><li>Floor anterior fossa </li></ul></ul><ul><li>Important structures: </li></ul><ul><ul><li>Supraorbital notch which transmits the supraorbital nerve </li></ul></ul>
    6. 6. Medial Orbital Wall <ul><li>Formed by (from anterior to posterior): </li></ul><ul><ul><li>Maxilla </li></ul></ul><ul><ul><li>Lacrimal bone </li></ul></ul><ul><ul><li>Ethmoid </li></ul></ul><ul><ul><li>Sphenoid </li></ul></ul><ul><li>Important structures: </li></ul><ul><ul><li>Lamina papyracea </li></ul></ul><ul><ul><li>Nasolacrimal canal </li></ul></ul>
    7. 7. Lamina Papyracea <ul><li>Thin segment of the medial orbital wall </li></ul><ul><li>Separates the orbit from the ethmoid air cells </li></ul>
    8. 8. Nasolacrimal canal <ul><li>Contains nasolacrimal duct </li></ul><ul><li>Passes from lacrimal sac to inferior meatus </li></ul>
    9. 9. Lateral Orbital Wall <ul><li>Formed by: </li></ul><ul><ul><li>Zygomatic bone </li></ul></ul><ul><ul><li>Greater wing of sphenoid </li></ul></ul><ul><li> </li></ul>
    10. 10. Orbital Floor <ul><li>Formed by: </li></ul><ul><ul><li>Maxilla </li></ul></ul><ul><ul><li>Palatine </li></ul></ul><ul><li>Important structures: </li></ul><ul><ul><li>Infraorbital groove </li></ul></ul><ul><ul><ul><li>Transverses floor from lateral to medial </li></ul></ul></ul><ul><ul><ul><li>Location of infraorbital nerve which supplies sensation to check and ipsilateral upper alveolus and teeth </li></ul></ul></ul>
    11. 11. Orbital Floor <ul><li>Forms roof of maxillary sinus </li></ul><ul><li>Location of more blow out fractures due to inherent weakness of bone overlying maxillary sinus </li></ul>
    12. 12. Three important apertures at the apex of bony orbit <ul><li>Optic canal </li></ul><ul><li>Superior orbital fissure </li></ul><ul><li>Inferior orbital fissure </li></ul>
    13. 13. Optic Canal <ul><li>Contains: </li></ul><ul><ul><li>Optic nerve </li></ul></ul><ul><ul><li>Ophthalmic artery </li></ul></ul>
    14. 14. Superior Orbital Fissure <ul><li>Separates lateral wall from roof </li></ul><ul><li>Transmits the following structures: </li></ul><ul><ul><li>Oculomotor nerve (CN II) </li></ul></ul><ul><ul><li>Trochlear nerve (CN IV) </li></ul></ul><ul><ul><li>Abducens nerve (CN VI) </li></ul></ul><ul><ul><li>Ophthalmic division of trigeminal nerve </li></ul></ul><ul><ul><li>Ophthalmic vein </li></ul></ul>
    15. 15. Inferior orbital Fissure <ul><li>Connects to pterygopalantine fossa </li></ul><ul><li>Located between floor and lateral wall </li></ul><ul><li>Transmits: </li></ul><ul><ul><li>Infraorbital branch V2 </li></ul></ul><ul><ul><li>Orbitalis muscle </li></ul></ul>
    16. 16. Blowout Fractures of Orbit <ul><li>Originally defined as orbital floor fractures without fracture orbital rim, but with entrapment one or more soft tissue structures </li></ul>
    17. 17. Blowout Fractures <ul><li>Blowout fractures now refer to fractures of the: </li></ul><ul><ul><li>Orbital floor </li></ul></ul><ul><ul><li>Medical wall </li></ul></ul><ul><ul><li>Lateral wall </li></ul></ul><ul><ul><li>Superior wall </li></ul></ul><ul><li>“ pure” blowout fractures – trapdoor rotation to bone fragments involving central area of bone </li></ul><ul><li>“ impure” fracture – fracture line extends to orbital rim </li></ul>
    18. 18. Physiology of Blowout Fracture <ul><li>The bony defect is filled with soft tissue and fat from the orbit </li></ul><ul><li>Alters support mechanisms for EOM </li></ul><ul><li>EOM can become entrapped </li></ul><ul><li>Direct muscle damage can result </li></ul>
    19. 19. Common causes of orbital fractures <ul><li>Falling </li></ul><ul><li>Aggression </li></ul><ul><li>Sporting events </li></ul><ul><li>MVAs </li></ul>
    20. 20. Initial Evaluation <ul><li>History </li></ul><ul><ul><li>Time and mechanism of injury </li></ul></ul><ul><ul><li>Change in appearance of eye </li></ul></ul><ul><ul><li>State of vision immediately after injury </li></ul></ul><ul><ul><ul><li>Immediate loss of vision – severe damage to retina </li></ul></ul></ul><ul><ul><ul><li>Loss of light perception - vascular occlusion or optic nerve compression </li></ul></ul></ul><ul><ul><ul><li>Initial good vision – compression optic neuropathy </li></ul></ul></ul>
    21. 21. Initial Evaluation <ul><li>Physical Exam </li></ul><ul><ul><li>Cranial nerve examination </li></ul></ul><ul><ul><ul><li>EOM </li></ul></ul></ul><ul><ul><ul><li>Numbness check </li></ul></ul></ul><ul><ul><li>Palpation orbital rim </li></ul></ul><ul><ul><li>Papillary function </li></ul></ul><ul><ul><li>Visual acuity </li></ul></ul><ul><ul><li>Fundus examine </li></ul></ul><ul><ul><li>Ophthalmologic evaluation </li></ul></ul>
    22. 22. Visual Acuity <ul><li>Light perception </li></ul><ul><li>Finger counting </li></ul><ul><li>Visual acuity </li></ul>
    23. 23. Consultation <ul><li>Do not hesitate to obtain an ophthalmologic consultation </li></ul>
    24. 24. Common physical signs <ul><li>Periorbital eccyhmosis </li></ul><ul><li>Impaired extraocular muscles </li></ul><ul><li>Hypoesthesia in V2 distribution </li></ul><ul><li>Intraorbital emphysema </li></ul>
    25. 25. Common Symptoms <ul><li>Diplopia </li></ul><ul><li>Pain with eye movement </li></ul>
    26. 26. Radiographic Evaluation <ul><li>CT scan of the orbits </li></ul><ul><li>Plain films not useful due to a high rate of false negatives and non-diagnostic studies </li></ul>
    27. 27. Injuries associated with blow out fractures <ul><li>Ruptured globe </li></ul><ul><li>Retroorbital hemorrhage </li></ul><ul><li>Vitreous hemorrhage </li></ul><ul><li>Hyphema </li></ul><ul><li>Anterior chamber angle recession </li></ul><ul><li>Dislocated lens </li></ul><ul><li>Secondary glaucoma </li></ul><ul><li>Retinal detachment </li></ul>
    28. 28. Treatment Options <ul><li>Nonsurgical </li></ul><ul><li>Surgical </li></ul>
    29. 29. Initial Management <ul><li>Ice affected area for 48 hours </li></ul><ul><li>Elevation HOB </li></ul><ul><li>Use of nasal decongestants </li></ul><ul><li>Broad spectrum antibiotics like Augmentin </li></ul><ul><li>Oral steroids to prevent fibrosis </li></ul><ul><li>No ASA </li></ul><ul><li>No nose blowing </li></ul>
    30. 30. Absolute Indications for Surgical Repair <ul><li>Diplopia </li></ul><ul><li>Enophthalmos >2 mm </li></ul>
    31. 31. Relative Indications for Surgery <ul><li>CONTOVERSIAL AREA </li></ul><ul><li>Substantial soft tissue herniation into maxillary sinus </li></ul><ul><li>Intraoribital emphysema </li></ul><ul><li>Hypoestheia in V2 distribution </li></ul>
    32. 32. Contraindications to surgery <ul><li>Hyphema </li></ul><ul><li>Retinal detachment </li></ul><ul><li>Globe perforation </li></ul><ul><li>Only seeing eye </li></ul><ul><li>Medically unstable patient </li></ul>
    33. 33. Timing of Surgery <ul><li>Usually seven to ten days after trauma </li></ul>
    34. 34. Surgical Approaches <ul><li>Transconjunctival approach </li></ul><ul><li>Transcutaneous </li></ul><ul><li>Subciliary </li></ul><ul><li>Trasantral </li></ul>
    35. 35. Factors to consider for surgery <ul><li>Site </li></ul><ul><li>Location </li></ul><ul><li>Severity </li></ul><ul><li>What needs to be corrected </li></ul>
    36. 36. Surgical procedures for orbital floor fractures <ul><li>Incision </li></ul><ul><li>Subtarsal dissection </li></ul><ul><li>Skin-muscle flap </li></ul><ul><li>Incision of maxilla </li></ul><ul><li>Floor dissection </li></ul><ul><li>Placement of Marlex mesh </li></ul><ul><li>Periosteal closure </li></ul><ul><li>Skin closure </li></ul>
    37. 37. Orbital Implants <ul><li>Use of implants based on degree of comminution and size of fracture </li></ul><ul><li>Various implant material used </li></ul><ul><ul><li>Autogenous bone and cartilage </li></ul></ul><ul><ul><li>Alloplastic material </li></ul></ul><ul><ul><ul><li>Teflon </li></ul></ul></ul><ul><ul><ul><li>Marlex </li></ul></ul></ul><ul><ul><ul><li>PDS </li></ul></ul></ul><ul><ul><ul><li>Etc. </li></ul></ul></ul>
    38. 38. Complications of Surgery <ul><li>Ectropion </li></ul><ul><li>Lid retraction </li></ul><ul><li>Persistent diplopia </li></ul><ul><li>Malposition of eye </li></ul><ul><li>hypoesthesia </li></ul><ul><li>Extrusion of orbital floor implant </li></ul>
    39. 39. Rare complications <ul><li>Ipsilateral fourth cranial nerve palsy </li></ul><ul><li>Post-op mydriasis </li></ul><ul><li>Blindness (1/1,500) </li></ul>
    40. 40. Conclusions <ul><li>Assessment of orbital fractures is an area that requires a high index of suspicion </li></ul>

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