The document summarizes orbital bone fractures, including the anatomy of the orbit, classification of fractures, causes of blowout fractures, clinical presentation, diagnosis, management, and complications. Key points are: - The orbit is formed by multiple bones and contains extraocular muscles and neurovascular structures. - Fractures are classified based on the involved walls. Blowout fractures cause bone to be displaced away from the orbit. - Clinical features include diplopia, enophthalmos, and nerve dysfunction. CT is used to confirm fractures. - Management involves initial monitoring then later surgery if needed to repair muscle entrapment or significant deformity. Complications include vision loss, persistent diplopia, and infection

1. Orbital bone fractures

2. Anatomy
• Anatomically the orbit resembles a four
sided pyramid.
• The orbital roof formed from
• Orbital plate of the frontal bone
• Lesser wing of the sphenoid bone.
• The floor of the orbit is formed from
three bones:
• Maxillary bone
• Palatine bone
• Orbital plate of the zygomatic bone.

3. • Then medial wall of the orbit is formed from four bones:Frontal
process of the maxilla
• Lacrimal bone
• Orbital plate of the ethmoidal bone
• Lesser wing of the sphenoid
• The Lateral wall is formed from two bones:
• Zygomatic bone
• Greater wing of the sphenoid
• Frontal

5. EXTRAOCULR
MUSCLES
• Superior Rectus
• Inferior rectus
• Lateral rectus
• Medial rectus
• Superior oblique
• Inferior oblique
• All are supplied by oculomotor nerve
III
• Except oblique(Trochlear Nerve) and
lateral rectus (Abducens)

6. BLOOD SUPPLY
AND NERVE
SUPPLY
The arterial supply to the orbit is
from ophthalmic artery.
The venous drainage is through the
superior and interior ophthalmic
veins.
The innervation of the orbit is
through
Oculomotor nerve
Trochlear nerve
Abducens nerve
Opthalmic nerve

7. Classification
• Fractures involving orbit classified according to
the pattern of involvement of walls of the orbit as
1. Fractures limited to internal orbital skeleton(Blow
out and blow in fractures). Orbital floor, medial
wall or roof can be involved.
2. Fractures involving orbital/rim along with internal
orbital skeleton.
These fractures may be sub classified into:
• Inferior rim fracture
• Superior rim fracture
• Lateral rim fracture
• Rim fracture in association with fractures
involving internal orbital skeleton

8. 3.Fractures of orbit associated with other
fractures of facial skeleton.
These include:
• 1. Zygomatico maxillary fracture
• 2. Naso-orbito-ethmoid fracture
• 3. Frontal sinus fracture
• 4. Lefort II
• 5. Lefort III

9. • 4. Orbital apex fractures :
• These fractures should be
identified early because of
potential threat to neurovascular
structures at superior orbital
fissure and optic canal.
• Optic canal injuries can lead to
traumatic optic neuropathy.

10. Blow out fractures of
orbit
• An orbital blowout fracture
is a traumatic deformity of
the orbital floor or medial
wall, typically resulting from
impact of a blunt object
larger than the orbital
aperture.
• Bone is displaced away
from the orbit.

11. There are two broad categories of blowout fractures:
• OPEN DOOR : large, displaced and comminuted
• TRAPDOOR : linear, hinged, and minimally displaced.
Blowout fractures can also be classified as
• PURE BLOWOUT FRACTURES – not involving orbital rim
• IMPURE FRACTURE – fracture line extends to orbital rim
Trapdoor

12. Pathophysiology
Blow
Backward displacement of eyeball
Intraorbital pressure increases
Fracture of the weakest point of orbit

13. Two theories have been proposed to account for blow out
fracture:
1. Hydraulic theory: This theory suggests that sudden increase
in intraorbital pressure causes decompressing fracture into the
adjacent sinus
2.Buckling theory: It states that the orbital rim buckles and
transmits forces to the orbital walls, resulting in an orbital
floor fracture.

14. White-eyed Blow-
out Fracture
• The greenstick fracture is a pediatric
response to external deforming
forces.
• Here, intra-orbital soft tissue (fat
and muscle) may become entrapped
within the fracture as the elastic
bones snap back into place,
resulting in severe restrictive
external ophthalmoplegia.
• There is lack of external periocular
signs of trauma in many pediatric
cases and hence known as the
white-eyed blow-out fracture.
• Surgery must be performed within
48-72 hours, as there is a high risk
of necrosis of the entrapped ocular
muscle

15. Effects of blow out fracture
• Muscle entrapment
• Damage to infra orbital nerve
• Herniation of orbital contents into the sinus

16. Blow in fracture
• Bone is displaced into the orbit.
• May involve the roof, floor, medial or lateral
wall.
• If orbital rim is intact, then it is termed as
pure orbital rim fractures.
• Exophthalmos present.

17. Etiology
• RTA
• Sports
• Assault

18. Clinical features
EARLY FEATURES:
Periocular Edema
Paresthesia of infra orbital nerve
Subconjuctival hemorrhage
Circumorbital ecchymosis
Ptosis
Limitation of ocular movement
Unilateral epistaxis

19. LATE FEATURES:
• Diplopia (due to muscle entrapment)
• Enopthalmos (due to retraction of extraoccular muscles and escape of orbital fat)
• Lowering of ocular level
• Narrowing of palpebral fissure

20. Diagnosis
FORCED DUCTION TEST:
• The limbus is gripped with forceps, and the globe is
moved in multiple position to stretch the rectus
muscles and superior oblique muscle and tendons,
evaluating for any restriction in movement

21. Investigations
• CT (Coronal and sagittal): GOLD STANDARD
• MRI
• Waters view (hanging drop opacity)

22. Radiological Findings
• Floor disruption
• Sinus opacification
• Prolapsed soft tissue classically gives rise to the ‘tear
drop’ sign.
• Orbital emphysema
• Asymmetry
• Soft tissue swelling

23. Initial Management
• Ice affected area
• Elevation of head
• Use of nasal decongestants
• Broad spectrum antibiotics like Augmentin
• Oral steroids to prevent fibrosis
• No nose blowing

24. Indications for Repair
• Diplopia that persists beyond 7 to 10 days.
• Obvious signs of entrapment.
• Relative enophthalmos greater than 2mm.
• Fracture that involves greater than 50% of the orbital
floor.
• Entrapment that causes an oculocardiac reflex with
resultant bradycardia and cardiovascular instability.
• Progressive infra orbital nerve numbness

25. Immediate repair
• Non resolving oculocardiac reflex with entrapment
• Bradycardia, heart block, nausea, vomiting, syncope
• Early enophthalmos or hypoglobus causing facial
asymmetry “White-eyed” floor fracture with
entrapment

26. Delayed repair
• The majority of orbital fractures are managed initially
with observation, then surgical intervention, if indicated,
within 14 days of injury.
• 1.Symptomatic diplopia with positive forced duction test
• 2. Large fracture causing enophthalmos
• 3. Significant hypoglobus
• 4. Progressive infraorbital hypoanesthesia

27. • Surgical approach Surgical repair of orbital fractures
typically involves the following steps:
1. Exposure with degloving the facial skeleton
2. Reduction
3. Rigid fixation with replacement of lost or comminuted
bone
4. Soft-tissue resuspension
5. Closure

28. Titanium meshes
• INDICATION: Large orbital floor defects
• ADVANTAGES:
• Stability Biocompatible
• Ease in Contouring
• Adequate in large three-wall fractures
• Radiopacity
• Spaces within the mesh to allow dissipation
of fluids
• No donor site needed
• Tissue incorporation may occur
• DISADVANTAGES: Cost
• Possible sharp edges if not properly trimmed

29. Porous polyethylene sheets (PPE)
• ADVANTAGES:
• Availability
• Contouring (eased by the artificial sterile skull)
• Smooth edges
• Allows tissue ingrowth
• DISADVANTAGES:
• Not radiopaque (not visible on postoperative images)
• Lack of rigidity when a very thin wafer of PPE is used.
When a thicker rigid wafer is used there is a risk of
causing a dystopia.
• Less drainage from the orbit than with titanium

30. Composite of porous polyethylene and titanium
mesh
• By combining titanium mesh with porous
polyethylene the material becomes radiopaque, and
more rigid than porous polyethylene of a similar
thickness

31. • Resorbable sheeting
• Sheets made of polylactide, polyglactin, and polydioxanone have been commercially
made from resorbable materials for orbital reconstruction.
• INDICATION : Can be used in small gaps <2.5 cm2 with stable medial and lateral
borders
• ADVANTAGES: Biocompatible
• Pliable and can be contoured to the defect
• Resorbable
• DISADVANTAGES:
• Cost
• Concern for long-term stability and support
• Not radio-opaque

32. Customized orbital implants
• ADVANTAGES:
• Digitally designed by the surgeon based on the
contralateral orbit
• Radiopaque
• Smooth surface o Minimal or no contouring necessary
• DISADVANTAGES:
• Cost
• Time required to obtain the implant

33. • Complications
• Intraoperative complications include the following:
• Globe and optic nerve injury
• Injury to the infraorbital nerve
• Inadequate reduction of prolapsed tissue
• Orbital hemorrhage

34. • Postoperative complications include the following: Blindness
• Persistent diplopia
• Globe malpositioning, particularly enophthalmos or hypoglobus
• Infection that presents as orbital cellulitis
• Infraorbital nerve dysfunction in an orbital floor repair
• Lid malpositioning, especially lower-lid retraction or entropion
• Implant infection, migration, or extrusion
• Epistaxis or cerebrospinal fluid (CSF) leakage in medial wall repairs

35. Recent advance
• 3D Printing (stereolithography)
• 3D printing helps visualize a patient’s
missing orbital floor (left) versus original
shape before
• 3D printed prototypes help improve
accuracy and shorten the operation.

36. • Thank you