Fx max orb-0001

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Fx max orb-0001

  1. 1. Maxillary and Periorbital Fractures Michael E. Decherd, MD Shawn D. Newlands, MD, PhD January 26, 2000
  2. 2. Overview • Classic tripod, orbital floor, LeFort fractures better thought of as orbitozygomaticomaxillary fractures • Precise anatomic reduction is key • Goal is functional and cosmetic rehabilitation
  3. 3. Epidemiology • Males : Females -- 4:1 • Predominantly in 20’s or 30’s • Cause – MVA > altercation > fall • Site – Nasal > Zygoma > other • In altercations left zygoma fractured more often
  4. 4. Anatomy
  5. 5. Anatomy
  6. 6. Anatomy of the Orbit • Bones: Frontal, Zygomatic, Ethmoid, Lacrimal, Maxilla, Palatal, Sphenoid
  7. 7. Anatomy of the Orbit • Four-sided pyramid or cone
  8. 8. Anatomy of the Orbit • Maximum vertical dimension 1.5 cm behind rim • Floor is concave and then convex
  9. 9. Anatomy of the Orbit • Floor slopes into medial wall • Optic nerve superomedial to true apex
  10. 10. Anatomy of Zygoma • Four superficial and two deep articulations • Intersection of arcs define malar prominence
  11. 11. Anatomy of the Maxilla • Paired embryologically • Functionally acts with palatine bone
  12. 12. Anatomy of the Maxilla
  13. 13. Vertical Buttresses • Resist occlusal load
  14. 14. Horizontal Buttresses
  15. 15. Fracture Patterns
  16. 16. LeFort Fractures • Experimentally determined weak points • Can be in combinations bilaterally • Useful descriptor • Results from anterior forces
  17. 17. Le Fort I
  18. 18. Le Fort II
  19. 19. Le Fort III
  20. 20. Zygoma Fractures • Results from lateral forces
  21. 21. Zygoma Fractures • Impacted zygoma may mask orbital floor defect
  22. 22. Orbital Blowout Injury
  23. 23. Orbital Blowout Injury
  24. 24. Orbital Blowout Injury • Usually inferior and/or medial wall • Cone will become more spherical • Leads to enophthalmos, inferior displacement • Muscle entrapment causes diplopia
  25. 25. Patient Evaluation
  26. 26. Physical Exam • Can be very difficult in traumatized patient • Don’t forget trauma ABC’s (ATLS) • Look for occlusion, trismus, stability, asymmetry, extraocular movements, V2 anesthesia, stepoffs, bowstring test, lacerations and ecchymosis
  27. 27. Physical Exam • Midface asymmetry may indicate zygoma fracture
  28. 28. Physical Exam • Palpate for midface instability
  29. 29. Physical Exam -- Ophthalmologic Considerations • Ophthalmologic Minimums – Visual acuities (subjective and objective) – Pupillary function – Ocular motility – Anterior chamber for hyphema – Fundoscopic exam • If in question ophthalmologic consultation is indicated
  30. 30. Eye Algorithm • If obtunded, afferent pupillary defect may indicate visual loss
  31. 31. Afferent Pupillary Defect
  32. 32. Ophthalmologic Exam
  33. 33. Ophthalmologic Exam • Hyphema is blood in anterior chamber • Hx - vision worse supine, clears upright • Can cause increased IOP
  34. 34. Ophthalmologic Exam • Tonometer measures IOP • Greatly increased IOP causes pulsatile optic disk
  35. 35. Ophthalmologic Exam • Retinal detachment requires ophthalmologic attention
  36. 36. Ophthalmologic Exam • Iridodialysis (torn iris • Opacified cornea
  37. 37. Ophthalmologic Exam • Fluorescsein reveals corneal abrasion • Dislocated lens
  38. 38. Ophthalmologic Exam • Subconjunctival ecchymosis may indicate orbital fracture
  39. 39. Forced Duction Testing
  40. 40. Physical Exam • Often edema, swelling, or patient’s mental status make physical exam difficult • CT is modality of choice -- axial and coronal
  41. 41. CT areas to evaluate • Vertical buttresses • Zygomatic arch • Orbital walls • Bony palate • Mandibular condyles
  42. 42. Treatment
  43. 43. Treatment • Goal is functional and cosmetic restoration • Treatment must be individualized • Various factors can affect management strategies – Multi-trauma – Concomitant mandible injury – Only-seeing eye
  44. 44. Order of Repairs • Work from stable to unstable • Use occlusion as guide • Generally stabilize mandible, zygoma and palate before midface before orbit and NOE
  45. 45. Order of Repairs
  46. 46. Zygoma • Ideally done between 5-7 days for resolution of edema • Pre- or intra- operative steroids can help with edema • After 10 days masseter begins to shorten
  47. 47. Zygoma • Minimally displaced, non comminuted can be treated with reduction only • Increasing amounts of displacement and comminution may require plating of lateral antrum, orbital rim, ZF suture, and even the zygomatic arch • One can wire the ZF suture first to assist with reduction, then plate it after other areas stabilized
  48. 48. Zygoma Algorithm
  49. 49. ORIF of Lateral Antral Wall
  50. 50. Gillies Reduction
  51. 51. Post-Gillies Reduction
  52. 52. Surgical Approaches • Coronal • Sublabial • Transconjunctival • Lateral Brow
  53. 53. Coronal Approach
  54. 54. Coronal Approach
  55. 55. Coronal Approach • Supraorbital nerve may be released for more exposure
  56. 56. Hemicoronal Approach
  57. 57. Lateral Brow Incision • Avoid shaving brow hairs • Goal is the ZF suture
  58. 58. Sublabial Approach • Leave mucosa to sew to later • Identify and preserve V2
  59. 59. Midface • “Rigid” fixation misnomer with small plates and thin bones • Semirigid fixation (wire) sometimes preferable • Early function can be achieved with soft diet only
  60. 60. Vertical Buttress Algorithm
  61. 61. Midface Disimpaction • May be necessary to restore facial dimensions before fixation
  62. 62. Palate Fracture • Wire can be placed posteriorly for stabilization before triangular reduction
  63. 63. ORIF of Midface
  64. 64. Orbital Floor • When to explore? (Shumrick study) – Persistent diplopia with positive forced duction – Obvious enophthalmos – Comminuted orbital rim by CT – >50% floor disruption by CT – Combined floor/medial wall defects by CT – Fracture of zygoma body by CT – “Blow-in” fx with exophthalmos by PE or CT
  65. 65. Orbital Floor • Best done 7-10 days • Other indications – 1-2 sq.cm of floor disrupted • Contraindications – hyphema, retinal tear, globe perforation – only seeing eye – medically unstable
  66. 66. Orbital Floor • Dotted line shows anatomic goal of restoration
  67. 67. Orbital Rim Access • A -- subciliary • B -- lower eyelid • C -- infraorbital
  68. 68. Transconjunctival Approach
  69. 69. Transconjunctival Approach • Conjunctiva is being used to protect globe
  70. 70. Lateral Canthotomy and Cantholysis • Allows wider exposure
  71. 71. Orbital Floor Materials • Marlex mesh – needs 360 degree support – better for concave anterior floor only • Medpor – needs medial/ lateral support – can use for anterior/posterior defect • Calvarial bone graft • Titanium mesh
  72. 72. Synthetic Mesh
  73. 73. Orbital Floor Bone Grafting • Need to support floor full 4 cm
  74. 74. Orbital Metallic Mesh
  75. 75. Orbital Roof • Uncommon due to high levels of force needed to fracture orbital roof • Commonly with intracranial problems
  76. 76. Orbital Roof Repair • Repair roof higher on frontal bar
  77. 77. Cutting Edge Topics • Bioresorbable plates • Intraoperative CT • 3-D CT reconstruction • Endoscopic assistance
  78. 78. Conclusion • Goal is functional and cosmetic rehabilitation • Precise anatomic restoration key • Treatment tailored to each individual • Knowledge of anatomy and techniques will lead to superior results
  79. 79. Case Presentation
  80. 80. • 30 yo WF • MVA • PMH unknown

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