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ORBITAL FRACTURES Dr. Ankit M. Punjabi  (drankitalways@gmail.com) Kota Eye Hospital, Kota, Rajasthan, India The Role of An...
 
<ul><li>Rate of orbital involvement : 15% of all serious injuries </li></ul><ul><ul><li>Fracture : 78% </li></ul></ul><ul>...
The Place & Source of Injury Source of Injury Place of Injury
Pathophysiology <ul><li>Orbit’s primary role: Protect the eyeball </li></ul><ul><li>The combination of superior & lateral ...
Evaluation of Orbital Trauma Injuries to orbit are often associated with severe neurological injuries, which are life-thre...
History in a case of Ocular Trauma
Evaluation of Visual Functions
<ul><li>CT: </li></ul><ul><ul><li>Best images of relationship between the bone and soft tissues </li></ul></ul><ul><ul><li...
 
<ul><li>LE FORT FRACTURES </li></ul><ul><ul><li>Type 1 Type 2 Type 3 </li></ul></ul><ul><li>Common to all Le Fort Fracture...
MAXILLOFACIAL INJURY <ul><li>LE FORT FRACTURES </li></ul><ul><ul><li>Type 1  Low Transverse Maxillary Fracture </li></ul><...
MAXILLOFACIAL INJURY <ul><li>LE FORT FRACTURES </li></ul><ul><ul><li>Type 2  Pyramidal Fracture </li></ul></ul>
MAXILLOFACIAL INJURY <ul><li>LE FORT FRACTURES </li></ul><ul><ul><li>Type 3  Craniofacial Dysfunction </li></ul></ul>
<ul><li>Most common orbital injury </li></ul><ul><li>Typical history of a blow by blunt, may be rounded object (>5cm in si...
Theories of Blow-Out Fracture <ul><li>Direct injury (Retropulsion): </li></ul><ul><ul><li>Sudden compression of globe with...
Clinical Features <ul><li>Diplopia (Defective Elevation) </li></ul><ul><li>Infraorbital numbness </li></ul><ul><li>Periocu...
X-Ray Herniation of orbital contents
CT – “Tear Drop” sign
The Myth & The Truth
<ul><li>Patients with isolated blow-out fractures: </li></ul><ul><ul><li>Initially they can be followed clinically </li></...
<ul><li>Early repair is necessary : </li></ul><ul><ul><li>Associated craniofacial trauma </li></ul></ul><ul><ul><li>Marked...
Surgical Repair <ul><li>Specific Indications: </li></ul><ul><ul><li>Restrictive Strabismus </li></ul></ul><ul><ul><li>CT e...
Orbital Floor Implants <ul><li>Autogenous materials </li></ul><ul><ul><li>Calverium </li></ul></ul><ul><ul><li>Iliac crest...
 
Individualised Pre-fabricated Implants
Endoscopic Approach
Recovery <ul><li>May take weeks to months </li></ul><ul><li>Last thing to recover from is numbness </li></ul>
<ul><li>Multiple fractures in and around the orbit </li></ul><ul><li>Can be seen in Tripod & LeFort III fractures </li></u...
<ul><li>Extension of a floor fracture </li></ul><ul><li>Component of naso-orbital-ethmoid (NOE) fractures </li></ul><ul><l...
<ul><li>Distinctly uncommmon </li></ul><ul><li>Due to moderate-high energy impact </li></ul><ul><li>Associated with signif...
<ul><li>Indications of surgery: </li></ul><ul><ul><li>Depressed skull fracture (if the anterior cranial fossa is compromis...
<ul><li>Tripod or trimalar fracture </li></ul><ul><li>Now considered to have </li></ul><ul><li>4 components: </li></ul><ul...
Features of ZMC complex fracture <ul><li>Highly variable </li></ul><ul><li>Point tenderness & ecchymosis </li></ul><ul><li...
<ul><li>Specific indications for surgical intervention include the following: </li></ul><ul><ul><li>Significant malar flat...
<ul><li>Complex multilevel injuries </li></ul><ul><li>Associated with extensive craniofacial trauma </li></ul><ul><li>Most...
 
Flowchart Showing elements of Counseling
 
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Orbital Fractures - The Role of an Ophthalmologist

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Orbital fractures are a common finding in maxillofacial trauma. although a multi-disciplinary approach is essential, the role of ophthalmologist cannot be overemphazised. here we discuss the same.

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Orbital Fractures - The Role of an Ophthalmologist

  1. 1. ORBITAL FRACTURES Dr. Ankit M. Punjabi (drankitalways@gmail.com) Kota Eye Hospital, Kota, Rajasthan, India The Role of An Ophthalmologist
  2. 3. <ul><li>Rate of orbital involvement : 15% of all serious injuries </li></ul><ul><ul><li>Fracture : 78% </li></ul></ul><ul><ul><li>Foreign body : 24% </li></ul></ul><ul><ul><li>Hemorrhage : 1% </li></ul></ul><ul><li>Males : 78% </li></ul>
  3. 4. The Place & Source of Injury Source of Injury Place of Injury
  4. 5. Pathophysiology <ul><li>Orbit’s primary role: Protect the eyeball </li></ul><ul><li>The combination of superior & lateral strength with medial and inferior wall weakness allows dissipation of energy when orbit is struck </li></ul><ul><li>Evolutionary master piece: the ability of the orbital floor to fracture selectively, similar to a safety valve </li></ul>
  5. 6. Evaluation of Orbital Trauma Injuries to orbit are often associated with severe neurological injuries, which are life-threatening and take precedence over the orbital treatment
  6. 7. History in a case of Ocular Trauma
  7. 8. Evaluation of Visual Functions
  8. 9. <ul><li>CT: </li></ul><ul><ul><li>Best images of relationship between the bone and soft tissues </li></ul></ul><ul><ul><li>Suspected orbital fractures </li></ul></ul><ul><ul><li>Palpable bone step-offs </li></ul></ul><ul><ul><li>Restricted extra-ocular movements </li></ul></ul><ul><ul><li>Metallic orbital foreign bodies </li></ul></ul><ul><li>MRI: </li></ul><ul><ul><li>Best at differentiating soft tissues </li></ul></ul><ul><ul><li>Associated neurological damage </li></ul></ul><ul><ul><li>Wooden foreign bodies </li></ul></ul>
  9. 11. <ul><li>LE FORT FRACTURES </li></ul><ul><ul><li>Type 1 Type 2 Type 3 </li></ul></ul><ul><li>Common to all Le Fort Fractures </li></ul><ul><li>is </li></ul><ul><li>involvement of Pterygoid Plates </li></ul>
  10. 12. MAXILLOFACIAL INJURY <ul><li>LE FORT FRACTURES </li></ul><ul><ul><li>Type 1 Low Transverse Maxillary Fracture </li></ul></ul>
  11. 13. MAXILLOFACIAL INJURY <ul><li>LE FORT FRACTURES </li></ul><ul><ul><li>Type 2 Pyramidal Fracture </li></ul></ul>
  12. 14. MAXILLOFACIAL INJURY <ul><li>LE FORT FRACTURES </li></ul><ul><ul><li>Type 3 Craniofacial Dysfunction </li></ul></ul>
  13. 15. <ul><li>Most common orbital injury </li></ul><ul><li>Typical history of a blow by blunt, may be rounded object (>5cm in size) </li></ul><ul><li>Fracture of the inferior medial orbit </li></ul><ul><li>Classical triad of: </li></ul><ul><ul><li>Diplopia </li></ul></ul><ul><ul><li>(restrictive strabismus) </li></ul></ul><ul><ul><li>Infraorbital numbness </li></ul></ul><ul><ul><li>(interruption of infraorbital nerve) </li></ul></ul><ul><ul><li>Periocular ecchymosis </li></ul></ul><ul><ul><li>(skin & muscle damage) </li></ul></ul>Left Orbital Blow-out Fracture
  14. 16. Theories of Blow-Out Fracture <ul><li>Direct injury (Retropulsion): </li></ul><ul><ul><li>Sudden compression of globe with orbital floor fracture (increased orbital & ocular pressure) </li></ul></ul><ul><li>Indirect injury (Buckling) </li></ul><ul><ul><li>Blow to inferior rim causes a ripple effect causing fracture </li></ul></ul>
  15. 17. Clinical Features <ul><li>Diplopia (Defective Elevation) </li></ul><ul><li>Infraorbital numbness </li></ul><ul><li>Periocular ecchymosis & Edema </li></ul><ul><li>Enophthalmos </li></ul><ul><li>Orbital Emphysema </li></ul><ul><li>Hyphaema, angle recession </li></ul><ul><li>Commotio Retina, Retinal dialysis </li></ul><ul><li>Positive forced Duction Test </li></ul><ul><li>In Children: </li></ul><ul><ul><li>GREEN STICK FRACTURE </li></ul></ul><ul><ul><li>clinically evident, absence on CT </li></ul></ul>
  16. 18. X-Ray Herniation of orbital contents
  17. 19. CT – “Tear Drop” sign
  18. 20. The Myth & The Truth
  19. 21. <ul><li>Patients with isolated blow-out fractures: </li></ul><ul><ul><li>Initially they can be followed clinically </li></ul></ul><ul><ul><li>If surgery is needed, it is usually planned for 7-14 days after the trauma </li></ul></ul><ul><li>Waiting allows time for: </li></ul><ul><ul><li>Spontaneous improvement </li></ul></ul><ul><ul><li>Resolution of swelling associated with the initial trauma </li></ul></ul><ul><ul><li>Precise surgical planning </li></ul></ul><ul><li>Delaying surgery for over 14 days results in increased scarring of orbit </li></ul>
  20. 22. <ul><li>Early repair is necessary : </li></ul><ul><ul><li>Associated craniofacial trauma </li></ul></ul><ul><ul><li>Marked enophthalmos & hypoglobus </li></ul></ul><ul><ul><li>Complete disruption of the orbital floor </li></ul></ul><ul><li>Causes of delayed presentation: </li></ul><ul><ul><li>Life-threatening injuries which took precedence </li></ul></ul><ul><ul><li>Non-exploration & non-repair by craniofacial surgeons </li></ul></ul><ul><ul><li>Too edematous orbit to allow effective repair </li></ul></ul>
  21. 23. Surgical Repair <ul><li>Specific Indications: </li></ul><ul><ul><li>Restrictive Strabismus </li></ul></ul><ul><ul><li>CT evidence of muscle entrapment </li></ul></ul><ul><ul><li>Enophthalmos <2mm </li></ul></ul><ul><ul><li>Oculocardiac Reflex </li></ul></ul><ul><ul><li>Hypo-ophthalmos </li></ul></ul><ul><ul><li>Large floor fracture <50%, based on CT estimate of fracture size </li></ul></ul><ul><li>Usually transconjunctival approach: </li></ul><ul><ul><ul><li>Excellent exposure </li></ul></ul></ul><ul><ul><ul><li>Conceals the incision </li></ul></ul></ul><ul><ul><ul><li>Prevents postoperative lid retraction </li></ul></ul></ul>
  22. 24. Orbital Floor Implants <ul><li>Autogenous materials </li></ul><ul><ul><li>Calverium </li></ul></ul><ul><ul><li>Iliac crest </li></ul></ul><ul><ul><li>Ribs </li></ul></ul><ul><li>Alloplastic materials </li></ul><ul><ul><li>Porous polyethelene implant </li></ul></ul><ul><ul><li>Titanium mesh </li></ul></ul><ul><ul><li>Polymer of polylactic & polyglactic acid (resorbable) </li></ul></ul>
  23. 26. Individualised Pre-fabricated Implants
  24. 27. Endoscopic Approach
  25. 28. Recovery <ul><li>May take weeks to months </li></ul><ul><li>Last thing to recover from is numbness </li></ul>
  26. 29. <ul><li>Multiple fractures in and around the orbit </li></ul><ul><li>Can be seen in Tripod & LeFort III fractures </li></ul><ul><li>Clinical signs & symptoms </li></ul><ul><ul><li>Enophthalmos </li></ul></ul><ul><ul><li>Deep superior sulcus </li></ul></ul>
  27. 30. <ul><li>Extension of a floor fracture </li></ul><ul><li>Component of naso-orbital-ethmoid (NOE) fractures </li></ul><ul><li>Signs & symptoms: </li></ul><ul><ul><li>Horizontal diplopia </li></ul></ul><ul><ul><li>Orbital Emphysema </li></ul></ul><ul><ul><li>Orbital Hemorrhage </li></ul></ul><ul><ul><li>Enophthalmos </li></ul></ul>
  28. 31. <ul><li>Distinctly uncommmon </li></ul><ul><li>Due to moderate-high energy impact </li></ul><ul><li>Associated with significant concomittant non-ocular injuries </li></ul><ul><li>C/F: </li></ul><ul><ul><li>Restricted up-gaze & ptosis </li></ul></ul><ul><ul><li>Epistaxis, CSF Rhinorrhoea, Anosmia </li></ul></ul><ul><ul><li>Depression of Supraorbital rim </li></ul></ul><ul><ul><li>Hyperaesthesia of Cranial nerve V1 </li></ul></ul><ul><ul><li>Hypo-ophthalmos & pulsatile exophthalmos </li></ul></ul>
  29. 32. <ul><li>Indications of surgery: </li></ul><ul><ul><li>Depressed skull fracture (if the anterior cranial fossa is compromised, a craniotomy is often required); </li></ul></ul><ul><ul><li>Significant diplopia; </li></ul></ul><ul><ul><li>Significant exophthalmos; and </li></ul></ul><ul><ul><li>Frontal sinus fracture with compromise of the nasofrontal duct. </li></ul></ul>
  30. 33. <ul><li>Tripod or trimalar fracture </li></ul><ul><li>Now considered to have </li></ul><ul><li>4 components: </li></ul><ul><ul><li>ZM suture </li></ul></ul><ul><ul><li>ZF suture </li></ul></ul><ul><ul><li>ZT suture </li></ul></ul><ul><ul><li>ZMC buttress (most important) </li></ul></ul><ul><li>2 nd most common fracture </li></ul><ul><li>Varied presentations </li></ul><ul><li>(thus often missed) </li></ul>
  31. 34. Features of ZMC complex fracture <ul><li>Highly variable </li></ul><ul><li>Point tenderness & ecchymosis </li></ul><ul><li>Malar flattening & increased facial width </li></ul><ul><li>Lateral canthal dystopia </li></ul><ul><li>Dysesthesia of Cranial Nerve V1 </li></ul><ul><li>Trismus & malocclusion </li></ul><ul><li>Inferior or Lateral Rim Step-off </li></ul><ul><li>Associated floor fracture findings </li></ul>
  32. 35. <ul><li>Specific indications for surgical intervention include the following: </li></ul><ul><ul><li>Significant malar flattening </li></ul></ul><ul><ul><li>Lateral canthal dystopia or lower-lid malposition </li></ul></ul><ul><ul><li>Trismus or malocclusion </li></ul></ul><ul><ul><li>Significant orbital enlargement, with or without orbital floor symptoms </li></ul></ul><ul><ul><li>Significant displacement or comminution </li></ul></ul>
  33. 36. <ul><li>Complex multilevel injuries </li></ul><ul><li>Associated with extensive craniofacial trauma </li></ul><ul><li>Mostly due to direct high-energy frontal impact </li></ul><ul><li>Invariably bilateral and comminuted </li></ul><ul><li>Clinical features: </li></ul><ul><ul><li>Facial flattening </li></ul></ul><ul><ul><li>Traumatic telecanthus </li></ul></ul><ul><ul><li>Damage to nasolacrimal system </li></ul></ul><ul><ul><li>Epistaxis, CSF rhonirrhoea, anosmia </li></ul></ul><ul><ul><li>Traumatic optic neuropathy </li></ul></ul><ul><ul><li>Associated craniofacial fractures </li></ul></ul>Presence of NOE is itself an indication of surgery
  34. 38. Flowchart Showing elements of Counseling

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