blow out fracture, oculoplasty

1. BLOW OUT FRACTURE
Dr. Somy Purohit

2. • Type of fracture- isolated comminuted
• which walls get affected-
– orbital floor
– medial wall
• type of trauma- indirect

3. Mechanism
of
injury
buckling theory
hydraulic theory

4. buckling theory -
• blunt trauma hits the
inferior rim of the orbit
• the floor of orbit folds
• fracture
hydraulic theory-
• blunt trauma hits the
circumference of the orbit
• intraorbital pressure
increases
• thinnest wall breaks
• floor or medial wall

5. buckling theory

6. hydraulic theory

7. Classification
pure- orbital rim not
involved
impure- other
fractures associated-
facial bone #

8. Fig.- a,c pure blowout fracture, b,d impure blow out fracture

9. clinical features
• periorbital edema
• ecchymosis
• emphysema
• parasthesia, anasthesia
• epistaxis
• proptosis
• enophthalmos and mechanical ptosis
• diplopia
• intraocular damage

10. periorbital edema
it occus almost immediately and can mask other signs

11. ecchymosis

12. emphysema
• crepitus subcutaneous presence of air from paranasal
sinus
• happens more in medial wall fracture
• can compress optic nerve and endanger vision

13. parasthesia, anasthesia
• area of infra orbital nerve
cutaneous supply
• face, lower lid, cheek, side
of nose upper lip and
upper teeth

14. epistaxis
• ipsilateral
• early sign
• bleeding from maxillary sinus

15. proptosis
• variable
• initially due to hemorrhage and edema.

16. enophthalmos and mechanical ptosis
• backward and down ward movement of eye ball
• 3 reasons
– orbital fat sinks to maxillary sinus
– entrapment of inferior rectus causes backward traction
– due to displacement of bone fragments , enlargement of bony
cavity.
• happens 10 days after edema reduses.

18. diplopia
• vertical diplopia- both in up
and down gaze
• due to inferior rectus
entrapment
• positive forced duction test

19. intraocular damage
check for intra ocular damage

21. WHITE EYE FRACTURE
• children
• greenstick fracture
• flexible bone- small crack- trap door effect- entrapment of
content of eye ball
• eye is quite
• symptoms- diplopia
• needs urgent attention

23. investigations
• plain X ray- waters view
• Ct scan
• MRI

24. plain x ray

25. ct scan

26. MRI

27. Management
• general measure
• surgical intervention

28. genral measures
• avoid blowing nose- may case mre herniation of orbital
content into maxillary antrum
• systemic antibiotics
• analgesis and anti inflammatory
• cold compress- vaso constriction

29. surgical repair
• immediate repair-
– white eye #
– globe luxation into maxillary antrum
• after 2 weeks(edema subsides)
– unresolving diplopia
– a fracture with large herniation into antrum >50% in ct scan
– enophthalmos mre than 3mm
– large fracture that may cause enophthalmos
– ct evidence of muscle entrapment

30. • wait and observe
– good clinical motility
– minimal diplopia
– clinical improvement in 1-2 week
– absence of enophthalmos
– no Ct evidence of entrapment
– small bony defect that dose not cause enophthalmos

31. implants
• autologous bone graft
• autologous cartilage graft
• silicone
• titanium
• porous polyethylene

32. approach for surgery
• transcutaneous • transconjunctival

35. thank you