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BLOW_OUT_FRACTURE_(1) presentation dhir hospital bhiwani.pptx
- 1. BLOW OUT FRACTURE PRESENTED BY : DR RUCHIKA DHIR(1ST YEAR RESIDENT) MODERATED BY : DR URMILA KUMARI DHIR HOSPITAL AND POST GRADUATE INSTITUTE OF OPHTHALMOLOGY
- 2. BLOWOUT FRACTURE • Isolated fractures of the orbital walls without involvement of the orbital rim
- 3. CLASSIFICATION PURE BLOW OUT FRACTURE • Orbital rim is intact • Only orbital floor is involved IMPURE BLOW OUT FRACTURE • Orbital rim is not intact • Associated with fracture of medial third of facial skeleton • Severe trauma
- 4. ANATOMY OF ORBIT FORMED BY : • Frontal • Ethmoid • Lacrimal • Palatine • Maxilla • Zygomatic • Sphenoid
- 5. Orbital part of frontal bone ROOF OF ORBIT Lesser wing of sphenoid
- 6. Orbital surface of Maxilla Orbital process of Palatine Orbital surface of Zygoma FLOOR
- 7. Frontal process of maxilla Orbital plate of ethmoid Lacrimal bone Body of sphenoid MEDIAL WALL
- 8. Zygomatic bone Greater wing of sphenoid LATERAL WALL
- 9. • The medial wall (0.2 – 0.4 mm)/ lamina papyracea, is thinner than the orbital floor (0.5 – 1 mm) • Fracture: orbital floor > medial wall • This is related to new theory proposes that ethmoidal conchae-like endoturbinal elements originating from ethmoid lateral wall are folded upon each other, creating pseudo sinus cells • This supports the medial wall
- 10. • COMMONEST SITE OF FRACTURE MEDIAL TO INFRAORBITAL GROOVE
- 11. GENERAL PATHOLOGY Thin floor of orbit(medial to infraorbital neurovascular bundle) BROKEN Piece of this bone displace downward into maxillary sinus Herniated orbital tissue become entrapped Diplopia and oculocadiac reflex Enopthalmos ( In case of Large Displacement)
- 12. MECHANISM 3 MECHANISM HYDRAULIC MECHANISM BUCKLING MECHANISM GLOBE TO WALL MECHANISM
- 13. Blunt trauma to the eye increases the pressure of the orbital contents, which then causes a fracture of the thin and fragile parts of the orbit 1. HYDRAULIC THEORY
- 14. Orbital walls bend in response to impacts to the anterior rim, then get fractured in thinnest area 2. BUCKLING THEORY
- 15. Globe is pushed posteriorly and directly fractures the medial wall and floor 3. GLOBE TO WALL THEORY
- 16. SYMPTOMS • Pain with DOV • Peri orbital edema : in and around the orbit • Diplopia: may be in primary gaze or only in secondary gaze • Numbness over face : in distribution of infraorbital nerve area • Epistaxis : bleeding from maxillary sinus into nose • Inability to move eye : due to edema , muscle and tissue entrapment
- 17. SIGNS • Eyelid signs: ecchymosis and edema of the eyelid • Enophthalmos : when edema decrease , eye ball sinks backward and goes inferiorly – Orbital fat escape into maxillary sinus – Backward traction of globe by entrapped inferior rectus muscle • Emphysema of orbit • Restriction of eye movement • Nausea and/or bradycardia with vertical eye movements - tethering or entrapment of orbital tissue in the fracture • Proptosis : due to associated edema and hemorrhage
- 18. WHITE EYE / TRAP DOOR FRACTURE • Blow out fracture with entrapment of muscle without many sign like ecchymosis, swelling , hemorrhage • Eye is white and quiet even in the presence of fracture • Occur in children as they have flexible bone which snap back and cause entrapment of tissue or muscle
- 19. MANAGEMENT • Visual acuity • Inspection- Edema, Ecchymosis, Enophthalmos • Palpation – Tenderness, Crepitus , Anesthesia in infraorbital region , Continuity of orbital rim • Ocular movement • RAPD • Diplopia charting • Slit lamp examination – Anterior and Posterior segment evaluation • Examination of nose • FDT • IMAGING
- 20. IMAGING 1. FLOOR FRACTURE /ANTRAL BLOW OUT FRACTURE M/C
- 21. GENERAL AND MEDICAL TREATMENT • Avoid nose blowing • Cold compression • Analgesic • Prednisolone - 1.0 mg/kg per day (to subside periorbital and EOM edema • Systemic antibiotic • IVMP in case of traumatic optic neuropathy
- 22. • Minimal diplopia but not present in primary gaze • Good ocular motility • No significant enophthalmos • No significant hypoglobus • • Assess the patient every 3-4 days in first few week • At every visit assess VA, ocular movement , diplopia charting , improvement in orbital displacement , development of enophthalmos OBSERVE
- 23. Functional reasons • Impingement of the soft tissue structure upon or by the fracture • White-eyed blowout fracture • 2X2 cm defect or defects larger than 50% of the wall Aesthetic reasons • Globe malposition • Progressive infraorbital hypoesthesia • Enophthalmos (> 2 mm) • Hypoglobus INDICATION OF SURGERY Immediate repair Repair within 2 week
- 24. AIM of Sx • Permanently close the bony defect • Free entrapped tissue or muscle from the fracture • To give best functional and cosmetic outcome • To prevent late complication – Persistent diplopia – EOM motility restriction – LOV – Disfigurement due to globe malposition
- 25. SURGICAL APPROACHES 1.Subciliary incision 2.Subtarsal 3.Infraorbital 4.Transcaruncular 5. Transconjunctival 6. Transconjunctival with lateral canthotomy Transcutaneous approach
- 26. Advantage • Better cosmosis • Minimum chance of ectropion or lower lid retraction Disadvantage • Corneal abrasion • Symblepharon formation Advantage • Easy to perform • Give wide access to floor of orbit Disadvantage • Ectropion • Lower lid retraction • Visible scarring Transconjunctival approach Transcutaneous approach
- 27. CONTRAINDICATION OF SURGERY • Hyphema • Retinal tears • Globe perforation • Only seeing eye • Medical instability
- 28. COMPLICATIONS Intraoperative • Bleeding • Excessive dissection of the orbit posteriorly • Deep insertion of the implant ,cause impingement on the orbital apex • Retrobulbar hematoma ( resulting in vision loss) Late complications • Ectropion • Persistent postoperative diplopia • Infraorbital nerve dysfunction • Enophthalmos • Hyperglobus
- 29. IMPLANTS IDEAL IMPLANT • Stability and fixation: strong enough to support orbital contents • Contour and handling: easy to shape and fit the orbital defects preserving regional anatomy • No sharp edges that impinge or tether soft tissues • Biologic behaviour: inert (non-allergenic and non-carcinogenic) with low risk of infection, migration, extrusion or inducing foreign body reaction • Cost and availability: Affordable and readily available to patients/surgeon • Biointegrate easily
- 30. TITANIUM IMPLANT
- 31. Advantage • Permanent, Osteointegration • Inert, biologically compatible • Porous (low risk of compartment syndrome) • 1 or 2 wall fractures • Radiologically visible • Various sizes Disadvantage • Permanent: late exposures, late infections (with chronic sinusitis) • Palpability (rim implants with thin overlying soft tissue) • Difficult to remove • Expensive TITANIUM
- 32. Advantage • Time tested • Inert • Tissue integration Disadvantage • Late hematoma, exposure • Radiologically invisible • Risk of compartment syndrome • Expensive POROUS POLYPROPYLENE
- 33. • Infections • Implant migration • Exposure • Palpability • Local inflammatory reaction • serious complications: very rare – Postoperative optic neuropathy – Blindness – Retrobulbar hematoma IMPLANT RELATED COMPLICATION
- 34. 1 THANK YOU
- 35. SURGICAL APPROACHES • Transconjunctival incision • Transcutaneous approach – Subciliary incision – Subtarsal – Infraorbital • Transcaruncular approach : for medial wall fracture • Transconjunctival with lateral canthotomy and cantholysis / swinging eyelid apporach
Editor's Notes
- CHANGE PHOTO
- Bony orbit – quadrangular truncated pyramid + between the anterior cranial fossa above and maxillay sinus below
- Fewer ethmoidal air cell septa / large medial wall area / septum : medial wall > floor fracture
- Emphysema: more with medial wall fracture Made worse by blowing of nose Diplopia on upward gaze is often seen in fractures of the inferior wall due to entrapment of inferior rectus, inferior oblique Epistaxis : bleeding from maxillary sinus into nose
- Emphysema of orbit: Any fracture that extends into a sinus may allow air to escape into the subcutaneous tissues and is commonly associated with fractures of the medial orbital wall. Patients with fractures are advised to avoid nose blowing to prevent orbital emphysema. Oculo-cardiac Reflex: Stretch receptors in ophthalmic nerve are activated in response to pressure in the ocular and periorbital soft tissue leading to stimulation of a vagal response
- Cause of trap door fracture ;Greater bone pliability Thicker periosteum Incompletely fused suture lines
- Tear drop pupil should raise concern for globe rupture
- Analgesic and anti inflammatory – to reduce pain and swelling Systemic antibiotic – to prevent secondary infection IVMP in case of traumatic optic neuropathy
- DIPLOPIA IN AOWN GAZQ OPERATE
- With white-eyed blowout fracture, ischemia can cause permanent damage to the involved EOM with resultant Volkmann contracture of extraocular muscles VC-EOM could also occur in orbital compartment syndrome, in elderly patients who are hypotensive, and in those with small-fracture diplopia [
- ORBITAL RECONSTRUCTION