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Orbital fractures ih
This document discusses orbital fractures, including: - The surgical anatomy of the orbit and boundaries like the lateral wall and medial wall. - Biomechanics, etiology, fracture patterns, and classification of orbital fractures. - Clinical presentation, diagnosis using imaging like CT, and management including complications. - Recent trends involve use of stereolithography models and computer-assisted reconstruction based on cone beam tomography for complex orbital fractures.
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Orbital fractures ih
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- 3. INTODUCTION SURGICALANATOMY BIOMECHANICS OF ORBITAL FRACTURE ETIOLOGY AND EPIDEMIOLOGY FACTURE PATTERN CLASSIFICATION CLINICAL PRESENTATION DIAGNOSIS & IMAGING MANAGEMENT COMPLICATIONS RECENT TRENDS
- 4. Its isa four sided pyramid with its apex at the optic foramina Paired bony cavities, housing and protecting globe. Orbital Growth By 5 yrs - 85% by Puberty - 100%
- 7. BOUNDARIES OFORBIT LATERAL WALL – formed by : a) Anterior surface of greater wing of sphenoid posteriorly. b) Orbital surface of zygomatic bone anteriorly.
- 8. Frontal andzygomatic bone FZ suture - Narrowest and weakest The lateral wall is almost devoid of foramina, so its anterior portion can be broached without serious haemorrhage
- 9. MEDIAL WALL – a)Orbital plate of the ethmoid bone. b) Anteriorly - continues as the lacrimal bone which is weakened by the nasolacrimal canal passing through the fossa. c)Posteriorly – optic foramen in sphenoid bone
- 10. Poorly definedand merges posteriorly with lacrimal bone. Displacement in this region results in deformity of naso orbital valley and displacement of canthal ligament.
- 11. ROOF : Orbital part of frontal bone. Posteriorly - lesser wing of sphenoid The junction of the roof with the medial wall is in close proximity to the cribriform plate of the ethmoid. Penetration of the duramater will allow cerebrospinal fluid to escape into either the orbit or the nose, or both cavities.
- 12. Infraorbital foramento midpoint of inferior orbital fissure : 24mm Anterior lacrimal crest to medial aspect of optic canal :42mm FZ suture to superior orbital fissure : 35mm Supraorbital notch to superior orbital fissure : 40mm Supra orbital notch to superior aspect of optic canal : 45mm
- 13. The lamina papyracea (or orbitallamina) is a smooth, oblong bone plate which forms the lateral surface of the labyrinth of theethmoid bone in the skull. The plate covers in the middle and posterior ethmoidal cells and forms a large part of the medial wall of the orbit.
- 14. It articulatesabove with the orbital plate of the frontal bone, below with the maxilla and the orbital process of palatine bone, in front with the lacrimal, and behind with the sphenoid. Its name lamina papyracea is a literal description, as this part of the ethmoid bone is paper-thin and fractures easily. A fracture here could cause entrapment of the medial rectus muscle.
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- 22. Fractures producedby the limited to the anterior part of Buckling mechanism the orbital floor Hydraulic-type fractures Involving Anterior & Posterior were much larger parts of the Floor as well as the Medial Wall of the Orbit The Average Energy required to fracture the orbital floor BUCKLING MECHANISM - 1.54 J HYDRAULIC MECHANISM - 1.22 J Ahmad, Fateh; et al.. Journal of Craniofacial Surgery. 17(3):438-441, May 2006. 2006 Muntaz B. Habal, MD
- 27. Pure and impure A3-mm downward displacement of the entire floor Orbital volume that is increased by 1.5 cm3 a 5% increase Producing 1-1.5 mm of Enophthalmos 1957 by Smith & Regan
- 28. A blow-infracture is an inwardly displaced fracture of the orbital rim or wall resulting in decreased orbital volume. Described by dingman and natvig in 1964. Antonyshyn et al noted proptosis because of decrease orbital volume in 41 cases.
- 29. CHILDREN UP TO AGE7 ORBITAL ROOF FRACTURE - larger cranium - lack of frontal sinus pneumatization ORBITAL FLOOR FRACTURE Occurs primarily in older Children
- 30. Children areparticularly susceptible to pure orbital fractures of the trapdoor variety . Trapdoor fracture, which first described by Soll and Poley . Occurs when a segment of the bony orbit fractures and becomes displaced, but remains attached on one side. It makes orbitral contents herniated through the fracture sites, which results in entrapment of these herniated contents • Immature bone greater elasticity of the orbital bone
- 32. Superior rim Lateral 3rd ( lacrimal recess) Central 3rd (supraorbital nerve) Medial 3rd (frontal sinus) Inferior rim Central 3rd (infraorbital nerve) Medial 3rd (inferior oblique origin) Rowe and Wiliams Medial rim Medial canthal ligament Lacrimal passage Lateral rim Lateral canthal ligament Suspensory ligament
- 33. Roof Anteriorcranial fossa, superior rectus, frontal sinus. Floor Antrum, inferior rectus/inferior oblque, infraorbital nerves and vessels. Medial wall Ethmoidal sinus, medial rectus, suspensory ligament. Lateral wall Superior orbital fissure and associated structures
- 34. 1. No treatment 2.Indirect reduction with a. no fixation b. temporary support 3. Direct reduction and fixation 4. Immediate reconstruction by grafting 5. Delayed reconstruction by osteotomy or grafting.
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- 37. Lang (1888)– Expanded orbit Bite et al (1985), Manson et al (1986), Whitehouse et al (1994) – Orbital expansion was the primary reason for enophthalmos & not the fat atrophy.. It has been shown that a 0.8–1 ml increase of bony orbital volume corresponds to 1 mm on the Hertel exopthalmometer (Lee & Chiu 1993; Ploder et al. 2002). 37
- 38. Is definedas a retro position of the globe in its three- dimensional relationship in the orbit and should be assessed in relation to the contra lateral eye and facial structures Hertels exophthalmometer is used to determine the degree of enophthalmos more than 3mm is indicative of surgery.
- 39. The effusionof blood into and around extra-ocular muscles interferes with their delicate action required to maintain co-ordination of the eye movement. Binocular – neurogenic injury or restricted motility. Monocular-one eye – detached lens Traumatic diplopia can result by – Physical interference: 1. Extravasation of blood into and around the muscles and oedema 2. Impingement of bony spicules 3. Displacement of the inferior oblique muscle
- 40. Koornneef &Zonneveld found that entrapment of IR ms is not the major cause of diplopia. They found that impaired globe motility is caused by connective tissue derangement inside the orbit Tessier – oculomotor imbalance 40
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- 45. If fractureoccurs above whitnall’s tubercle Bone displaced downwards along with upper eyelid Physical sign - hooding of globe
- 46. Epiphora is anoverflow of tears onto the face. A clinical sign or condition that constitutes insufficient tear film drainage from the eyesin that tears will drain down the face rather than through the nasolacrimal system. Causes of epiphora include ocular irritation and inflammation (including trichiasis and entropion) or an obstructed tear outflow tract which is divided according to its anatomical location .
- 47. Another causecould be poor reconstruction of the nasolacrimal duct system after trauma to the area. Cause of trauma could be facial fractures (including nasoethmoid fractures or maxillary Le Fort fractures), and soft tissue trauma involving the nose and/or the eyelid. This condition is often frustrating or irritating
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- 52. Plain radiography. PNS APskull and PA skull view. Computed Tomography. MRI
- 54. Floor Fracture TrapDoor Fracture
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- 57. History CompleteGeneral Physical Examination Palpation of the Bony walls of the orbit and other associated structures
- 58. Visual acuity Ocular movements Presenceof Diplopia,Exopthalm os or Enopthalmos Ligaments Inter pupilary distance Oedema Circumorbital Ecchymosis Subconjunctival Haemorrhage Orbital Emphysema The Periorbital tissues.Ey e
- 60. Surgery should beperformed within 2 weeks after the edema around the eye has decreased. In children, callus is formed on the bone fracture in 7 days, which makes it difficult to reduce fractures accurately. Hence, facial bone fractures should be operated on earlier in children than in adults.
- 61. 1957 :Converse & Smith – should be corrected ..within 1st three weeks. 1974 : Puttermann – proposed conservative management – if diplopia persists for >4 months do contralateral eye muscle surgery. Dulley & Fells criteria – 2 wks of observation for diplopia with corticosteroids and physiotherapy. Surgical Intervene if enophtholmous >3mm, Diplopia persists, large herniation Dortzbeck - >2mm enopthalmous, Persistent diplopia for >2wks.
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- 65. Ectropion is a medicalcondition in which the lower eyelid turns outwards. It is one of the notable aspects of newborns exhibiting congenital Harlequin-type ichthyosis . can occur due to any weakening of tissue of the lower eyelid. The condition can be repaired surgically.
- 67. Placement of anterior maxillarywall graft Placement of Ballon Catheter
- 71. Titanium Silicone Polyethylene Teflon Bioactive glass implants
- 72. Polydioxanone Polylactide Polyglycolic acid Vicrylmesh - polyglactin-910
- 73. Complex orbital fracturesrequired more than one material for reconstruction. additional bone chips can be introduced to fill up the gaps and to tune projection by comparing the reconstruction with unaffected orbit.
- 74. In terms ofanatomic accuracy , Ti meshes are preferred –over autologous bones grafts, but in terms of function autologous bones grafts are preffered In case of larger defects is often restricted by limited access to the internal orbit and bears the risk of iatrogenic damage to the periorbital tissue.
- 76. Retrobulbar Hemorrhage Superior orbital fissure syndrome Orbital apex syndrome
- 77. Loss of visionas a complication of Maxillo- facial trauma occurs in 3-12% The blindness due to Retrobulbar Haemorrhage 48- 50%
- 78. Proptosis Subconjunctivaledema & ecchymosis Dialating pupil Loss of direct light reflex Opthalmoplegia Increased intraoccular pressure Constriction of retinal arterioles Cherry red macular spot Globe hard on palpation
- 79. Diagnosis and treatmentof Retrobulbar Haematomas following blunt orbit trauma Int J Oral Maxillofac Surg 2005 Mar;34(2):127-31
- 80. Immediate action Remove anysutures in the area, for pressure relief Surgical decompression…. Medication Mannitol 1g/Kg as 20% infusion Osmotic diuretic Contra-indicated in congestive cardiac Failure. Acetazolamide 500mg IV Dexamethasone 8mg Papaverine 40mg smooth muscle relaxant Dextran 40 500mls IV improves perfusion IF NO RESPONSE TILL 48 HRS STEROIDS TO BE DISCONTINUED… Consider Surgical decompression….
- 81. Objective –decompression of orbit. If retro bulbar hemorrhage arises after surgery which involved access to orbital floor, same incisions may be used for evacuation of blood from extra conal space. If this approach is unsuccessful antrum is approached ,any pack on balloon is defected, and roof is inspected for any spicules free of periosteum and it is picked up . After creation of adequate space, suction may be applied.
- 82. For intraconalspace: Incision in placed above and below lateral canthal ligament, dividing the orbital septum – provides access to inter muscular septum between inferior and lateral rectus muscle
- 83. By banksin 1967 An instructive example of precise anatomic localization of a lesion by neurologic sign. SIGN AND SYPTOMS Gross and persistent oedema Proptosis and subconjuctival ecchymosis. Dilation of pupil, ptosis Radiological evidence of reduction in the dimensions of the superior orbital fissure.
- 84. Combination ofsuperior orbital fissure syndrome and optic nerve injury Etiology: bony compression of optic nerve and superior orbital fissure Symptoms: loss of direct light reflex maintenance of consensual reflex
- 86. Fracture types canbe evaluated and repaired endoscopically without the need for an extensive eyelid incision. It offers improved visualization, anatomic fracture repair, no risk of postoperative eyelid complications, and good clinical results. Facial Plast Surg 2004;
- 87. STEREOLITHOGRAPHY Stereolithography is an industrialprocess which uses data generated from computer-assisted design (CAD) to generate three- dimensional models. Journal of Oral and Maxillofacial Surgery Volume 63, Issue 2, February 2005, Pages 200-208
- 88. Computer-assisted reconstruction of orbital floorbased on cone beam tomography bjoms.2005.06.031 Christoph Zizelmann et al.. BJOMS Jan 2007 (Vol. 45, Issue 1, Pages 79-80)
- 89. A straight titaniumplate size 1.0mm to 1.3mm is cut lengthwise to be inserted into one of the channels.
- 90. The implant issized and cut with heavy scissors to fit the defect. The straight plate is inserted into one of the channels.
- 91. The MEDPOR ChannelImplant and straight plate are shaped to conform to the size and configuration of the orbital floor.
- 92. The implant ispositioned on solid bone (if available). It is advanced carefully so as not to pinch or incarcerate orbital soft tissue.
- 93. Once positioned, theplate is cut to the appropriate length so it can be secured to solid bone with a 4, 5, or 6mm screw.
- 94. The screw securesthe plate and the MEDPOR Channel Implant in position.
- 95. Accuracy ofreconstruction is a prerequisite for anatomical positioning of the eye ball in order to prevent functional disorders. The management of orbital fractures and their complications will be benefited from a multidisciplinary approach. Hence the continued relationship between Cranio -Maxillofacial Surgeons, Plastic Surgeons & the Ophthalmic Surgeons, will contribute to the progression of orbital reconstruction techniques.
- 96. Fonseca –Trauma vol 2 Trauma and Esthetic reconstuction – Peter Ward Booth Surgical approaches to facial skeleton – Ellis . Rowe and William’s Maxillofacial Injuries – Vol 1 and 2 -1994 Oral & Maxillofacial Surgery Clinics of North America – Orbital Trauma
- 97. THANK YOU An executiveis a person who always decides; sometimes he decides correctly, but he always decides.
Editor's Notes
- #5 …
- #8 Oculomotor nerve (CN lII) Trochlear nerve (CN IV) Abducens nerve (CN VI) Ophthalmic division of trigeminal nerve Ophthalmic vein
- #9 Infraorbital branch V2 Orbitalis muscle Communication b/w inferior opthalmic vein & pterygoid plexus of vein….1.0 cm below the suture and 3.0 mm inside the rim - impalpable prominence termed the Whitnall orbital tubercle
- #17 e annulus of Zinn, also known as the annular tendon or common tendinous ring, is a ring of fibrous tissue surrounding theoptic nerve at its entrance at the apex of the orbit. It is the origin for four of the seven extraocular muscles, omitting the inferior oblique muscle.[1]
- #18 Intorsion depression and abduction
- #19 extorsion elevation and abduction
- #20 Lateral rectus abduction Medial rectus adduction
- #22 "buckling theory" proposes that the force transmitted through the rigid orbital rim directly to the thin floor , causes the floor to fracture, usually leaving the rim intact. The "retropulsion" theory, advanced by Smith and Regan, refers to a fracture of the orbital floor caused by sudden increase in intra-orbital pressure; a fracture may result from the hydraulic forces generated in the closed orbital cavity. Blows from a fist, for instance, or objects larger than the horizontal diameter of the orbit, are the most frequent cause of this type of fracture
- #25 Classification and epidemiology of orbital fractures diagnosed by computed tomography …Juan Marcelo Reyes, María Fernanda García Vargas, Jonathan Rosenvasser, María Asunción Arocena, Ana Josefina Medina, Jorge Funes
- #28 Pure-orbital rim and other wall remain intaact Impure –concominant fracture of the rim
- #34 Oculomotor nerve (CN lII) Trochlear nerve (CN IV) Abducens nerve (CN VI) Ophthalmic division of trigeminal nerve Ophthalmic vein
- #37 Periorbital tissue Extravasation of blood into and around the muscles and oedema
- #38 Incse in size,decrease in orbital content,and disruption of the ligamentous structure.
- #39 ecchymosis - has a more delayed onset may arise from a fracture in the roof of the orbit or track into the orbit from hemorrhage originating in the anterior
- #40 Is due toorbital floor fracture --- displacement of globe --- disturbance to inferior rectus and inferior oblique muscle.
- #42 (levator and superior tarsal muscles , damage to the superior cervical sympathetic ganglion or damage to thenerve (3rd cranial nerve (oculomotor nerve) Levator resection Müller muscle resection. Eye proptosis is a condition resulting in forward displacement and entrapment of the eye from behind by the eyelids. The condition is also known as eye dislocation and eye luxation. .rapture of rectus muscle
- #43 Medial palpebral ligament is more readily disturbed if the frontal process of maxilla is # and avulsion. Inferior displacement of the bone to which the ligament is attached will result in a mongoloid slant.detachment of medial canthal ligament associated with naso ethmoidal injuries can lead to traumatic telecanthus
- #44 Changes in the inclination of palpebral fissure due to datachment of canthal ligament.
- #45 By pulling the tarsus of lid
- #60 Positive means orbital floor fracture or in trapdoor type injuries
- #62 1984 : Smith – Volkmann’s contracture
- #64 Over inftraorbital rim 4.5 mm inferior to grey line. Transconjuctival-approach through conjuctiva parallel to grey line inferior to tarsal palte. Killian and lynch inscion formedial wall.
- #65 The incision for a subciliary approach is made approximately 2 mm inferior to the lashes, along the entire length of the lid (Fig. 2-13). The incision may be extended laterally approximately 1 to 1,5 cm in a natural crease if more exposure is necessary. Subcutaneous dissection of skin, leaving pretarsal portion of orbicularis muscle attached to the tarsus. Dissection 4 to 6 mm inferiorly in this plane is adequate. Use of scissors to dissect through orbicularis oculi muscle over lateral orbital rim to identify periosteum. Incision through the bridge of orbicularis oculi muscle.
- #67 Placement of incision within confines of eyebrow hair. The incision is made through skin and subcutaneous tissue to the level of the periosteum in one stroke. Incision through periosteum along lateral orbital rim and subperiosteal dissection into lacrimal fossa. Because of the concavity just behind the orbital rim in this area, the periosteal elevator is oriented laterally as dissection proceeds posteriorly.
- #69 The first plate is placed across the frontozygomatic fracture area.We recommend a minimum of a 5-hole plate with one hole spanning the fracture line. The plate should be properly adapted. When looking through the lower eyelid incision, the orbital rim plate should be properly adapted. Use a minimum of a 5-hole plate with the extra hole spanning the fracture line. Some surgeons recommend placement of a plate to reduce and fixate the lateral wall of the orbit between the greater wing of the sphenoid and the zygoma. This helps to guarantee a proper reduction of this fracture. It can only be used if there is no comminution of the lateral wall of the orbit. Placement of this plate is difficult because of necessary globe retraction.
- #72 Do not resorb
- #79 Paralysis or weakness of eye muscles
- #81 Anhydrase inhibitor
- #84 Oculomotor nerve (CN lII) Trochlear nerve (CN IV) Abducens nerve (CN VI) Ophthalmic division of trigeminal nerve Ophthalmic vein
- #90 The MEDPOR Microplate Channel Implant is removed from the sterile package.
- #91 The implant is sized and cut with heavy scissors to fit the defect.
- #92 The MEDPOR Channel Implant and straight plate are shaped to conform to the size and configuration of the orbital floor.
- #93 The implant is positioned on solid bone (if available). It is advanced carefully so as not to pinch or incarcerate orbital soft tissue.
- #94 Once positioned, the plate is cut to the appropriate length so it can be secured to solid bone with a 4, 5, or 6mm screw.
- #95 The screw secures the plate and the MEDPOR Channel Implant in position.