Orbital Fractures Farhad Fazel MD 1 Topics for

Orbital Fractures Farhad Fazel, MD 1

$Topics for Discussion ® Orbital anatomy ® Types of fractures ® Signs and symptoms$

Topics for Discussion ® Orbital anatomy ® Types of fractures ® Signs and symptoms ® Management 2

Bony Orbit ® Seven bones form the bony orbit ® Maxilla ® Zygoma ® Lacrimal ® Ethmoid ® Palantine ® Sphenoid ® Frontal 3

Anatomy 4

® Physical Exam ® Inspection ® Palpation ® Ophthalmologic exam Vision ® Extraocular movements ® Forced ductions ® Exophthalmometry ® Internal exam ® 5

Emergency Management A - Airway B - Breathing C - Circulation / Hemorrhage 6

$Blowout Fractures of Orbit ® Originally defined as orbital floor fractures without fracture orbital$

Blowout Fractures of Orbit ® Originally defined as orbital floor fractures without fracture orbital rim, but with entrapment one or more soft tissue structures 7

$Blowout Fractures ® Blowout the: fractures now refer to fractures of Orbital floor ®$

Blowout Fractures ® Blowout the: fractures now refer to fractures of Orbital floor ® Medical wall ® Lateral wall ® Superior wall ® ® “pure” blowout fractures – trapdoor rotation to bone fragments involving central area of bone ® “impure” fracture – fracture line extends to orbital rim 8

Physiology of Blowout Fracture ® The bony defect is filled with soft tissue and fat from the orbit ® Alters support mechanisms for EOM ® EOM can become entrapped ® Direct muscle damage can result 9

$Common causes of orbital fractures ® Falling ® Aggression ® Sporting events ® MVAs$

Common causes of orbital fractures ® Falling ® Aggression ® Sporting events ® MVAs 10

Common physical signs ® Periorbital eccyhmosis ® Impaired extraocular muscles ® Hypoesthesia in V 2 distribution ® Intraorbital emphysema ® Enophthalmos and ptosis 11

Common Symptoms ® Diplopia ® Pain with eye movement 12

$Injuries associated with blow out fractures ® Ruptured globe ® Retroorbital hemorrhage ® Vitreous$

Injuries associated with blow out fractures ® Ruptured globe ® Retroorbital hemorrhage ® Vitreous hemorrhage ® Hyphema ® Anterior chamber angle recession ® Dislocated lens ® Secondary glaucoma ® Retinal detachment 13

Treatment Options ® Nonsurgical ® Surgical 14

Initial Management ® Ice affected area for 48 hours ® Elevation HOB ® Use of nasal decongestants ® Broad spectrum antibiotics like Augmentin ® Oral steroids to prevent fibrosis ® No ASA ® No nose blowing 15

$Absolute Indications for Surgical Repair ® Diplopia ® Enophthalmos ® Large >2 mm fracture$

Absolute Indications for Surgical Repair ® Diplopia ® Enophthalmos ® Large >2 mm fracture 16

Contraindications to surgery ® Hyphema ® Retinal detachment ® Globe perforation ® Only seeing eye ® Medically unstable patient 17

Timing of Surgery ® Usually seven to ten days after trauma 18

Surgical Approaches ® Transconjunctival approach ® Transcutaneous ® Subciliary ® Trasantral 19

$Surgical procedures for orbital floor fractures ® Incision ® Subtarsal dissection ® Skin-muscle flap$

Surgical procedures for orbital floor fractures ® Incision ® Subtarsal dissection ® Skin-muscle flap ® Incision of maxilla ® Floor dissection ® Placement of Marlex mesh ® Periosteal closure ® Skin closure 20

Orbital Implants ® Use of implants based on degree of comminution and size of fracture ® Various implant material used ® Autogenous bone and cartilage ® Alloplastic material Teflon ® Marlex ® PDS ® Etc. ® 21

$Conclusions ® Assessment of orbital fractures is an area that requires a high index$

Conclusions ® Assessment of orbital fractures is an area that requires a high index of suspicion 22

MRI 23

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Maxillary Fractures Midfacial (Le. Fort)Fracture 32

® Le. Fort Type III 33

® Le Fort I - tooth bearing portion separated from upper maxilla ® Le Fort II - fracture across orbital floor and nasal bridge (pyramidal fracture) ® Le Fort III - fracture across frontozygomatic suture line, entire orbit and nasal bridge (craniofacial separation) 34

Maxillary Fractures Le. Fort Fractures 35

Maxillary Fractures Examination and Diagnosis ® Epistaxis ® Ecchymosis (periorbital, conjunctival, and scleral) ® Malocclusion With Anterior Open Bite ® Buccal Mucosa Hematoma ® Tear in Intraoral Soft Tissues ® Elongated, Retruded Appearance ® “Donkey-Like” Facies ® CSF Leak in 25 -50% of Le. Fort II and III 36

Maxillary Fractures Management ® Intermaxillary Fixation ® Open Reduction ® Le. Fort ® Bilateral Buccal Sulcus Incisions ® Le. Fort ® I II and III Coronal and Lower Eyelid Incisions 37

Maxillary Fractures Management ® Goals re-establish midfacial height and projection ® establish occlusal relationship ® maintain integrity of nose and orbits ® 38

Maxillary Fractures Management ® Rigid Internal Fixation Frontal Bone as a Guide ® Mandibuar Ramus Dictates Facial Height ® Stabilize Vertical Buttresses ® Bone Grafts If Necessary ® 39

Naso-Orbital-Ethmoidal Fractures Medial Orbital Wall Fracture 40

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Naso-Orbital-Ethmoidal Fractures Classification 42

Naso-Orbital-Ethmoidal Fractures 43

Naso-Orbital-Ethmoidal Fractures Physical Exam ® Flat nose ® Swollen medial canthal area ® Telecanthus (12 -20%) ® Lack of skeletal support on palpation of nose ® CSF leak ® Positive eyelid traction test 44