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Orbital Fractures

Orbital Fractures. Farhad Fazel, MD. Topics for Discussion. Orbital anatomy Types of fractures Signs and symptoms Management. Bony Orbit. Seven bones form the bony orbit Maxilla Zygoma Lacrimal Ethmoid Palantine Sphenoid Frontal. Anatomy. Physical Exam Inspection Palpation

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Orbital Fractures

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  1. Orbital Fractures Farhad Fazel, MD

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

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

  4. Anatomy

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

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

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

  8. Blowout Fractures • Blowout fractures now refer to fractures of the: • 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

  9. 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

  10. Common causes of orbital fractures • Falling • Aggression • Sporting events • MVAs

  11. Common physical signs • Periorbital eccyhmosis • Impaired extraocular muscles • Hypoesthesia in V2 distribution • Intraorbital emphysema • Enophthalmos and ptosis

  12. Common Symptoms • Diplopia • Pain with eye movement

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

  14. Treatment Options • Nonsurgical • Surgical

  15. 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

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

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

  18. Timing of Surgery • Usually seven to ten days after trauma

  19. Surgical Approaches • Transconjunctival approach • Transcutaneous • Subciliary • Trasantral

  20. 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

  21. 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.

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

  23. MRI

  24. Maxillary Fractures Midfacial (LeFort)Fracture

  25. LeFort Type I • LeFort Type II • LeFort Type III

  26. 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)

  27. Maxillary FracturesLeFort Fractures

  28. Maxillary FracturesExamination 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 LeFort II and III

  29. Maxillary FracturesManagement • Intermaxillary Fixation • Open Reduction • LeFort I • Bilateral Buccal Sulcus Incisions • LeFort II and III • Coronal and Lower Eyelid Incisions

  30. Maxillary FracturesManagement • Goals • re-establish midfacial height and projection • establish occlusal relationship • maintain integrity of nose and orbits

  31. Maxillary FracturesManagement • Rigid Internal Fixation • Frontal Bone as a Guide • Mandibuar Ramus Dictates Facial Height • Stabilize Vertical Buttresses • Bone Grafts If Necessary

  32. Naso-Orbital-Ethmoidal Fractures Medial Orbital Wall Fracture

  33. Naso-Orbital-Ethmoidal FracturesClassification

  34. Naso-Orbital-Ethmoidal Fractures

  35. Naso-Orbital-Ethmoidal FracturesPhysical Exam • Flat nose • Swollen medial canthal area • Telecanthus (12-20%) • Lack of skeletal support on palpation of nose • CSF leak • Positive eyelid traction test

  36. Management • Miniplate stabilisation

  37. Zygomatic fracture Tripod Fracture

  38. Tripod Fracture • Lateral rim • Inferior rim • Zygomatic arch • Lateral wall of maxillary sinuses

  39. Tripod Fracture

  40. Tripod Fracture

  41. Sign and Symptoms • Cosmetic deformity • Globe displacement • Diplopia • trismus

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