Orbital Fractures

Farhad Fazel, MD

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Topics for Discussion
Orbitalanatomy
Types of fractures
Signs and symptoms
Management

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

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Anatomy

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 Physical Exam
Inspection

Palpation

Ophthalmologic exam
Vision
Extraocular movements

Forced ductions

Exophthalmometry

Internal exam

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Emergency Management

A - Airway
B - Breathing
C - Circulation / Hemorrhage

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

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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

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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

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Common causes of orbital
fractures
Falling
Aggression
Sporting events
MVAs

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

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Common Symptoms
Diplopia
Pain with eye movement

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

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Treatment Options
Nonsurgical
Surgical

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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

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

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Contraindications to surgery
Hyphema
Retinaldetachment
Globe perforation
Only seeing eye
Medically unstable patient

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Timing of Surgery
Usually seven to ten days after trauma

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Surgical Approaches
Transconjunctival approach
Transcutaneous
Subciliary
Trasantral

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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

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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.

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

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MRI

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Maxillary Fractures
Midfacial (LeFort)Fracture

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 LeFort Type I

LeFort Type II

LeFort Type III

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 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)

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Maxillary Fractures
LeFort Fractures

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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 LeFort II and III
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Maxillary Fractures
Management
Intermaxillary
Fixation
Open Reduction
LeFort I
Bilateral Buccal Sulcus Incisions
LeFort II and III
Coronal and Lower Eyelid Incisions

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

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Maxillary Fractures
Management
Rigid Internal
Fixation
Frontal Bone as a
Guide
Mandibuar Ramus
Dictates Facial
Height
Stabilize Vertical
Buttresses
Bone Grafts If
Necessary
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Naso-Orbital-Ethmoidal
Fractures
Medial Orbital Wall Fracture

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Naso-Orbital-Ethmoidal Fractures
Classification

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Naso-Orbital-Ethmoidal
Fractures

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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

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Management
Miniplate stabilisation

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Zygomatic fracture

Tripod Fracture

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Tripod Fracture
Lateral rim
Inferior rim
Zygomatic arch
Lateral wall of maxillary sinuses

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Tripod Fracture

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Tripod Fracture

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Sign and Symptoms
Cosmetic deformity
Globe displacement
Diplopia
trismus

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Tripod fracture

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Tripod fracture

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Intraorbital Foreign Bodies
Plainfilm x-ray
CT scan
MRI(not in ferromagnetics)

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Forigin body

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Forigin body

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FB management
Vegetable matter must removed
Anterior easy access must removed

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Orbital Hemorrhage
Trauma or surgery
Spontaneous

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Retrobulbar
Hemorrhage(management)
Canthatomy and cantholysis if nerve
compression ,altered arterial
perfusion,hematic cyst.

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Orbital hemorrhage

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Canthotomy,cantholysis

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