ORBITAL
ORBITAL FRACTURES
FRACTURES
Sehar Uppal
Dept. of Oral and Maxillofacial Surgery
INTRODUCTION
Orbital fractures are unique among cranio-maxillofacial
(CMF) fractures.
fl
Management of orbital fractures poses a challenge to every
surgeon because of its complex anatomy, relationship to vital
structures such as the globe and the brain, and its direct
in uence on the most precious of senses, Vision.
ANATOMY OF THE BONY ORBIT
7 structural layers
•Skin and Subcutaneous Tissue
•Muscles of Protraction
•Orbital Septum
•Orbital Fat
•Muscles of Retraction
•Tarsus
•Conjunctiva
EYE GAZES
CLASSIFICATION
Converse and Smith
1960
(a) Pure (blow-in or blowout fractures) fracture of the internal walls
with intact rims
(b) Impure (complex with involvement of one or more rims) associated
fractures of the rims
CLASSIFICATION
Mason and colleagues
1990
Fractures based on the energy of impact, the degree, and extent of
comminu on and displacement observed on CT:
ti
(a) Trap door fractures
— Low-velocity injuries
(b) Medial blowout fractures — Intermediate-velocity injuries
(c) Lateral blowout fractures — High-velocity fractures
CLASSIFICATION
Hammer 1995
Fractures based on their occurrence with other fractures of the face:
ti
(a) Type I: Orbito-zygoma c fractures
(b) Type II: Internal orbital fractures
(c) Type III: Naso-orbito-ethmoid-type fractures
(d) Type IV: Complex fractures of the face
CLASSIFICATION
Hammer 1995
Fractures based on their occurrence with other
fractures of the face:
ti
(a) Type I: Orbito-zygoma c fractures
(b) Type II: Internal orbital fractures
(c) Type III: Naso-orbito-ethmoid-type fractures
(d) Type IV: Complex fractures of the face
CLASSIFICATION
Rowe and Williams
•ISOLATED FRACTURES OF THE ORBITAL RIM :
1. Superior rim
2. Inferior rim
3. Medial rim
4. Lateral rim
• COMPLEX COMMINUTED FRACTURES :
1. Naso-ethmoidal fractures
2. Fronto-naso-orbital fractures
Rowe and Williams
ISOLATED ORBITAL WALL FRACTURE
fi
ROOF
a)Anterior cranial fossa
b)Levator palpebrae superioris/superior rectus
c)Frontal sinus
FLOOR
a)Antrum
b)Infra-orbital nerves and vessels
c)Inferior rectus/inferior oblique
MEDIAL WALL
a)Lacrimal sac and naso-lacrimal canal
b)Ethmoidal sinus
c)Medial rectus
d)Suspensory ligament
LATERAL WALL
Superior orbital ssure and associated structures
PATHOPHYSIOLOGY
In the event of trauma
Thick rims protect the eyeball
Absorb shock by fracturing themselves
Orbital walls (esp. medial and oor) fracture in an isolated way
Get displaced outwards or inwards
fl
Blow-in / Blow-out Fracture
BLOW-OUT FRACTURES
MECHANISM OF INJURY
HYDRAULIC
THEORY
globe-to-wall theory
BUCKLING
THEORY
THE HYDRAULIC THEORY
First described by Pfeiffer in 1943
Hydrostatic pressure within the globe
or orbital contents is transmitted to
the orbital walls.
When there is a direct trauma to the
globe (eye), it causes a sudden
increase in the intraorbital pressure.
This increased pressure then causes a
fracture of the weakest point of the
orbit, which is usually the orbital floor
or the medial wall.
THE BUCKLING THEORY
Impact against the sturdy
orbital rim transmits force
to the more fragile orbital
walls, resulting in a
blowout fracture
Blow-out fractures can be classified into two broad categories
OPEN DOOR
TRAP DOOR
Trap-door
Open-door
EFFECTS OF BLOW-OUT FRACTURE
BLOW-IN FRACTURES
•Dingman and Natvig in 1964
•Fragmented bones of the orbital oor are displaced into
the orbit.
•Proptosis , Exopthalmos and diplopia are common
•Other unusual ndings are1. Rupture of the globe
2. Superior orbital ssure syndrome
3. op c nerve injury.
fl
fi
fi
ti
•More commonly seen in fractures of – orbital roof
CLINICAL EXAMINATION
• Periorbital Examina on
ti
ti
ti
ti
ti
ti
ti
• Ini al Opthalmological evalua on
• Visual acuity — SNELLEN CHART
• Ocular mo lity — FORCED DUCTION TEST & HESS CHART
• Pupillary examina on — SWINGING FLASH LIGHT TEST — pupillary size, shape & symmetry,
light reac vity
• Fundoscopic examina on- TONOMETRY – to assess Intraocular pressure (Normal
10-20mmHg) <30mmhg
•HERTEL EXOPTHALMOMETER – measure exopthalmous
RADIOLOGICAL INVESTIGATIONS
• Conventional radiographs have a minimal role
• CT scans -- ordered in fine cuts of 0.5 mm : all the three planes - “gold standard”
• Coronal and sagittal scans - # of floor and roof,
• Axial scans-- # of medial and lateral walls and to study optic canal integrity.
• CT imaging is critical in diagnosis of enophthalmos (# <2mm).
MRI Scan –
Limited to determining soft tissue injuries
• Entrapment of muscles and to assessing damage to the optic nerve.
• To identify intra-orbital herniation of brain in the case of blow-in #.
CLINICAL FEATURES
•Circumorbital Edema and ecchymosis
•Subconjunctival haemorrhage – due to fracture → subperiosteal bleeding →
escapes in subconjuctival plane.
•Enopthalmous
•Subcutaneous emphysema with crepitus
•Contusions and hematomas
•Lacerations involving the eyelids
•Unilateral Epistaxis – bleeding into antrum
•Injuries to the canthal apparatus (medial and lateral)
•Numbness in area of distribution of Infraorbital Nerve and facial nerve.
•Diplopia
ENOPHTHALMOS
Caused by• Lateral and inferior displacement of the zygoma
• Disruption of the inferior, medial, and/or lateral orbital walls
• Decrease in orbital soft tissue volume by herniation of orbital soft tissue
• Dislocation of trochlear attachment of superior oblique muscle.
• Diagnosis should be made after the swelling has dissipated.
• Clinically, suprapalpebral fold and reduced projection on viewing from an
inferior view or worm’s view, causing pseudoptosis of the upper lid.
•Hypophthalmos is noted as a change in the horizontal pupillary levels.
DIPLOPIA
• Greek word Diplous - Double and Ops – Eye
• Double vision
• Eyes are normally positioned so that image falls exactly on the same
spot on the retina of each eye.
• Slightest displacement of either eye causes DIPLOPIA as the image is
shifted to a different position on the retina of the displaced eye.
TYPES OF DIPLOPIA
Monocular
Diplopia
Binocular
Diplopia
• Monocular diplopia, (15%)
• Usually indicates a detached lens, hyphema, or other traumatic injury to the globe.
- There is distortion with the light path through the eye (typically an eye issue)
• Binocular diplopia, (85%)
• Approx. 10% to 40% of zygomatic injuries.
TRAUMATIC DIPLOPIA
1. Physical interference
a) Extravasation of blood into and around the muscles
b) Impingement of bone spicules
c) Displacement of the bony origin (e.g. inferior oblique)
d) Avulsion from the bony origin including displacement of the
pulley of the superior oblique
e) Entrapment of muscle within the fracture line
f) Incarceration of periorbital fat in a bony defect
g) Formation of fibrous adhesions between the muscle sheath,
periorbital fat or the periosteum and the margins of the defect.
2. Physiological imbalance
This is due to the muscles acting at a mechanical disadvantage
following displacement of the globe
3. Neurological deficits
a) Supra-nuclear (impairment of co-ordinated movements)
b) Nuclear lesions
c) Infra-nuclear and intra-cranial injury
d) Cavernous sinus compression (A/V fistula)
e) Superior orbital fissure contusion
f) Intra-orbital damage
ANALYSIS OF DIPLOPIA
Rules governing the relationship of two images
• RULE 1- displacement of the false image
-may be horizontal or vertical or both
• RULE 2- separation of the 2 images is greatest in the direction in
which the weak muscle has its purest action
• RULE 3- False image is displaced furthest in the direction in which the
weak muscle should move the eye
Tests for Diplopia
1. Hirschberg Test
2. Maddox rod assessment of ocular assessment
3.Cover Test
Two types : Alternating cover test
Unilateral cover test
( cover-uncover test )
Lazy eye will deviate inward and outward
Retrobulbar
Hemorrhage
Lacrimal System Injuries
•Injury to the canaliculi or the nasolacrimal ducts in naso-orbito-ethmoidal
injuries may present as epiphora.
•Patency of the naso-lacrimal duct and sac can be verified by jones test 1 and 2
or by a simple lacrimal probing test with insertion of a Crawford silicone
intubation tubes though the canaliculi and visualization of the same at the distal
end of the disruption.
•ROPLAS test or regurgitation on pressure over lacrimal sac may be performed
clinically to elicit posttraumatic blockage of the nasolacrimal duct .
•Confirmation with a CT dacrocystogram
•Reconstruction of the lacrimal drainage system is achieved by simple
intubations or a formal dacryocystorhinostomy
APPROACHES TO THE
ORBIT
LOWER EYELID
1.Transcutaneous
2.Transconjunctival
TRANSCUTANEOUS LOWER EYELID
APPROACHES
 Converse in 1944
SUB-CILIARY INCISION
by Converse
the year 1944
 Given
Incision
approxin2mm
It involves an incision made 2 mm just
below the lash line over the tarsal
plate.
 Skin undermined
Extended Lower Eyelid Approach
Extended Lateral Exposure with the Subciliary Approach
Subtarsal Approach
Initially described by Converse, the subtarsal approach is similar to the
subciliary approach, but it has shown to result in fewer complications and has
acceptable esthetics
Subtarsal Approach (CONVERSE)
Identification and Marking of the Incision Line
Suborbicularis Dissection
Skin Incision
fl
Subtarsal approach used to access a fracture of the infraorbital rim and oor
Infra-orbital Rim Approach
Relative indications : conjunctival or orbital pathology
A hypertrophic orbicularis oculi muscle
Preexisting laceration of the infraorbital rim
Persistent globe edema
Presence of globe prosthesis
An unstable globe or corneal injury.
Given the unsightly scar associated with the infraorbital incision and other
available less morbid approaches to the orbit, however, it should be rarely
used.
The incision is marked in at the level of the infraorbital rim margin in a minor skin
crease that is present at the transition of the thin eyelid and thick cheek skin
An incision is then made through skin, and then preorbital orbicularis oculi muscle
Dissection should take placed
down to the preorbital
periosteum.
The periosteum begins to blend
with orbital septum 1 to 2 mm
inferior to the infraorbital rim and
the periosteal incision should be
placed just below this transition
point.
Trans-conjunctival Incision
Vasoconstriction
inferior cantholysis
Corneal shield and traction sutures
lateral canthotomy
dissection in the subconjunctival plane.
Transconjunctival lncision
Periosteal incision
Closure of conjunctiva and inferior canthopexy.
Subperiosteal Orbital Dissection
Skin sutured
Trans-caruncular Approach
Transconjunctival Incision
Subconjunctival Dissection
Exposure of medial wall
Periosteal Incision
UPPER EYELID APPROACH A.K.A. BLEPHAROPLASTY INCISION
In this approach, a natural skin crease in the upper
eyelid is used to make the incision
The incision should begin at least 10 mm superior
to the upper lid margin and be 6 mm above the
lateral canthus as it extends laterally.
The dissection is carried over the orbital rim,
exposing periosteum. The skin-muscle flap is
retracted until the area of interest is exposed.
The periosteum is divided 2 to 3 mm posterior to
the orbital rim with a scalpel.
Trans-antral
Endoscopic-Assisted
Approach
(converse and Smith)
Supraorbital/Lateral Brow Incision
• Entry to the antrum is gained through a transoral Caldwell Luc procedure
• a 0° or 30° endoscope may be used to visualize the orbital floor.
(a) Lateral brow incision
(b) Lateral brow extension
Tarsorrhaphy
Corneal shield
Treatment Planning and Management of Orbital Fractures
Hammer’s classification
• Type I (Orbito-Zygomatic)- ORIF of the zygomatic complex
first, followed by internal orbital
reconstruction.
Type II (Internal Orbital)
1. Fractures of the Orbital Roof-
• Less than 10% may need any form of
surgical intervention.
• Most are amenable to conservative
management with observation and
follow-up of neurological and ophthalmic
status.
Symptoms • Dural tears,
• CSF leak,
• tension pneumocephalus,
• diffuse cerebral edema,
• contusions of the frontal lobe
(a)
(b)
(c)
(d)
Blow-in fracture,
Blow-out fracture,
Fracture of the supraorbital rim,
Fronto-basilar fracture
Indications for intervention•CSF leak
•Displaced intra cranial fragments
•Compromised vision
•Mechanical impediments
•significant enophthalmos or exophthalmos.
Choice of material -Titanium meshes
-Porous polyethylene implants fixed with micro-screws
-Split Calvarial grafts
2. Fractures of the Lateral Orbital Wall• Restoration of the architecture or augmentation of the same ensures
correction of enophthalmos.
Reconstruction(i) Alloplasts - titanium meshes,
- porous polyethylene sheets
- custom-made polyether ether ketone (PEEK ) implants
(ii) Bone grafts calvarium or ilium
3. Medial Wall Fractures
Incidence - 5–71% ; isolated fractures –rare
Indications –
1. Restriction of ocular motility
2. Diplopia
3. Enophthalmos
Choice of material –
1 Bioactive resorbable sheets
2 Titanium mesh
4. Orbital Floor Fractures
The internal orbit is
divided into three zones
which helps in
evaluating the difficulty
of approach and
exposure:
(i) Anterior third
(ii) Middle third
(iii) Dorsal third
Absolute Indications1. Enophthalmos and/or hypophthalmos
2. Severe restriction of ocular motility
3. “White eye blowout”
Relative Indications 1. Defect is larger than 50% of the orbital floor area or greater than 20 × 20 mm of defect
size especially in the zone between the floor and the medial wall
2. Diplopia which is non-resolving and persistent for more than 2 weeks due to entrapment
or fibrosis of orbital soft tissue
Relative Contraindications1. Associated ophthalmic injuries like retinal tears, hyphema, displacement of lens,
ruptured globe, avulsion injuries of the globe, etc.
2. Loss of vision in one eye with the only seeing eye involved in a fracture
Graphical representation of the equator of the
globe (E) and the associated equatorial (A)
and post-equatorial (B) zones of the foor
Type III NOE Fractures
The Key Elements for Managing Type III Fractures
•Management of the medial canthal tendon (MCT) as indicated with
the focus being the attachment or avulsion of the medial canthal
tendon (MCT) to the fracture fragment
•Management of the soft tissue drape after reposition of the MCT
•Restoration of the nasal dorsum projection
•Evaluation of injuriThe Key Elements for Managing Type III
Fractures to the lacrimal system: canaliculi, sac and the
nasolacrimal duct (NLD), and its management
Type IV (Complex Fractures of the Face with Orbital Fractures)
• This type includes all the combinations of the fractures of the face.
• Sequencing and fixation of all facial fractures need to be completed
prior to the reconstruction of the internal orbit.
ComplicationsThe most common immediate complications that are secondary to orbital surgery
include:
• Edema
• Infection
• Would dehiscence
• Aberrant implant position
• Extrusion of implants
• Hemorrhage
• Blindness – rare
• Paraesthesia or dysesthesia
Delayed complication may present in the form of:
• Persistent enophthalmos/hypophthalmos
• Persistent or worsened diplopia with altered vision
• Restricted ocular movement due to fibrosis and adhesion.
Other adverse outcomes include:
• Entropion
• Ectropion
• Hypertrophic scars/keloids
• Change in the axis of the palpebral fissure
Recent Advances in Management of Orbital Fractures
1. Computer-assisted surgery
2. Intraoperative imaging and navigation
3. Patient-specifc implants for reconstruction
Conclusion
-All patients with orbital trauma need to be subjected to ophthalmological
examinations both pre and post-surgery.
-Globe protection, gentle retraction of tissues, and intraoperative testing for
vision are mandatory during orbital surgery.
ORBITAL
THANK YOU
FRACTURES