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Orbital Fractures Farhad Fazel, MD.

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Presentation on theme: "Orbital Fractures Farhad Fazel, MD."— Presentation transcript:

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 Enophthalmos – backward displacement of eyeball into orbit

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 Infracilliary incsion or high eyelid incision Dissection if plane between orbicularis fibers and orbital septum Dissection continues to anterior wall of maxilla Skin-muscle flap this raised Infraoribital incision is then made Periosteum elevated from floor of orbit Soft tissues elevated from defect Bony trap door deformity reduced Fracture then reinformced with Merlex mesh

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

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32 Midfacial (LeFort)Fracture
Maxillary Fractures Midfacial (LeFort)Fracture

33 LeFort Type I LeFort Type II LeFort Type III

34 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)

35 Maxillary Fractures LeFort Fractures

36 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

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

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

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

40 Naso-Orbital-Ethmoidal Fractures
Medial Orbital Wall Fracture

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42 Naso-Orbital-Ethmoidal Fractures Classification

43 Naso-Orbital-Ethmoidal Fractures

44 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

45 Management Miniplate stabilisation

46 Zygomatic fracture Tripod Fracture

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

48 Tripod Fracture

49 Tripod Fracture

50 Sign and Symptoms Cosmetic deformity Globe displacement Diplopia
trismus

51 Tripod fracture

52 Tripod fracture

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56 Intraorbital Foreign Bodies
Plain film x-ray CT scan MRI(not in ferromagnetics)

57 Forigin body

58 Forigin body

59 FB management Vegetable matter must removed
Anterior easy access must removed

60 Orbital Orbital Hemorrhage
Trauma or surgery Spontaneous

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

62 Orbital hemorrhage

63 Canthotomy,cantholysis


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