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1 Orbital Fractures Farhad Fazel, MD. 2 Topics for Discussion  Orbital anatomy  Types of fractures  Signs and symptoms  Management.

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Presentation on theme: "1 Orbital Fractures Farhad Fazel, MD. 2 Topics for Discussion  Orbital anatomy  Types of fractures  Signs and symptoms  Management."— Presentation transcript:

1 1 Orbital Fractures Farhad Fazel, MD

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

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

4 4 Anatomy

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

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

7 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 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 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 10 Common causes of orbital fractures  Falling  Aggression  Sporting events  MVAs

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

12 12 Common Symptoms  Diplopia  Pain with eye movement

13 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 14 Treatment Options  Nonsurgical  Surgical

15 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 16 Absolute Indications for Surgical Repair  Diplopia  Enophthalmos >2 mm  Large fracture

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

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

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

20 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 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 22 Conclusions  Assessment of orbital fractures is an area that requires a high index of suspicion

23 23 MRI

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32 32 Maxillary Fractures Midfacial (LeFort)Fracture

33 33  LeFort Type I  LeFort Type II  LeFort Type III

34 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 35 Maxillary Fractures LeFort Fractures

36 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 37 Maxillary Fractures Management  Intermaxillary Fixation  Open Reduction  LeFort I  Bilateral Buccal Sulcus Incisions  LeFort II and III  Coronal and Lower Eyelid Incisions

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

39 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 40 Naso-Orbital-Ethmoidal Fractures Medial Orbital Wall Fracture

41 41

42 42 Naso-Orbital-Ethmoidal Fractures Classification

43 43 Naso-Orbital-Ethmoidal Fractures

44 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 45

46 Zygomatic fracture Tripod Fracture 46

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

48 48 Tripod Fracture

49 49 Tripod Fracture

50 Sign and Symptoms  Cosmetic deformity  Globe displacement  Diplopia  trismus 50

51 51 Tripod fracture

52 52 Tripod fracture

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

57 57 Forigin body

58 58 Forigin body

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

60 Orbital Orbital Hemorrhage  Trauma or surgery  Spontaneous 60

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

62 62 Orbital hemorrhage

63 63 Canthotomy,cantholysis


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