orbital floor fractures1

Types of orbital injuries

Blow out fracture

soft tissue injury

supraorbital fracture

naso-orbital fracture

zygoma fracture

What is a blow out fracture

• The orbit is hit & forces soft tissue content backwards without rupturing globe

• Rise in IOP fractures orbital walls - medial & orbital wall

• Males more than F - assault, road traffic port work related

Types of blow out fracture

Pure

• trap door

• linear

• hanging

• hinged bone crack

• Depressed

or combination

Impure

• Orbital rim is involved

Blow out fracture mechanism

• limitation of OM = direct entrapment & damage to EOM - commonly IR

• =entrapment of orbital fascia, septum, connective tissue & muscle pulley

CH

• Signs inc

  • Periorbital echhymosis

  • surgical emphysema

  • enophathalmos

  • depression of globe

  • traumatic mydriasis

  • sub conjunctival haemorrhage

  • hyphaema

  • facial asymmetry

• symptoms inc

  • diplopia - vertical

  • infraorbital anesthesia - from damage from the infraorbital nerve = loss of sensation of ipsilatral cheek and upper gum

  • pain on eye movement

VA & AHP

VA - can slightly reduce = hyphaema

AHP - Chin elevation/ depression

Maybe face turn for medial wall fractures

CT

CT with & without AHP

• hypotropia - entrapment of tissue anterior = limitation in elevation

• hypertropia - entrapment of tissue posterior = limitation of depression

OM

• Enophthalmos

• limitation in elevation & depression with orbital floor fractures

• limited abduction & adduction = medial wall fracture

• Retraction of globe position of maximum limitation

• Diplopia may swap depending position of gaze

• infraorbital anesthesia = damage or bruising to infraorbital nerve = numbing of nerve i.e cheeck, upper lps - side of nose

Hess chart

field of binoc single vision

Diplopia reverses w limitations in opposite position of gaze

• good binoc in pp w AHP = limitation in opposite direction of gaze

• examine fundus & media to check globe has been damaged or retinal detachment, vitreous detachment subluxed lens & optic nerve patency

• X-ray, CT, tomography to see point of fracture

• measure IOP if hyphaema

• FDT - mech/neuro

• Enophthalmos - exophthalmos

• measure saccadic velocity

mx

• wait for recovery wait apprx 14 days

• younger pts responded poorly than older pts due to faster formation of fibrous scar tissue in young pts

• pts w fractures involving alot of orbital floor be operated early

• soft tissue thats damaged when trapped between bone fragment = fibrosis & tethering of globe

• antibiotics & prednisolone help ↓ infection & inflammation

treatment options orbital injuries

• observation

• conventional treatments - prisms, exercises & occlusion

• surgical

indications for surgery - dulley & fells

• Diplopia not resolving

• enophthalmos >3mm

• large fracture

• incarceration of tissues w globe restriction

• IOP increase on upgaze

aims of surgery

• free trapped tissue & repair fracture site

• correct strabismus

Le fort classification

Le Fort type I

• Tooth bearing portion separated from upper maxilla

  

  Le Fort type II (pyramidal fracture)

  Fracture across orbital floor and nasal bridge (involves medial wall

  and floor)

  

  Le Fort type III (craniofacial separation)

  • Fracture across fronto-zygomatic suture line, entire orbit and nasal

    bridge (involves floor, medial and lateral walls

    
    
    
    

    

soft tissue injury

• due to trauma to orbital area - not causing fracture of any bone = damage to orbital area

  • muscle damage

  • lacerations

  • damage to nerve supply to EOMS

  • hemorrhage = limitations of movement & proptosis

lid injuries inc

• lid lacerations

• injuries involving lacrimal canal

• swelling & pseudoptosis

• levator damage with traumatic ptosis

ocular signs

• sub conjunctival haem

• corneal abrasions

• lens dislocation

• damage to iris with traumatic mydriasis

• hyphaema

• retinal detachment

• optic nerve damage

• choroidal ruptures

Supraorbital fracture

• sharp object going through orbital roof

  • characteristics

    • superior periorbital swelling & haem

    • lid oedema

    • supraorbital anesthesia

    • damage to levator and nerve supply

    • diplopia due to muscle damage

    • depression of supraorbital rim = globe retraction

    • CSF fluid discharge

naso orbital fracture

• direct trauma to naso orbital area

  • due to road traffic

• charactristics

  • dish face appareence

  • oedema & bruising

  • epistaxis

  • nasal obstruction

  • surgical emphysema

  • damage to tear duct and lacrimal sac

zygoma fracture

• bone displaced outwards = traumatic enophthalmos = swelling

• bone displaced inward = traumatic proptosis

characteristics

• muscle or nerve damage

• oedema - impair OM

• infra orbital anesthesia

white eye

• IR caught in trap door orbital floor fracture

• urgent surgical to prevent ischemic muscle damage

• Painful restriction of eye movement. 

• Double vision (diplopia). 

• Enophthalmos (a sunken appearance of the eye). 

• Autonomic symptoms like nausea and vomiting

• lack of significant soft tissue trauma (like bruising or swelling) around the eye, despite the presence of a fracture and potential muscle entrapment

A: Types of orbital fractures include:

• Pure fracture: Only the orbital floor is fractured

• Impure fracture: Involves the orbital rim

• Other types: Blow-out fractures - orbital floor, medial wall, or both

• naso-orbital fractures, orbital roof fractures, and zygomatic fractures

Q: What types of fractures are common in pediatrics?

• Depressed fractures: A detached bone piece

• Trapdoor fractures: A fracture where bone swings but doesn't fully detach

• Linear fractures: Bone breaks and closes, trapping tissue (greenstick fractures)

What is the hydraulic mechanism in blow-out fractures?

buckling

hydraulic mechanism= increase IOP = Blunt trauma pushes the globe back, causing the orbital floor or medial wall to fracture.

buckling

• They're a compression fracture, which means the break is caused by sudden pressure on a bone.

Blow-out (Smith & Regan 1957) - hydraulic

Q: What are common causes of blow-out fractures?

: Common causes include blunt trauma from sports, road traffic accidents, and assaults. These are most common in males in their 20s/30s.

Q: What are the eye symptoms associated with orbital fractures?

• Diplopia (double vision)

• Restriction in eye movement (due to muscle entrapment)

• Enophthalmos (sunken eye)

• Infraorbital anesthesia (tingling or loss of sensation)

Q: What deviations can occur with orbital fractures?

: Deviations can include hypotropia (downward deviation) or hypertropia (upward deviation) depending on the fracture.

Q: What are the periorbital signs of orbital fractures?

Periorbital signs include:

• Bruising

• Black eye (ecchymosis)

• Subconjunctival hemorrhage

• Crepitus (crackling sound)

• Epistaxis (nosebleed)

Q: What is the Oculocardiac Reflex (OCR) in relation to orbital fractures?

: The Oculocardiac Reflex (OCR) is triggered by EOM traction, leading to bradycardia (decreased heart rate).

Q: When is immediate surgery indicated for orbital fractures?

Immediate surgery is indicated for severe cases such as:

• Non-resolving OCR

• Significant enophthalmos

• Pediatric "white-eyed" fractures with muscle entrapment

Q: Why might late surgery be preferred for orbital fractures?

Late surgery may be preferred to:

•  Reduce risks of infection

• Reduce risk of blindness

• Assess late enophthalmos after edema has reduced

Q: What surgical techniques are used for orbital fractures?

• FDT (Forced Duction Test) to assess mechanical restriction

• Approaches: Trans-eyelid, trans-conjunctival, Caldwell-Luc (via the maxilla),

• endoscopic

• Medial wall exposure: incision can be used to expose the medial wall.

• Periosteum incision: The periosteum is incised and elevated to expose the fracture borders.

Q: What conservative management options are available for orbital fractures?

: Conservative management options include observation, prisms for small deviations, or no immediate surgery for mild cases.

what are the feature of a white eye fracture?

• a linear trapdoor blowout fracture - orbital wall fracture - in adults & children. Features:

  • Limited eye movement: Patients may avoid opening their eyes or looking up due to pain or nausea. 

  • diplopia

  • Nausea and vomiting: This can be caused by the oculocardiac reflex. 

  • Pain: Patients may experience pain during eye movement. 

  • Lack of bruising: The name "white-eyed" refers to the lack of periorbital bruising and swelling that's often present. 

  • No subconjunctival hemorrhage: This is a characteristic feature of a white-eye fracture. 

White-eye fractures are considered a surgical emergency and require urgent surgery within 24–48 hours.

infection travels through sinuses = bruising

bone breaks and snap back = eyes look normal

ocular cardiac reflex - A triad of symptoms that includes bradycardia, nausea, and syncope. It's a rare but serious complication

check elevation - IR

white eye fracture + OCR = emergency

medial wall = thin = more susceptible to fracture = eso

inferior wall - hypo

spinchter restrict

radial dilate

Orthoptic investigation

• diplopia - not always as can be too swollen to see

• numbness - 5th CN damage - trauma to floor infraorbital anesthesia

• ask about ocular cardiac reflex = IR trapped + SR

• increase pressure to eye = faint

• CHP = chin elevation - eyes move down = mechanical deviation

• CT scan

• pupil = traumatic mydriasis = pupil dilated slightly = mid dilated pupil

• haematoma - bruising anywhere

• conjunctiva bruising

• if blood in anterior orbit = hyphaema

• measure eye using exophthalmometer

• CT w/ CHP = BSV

• Common dev - hypo = pseudoptosis

• pulling sensation

trap door fracture

• scan looks normal

• broken but goes back to where it was

  severe

• floor is gone = inset plate

• completely breaks - eyes sink in - look lower

• medial wall and lr can break - IR = trapped anywhere

measurement & tests

BSV

• w/ CHP = normal BSV unless sublex lens - cornea scratch

• PCT - 5 position of gaze

• synoptophore

• if obliques were affected = no torsion

• MRI - soft tissue scan

• CT scan look at bones

• Hess chart - 2 stages of ms - affected = squashed

• field of unioc fixation - mechanical restriction

• field of BSV - surgery to stretch field of BSV

treatment

white eye

• immediate emergency + ocular cardiac reflex

• surgery release muscle - bc floor + wall provide no support - medial wall or sig wall entrapment = facial asymmetry

  Diplopia

• no muscle entrapment - just looks swollen - observe and occlusion

• sig dip - surgery

• cold compression

severe accident

• wait till medically stable

late surgery

• little to no opthalmus

• sm diplopia

Criteria for orbital fracture repair

10- 14 days after onset
-sig diplopia

herination

incareraion/retraction

significant enophthalmos >3mm

Timing - immediate vs early vs late - burnstein 2002

immediate

• Non-resolving oculocardiac reflex (e.g., bradycardia).

• Significant enophthalmos (>3mm) or facial asymmetry.

• White-eyed blow-out fracture (<18 yrs): minimal edema, marked restriction, tissue/muscle entrapment.

Early vs Late

• Early: After edema/hemorrhage reduction; assess enophthalmos.

• Late: Risk fibrosis; complications include blindness, infection, implant migration, diplopia.

Evidence

• Simon et al. 2009: Minimal motility outcome differences between early and late surgery (limited data).

Management: Surgical and Conservative

FDT

Trans-eyelid

Trans-conj

Caldwell-Luc

Endoscopic

Conservative

Suspect soft tissue

Small deviation (elevation)

Prisms

Record progress prior to any surgical

intervention