orbital fractures

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