orbital fractures

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