Blowout fracture

fractures of face

1. Blowout fracture ARUNACHALAM.L

2. Definition An orbital blowout fracture is a traumatic deformity of the orbital floor or medial wall, typically resulting from impact of a blunt object larger than the orbital aperture, or eye socket. Originally defined as orbital floor fractures without fracture orbital rim, but with entrapment one or more soft tissue structures

3. Anatomy Seven bones form the bony orbit Maxilla Zygoma Lacrimal Ethmoid Palatine Sphenoid Frontal

4. Intra-orbital neurovascular structures. 1-Superior orbital fissure III - Oculomotor nerve (Motor) IV - Trochlear nerve (Motor) VI - Abducens nerve V1 - Ophthalmic (Sensory) 2-Inferior orbital fissure V2 - Infra-orbital nerve. 3-Optic nerve foramen II - Optic nerve.

5. Ocular muscles: Lateral rectus muscle. Medial rectus muscle Superior rectus muscle Inferior rectus muscle Superior oblique muscle Inferior oblique muscle

6. Pathophysiology of Blowout fracture The bony defect is filled with soft tissue and fat from the orbit Alters support mechanisms for Extra ocular muscle EOM can become entrapped Direct muscle damage can result

7. Signs and symptoms: Orbital and lid subcutaneous ecchymosis or emphysema. Diplopia and enophthalmos. Limitation of eye movement. Orbital pain Loss of sensation due to infraorbital nerve injury.

8. Clinical significance of intra-orbital structures:- II = Optic (vision) III = Oculomotor nerve (Motor) double vision (diplopia) eyelid drooping (ptosis) pupil dilation (mydriasis) IV = Trochlear nerve (Motor) Sup. Oblique muscle Double vision (diplopia) Squint [lateral superior] VI = Abducens nerve. Lateral Rectus M Double vision (diplopia) Squint.[medial] V1 = Ophthalmic (Sensory) Corneal anaesthesia. V2 = Infra-Orbital (Sensory) Skin of lower eye lid-nose-upper lip.

9. Injuries associated with blowout fractures Ruptured globe Retroorbital haemorrhage Vitreous haemorrhage Hyphema Anterior chamber angle recession Dislocated lens. Secondary glaucoma Retinal detachment

10. Clinical examination Ocular motility: Test eye movements in all possible directions. Presence of squint or improper eye movement denoting muscle entrapment or neural damage. Forced duction test used for differentiation. Pupillary function test: Pupillary light reflex provides a useful diagnostic tool for testing the integrity of the sensory (CN II) and motor (CN III) functions of the eye.

11. Diagnosis: Imaging : Water’s view shows a convex opacity bulging into the antrum from the above. C.T: (coronal cut) teardrop sign, polypoid mass consists of herniated orbital contents, periorbital fat and inferior rectus muscle. The affected sinus is partially opacified on radiograph. Air-fluid level in maxillary sinus due to presence of blood. MRI: Detection of Inflammatory myopathy, Optic nerve condition, Vitreous haemorrhage.

12. Treatment Conservative Surgical

13. Conservative treatment: Ice affected area for 48 hours Elevation Head of bed Use of nasal decongestants Broad spectrum antibiotics like Augmentin Oral steroids to prevent fibrosis No nose blowing (most blowout fracture heals spontaneously without complication)

14. Surgery Indication Diplopia Enophthalmos >2cm Large fracture >50% and entrapment of extraocular muscle. Contraindication Hyphema Retinal detachment Globe perforation Only seeing eye Medically unstable patient

15. Pre-operative preparation: Surgical repair of a "blowout" is safely postponed for up to two weeks, if necessary, to let the swelling subside. All patients should follow-up with an ophthalmologist within one week of the fracture (Retinal examination, Intra-ocular pressure). To prevent orbital emphysema, patients are advised to avoid blowing of the nose. Nasal decongestants are commonly used. It is also common practice to administer prophylactic antibiotics when the fracture enters a sinus. (Amoxicillin-clavulanate and azithromycin). Corticosteroids are used to decrease swelling.

16. Surgical approach: Transantral Transconjunctival Transcutaneous Sub ciliary

17. Orbital implant Use of implants based on degree of comminution and size of fracture Various implant material used Autogenous bone and cartilage Alloplastic material Teflon, Marlex, polydioxanone , Etc.

18. Complication Ectropion Sunken eyes Graft morbidity

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