JR - - - - Blow Out Fracture - AL....pptx

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1. Presentant: Anis Nurul Farida Supervisor : : dr. Nur Akbar A., Sp.T.H.T.B.K.L Subsp. Onk (K) Delayed Management of an Orbital Floor Blow-out Fracture Jounal Reading DEPARTMENT OF OTORHINOLARYNGOLOGY-HEAD & NECK SURGERY FACULTY OF MEDICINE PADJADJARAN UNIVERSITY-HASAN SADIKIN GENERAL HOSPITAL BANDUNG 20 24

2. INTODUCTION Blow Out Fracture is a fracture of the orbital floor caused by sudden increase of intraorbital pressure without involvement of the orbital rim. occur both as isolated injuries and in conjunction with additional maxillofacial fractures or multisystem trauma. Most of the blow out fractures occurs on the floor of the orbit and others occurs on medial wall with or without fractur of the orbital floor . Ophthalmology consultation is appropriate in selected cases .

3. ANATOMY Ehrenfeld M, Manson PN dan Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and Orthognathic Surgery. AOCMF. Thieme . 2012

4. Ehrenfeld M, Manson PN dan Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and Orthognathic Surgery. AOCMF. Thieme . 2012

5. Yano et al presented a simple classification system for blow-out fractures, separating them into : Linear Punched out Burst Ehrenfeld M, Manson PN dan Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and Orthognathic Surgery. AOCMF. Thieme . 2012 CLASSIFICATION

6. This theory suggests that posterior transmission of a direct orbital rim force causes a buckling and resultant fracture of orbital wall. Biomechanics & Pathophysiology Buckling theory: Hydraulic theory : This theory suggests that sudden increase in intraorbital pressure causes decompressing fracture into the adjacent sinus . Ehrenfeld M, Manson PN dan Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and Orthognathic Surgery. AOCMF. Thieme . 2012

7. “ The historian should inquire about mechanism of impact , previous eye s ur gery , double vision, numbness, preinjury vision status, and use of anticoagulant medications or other comorbid factors. Pain, double vision, flashes of light ( photopsias ), blind spots (scotomata), and floaters are more sensitive indicators Hyphema  maybe occur intra ocular bleeding Assest diplopia with EOMs exam Asset N. Cranial (V & VII) CLINICAL FINDINGS AND PHYSICAL EXAMINATION Ehrenfeld M, Manson PN dan Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and Orthognathic Surgery. AOCMF. Thieme . 2012

8. Subconjunctival haemorrhage Periorbital edema Echymosis If the rim orbital involved , “step-off” and the complaint of pain with palpation of the rim Periorbital emphysema -> detected by a ‘crackling’ sensation on palpation possible entrapment, one must assess for the signs of the oculocardiac reflex: bradycardia, nausea, and syncope. Physical Examination Ehrenfeld M, Manson PN dan Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and Orthognathic Surgery. AOCMF. Thieme . 2012

9. DIAGNOSIS – FORCED DUCTION TEST The limbus is gripped with forceps, and the globe is moved in multiple position to stretch the rectus muscles and superior oblique muscle and tendons, evaluating for any restriction in movement FORCED DUCTION TEST Humphrey CD, Kriet JD. Orbital Fractures in Bailey’s Head and Neck Surgery Otolaryngology. 5 th ed. 2014. Lippincot Williams & Wilkins. Ch.154, p.1225– 1240.

10. DIAGNOSTIC PROCEDURES - CT SCAN CT Scan is the imaging modality of choice (gold standard) if a blowout fracture is suspected after blunt orbital trauma Patients suspected of suffering an orbital floor fracture should undergo thin cut (1.0 - 1.5mm) axial CT scans of the orbit with coronal reconstruction (Thin cut coronal reconstructions are actually preferred to direct coronal images as they avoid artifact from dental amalgam) Paul D. Langer, MD, et.al. Orbital floor fractures. American academy of ophthalmology. 2023 Nikolaenko VP, Astakhov YS. Section 3 : Orbital Floor Fractures. Dalam: Orbital Fractures: A Physician’s Manual. Saint-Petersburg : Springer; 2012.

11. All trauma patients should initially be stabilized and evaluated according to ATLS protocol. Patients with severe orbitofacial trauma decreased visual acuity, and/or double vision should be evaluated. Comprehensive screening c t scans have become needed. . MANAGEMENT Ehrenfeld M, Manson PN dan Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and Orthognathic Surgery. AOCMF. Thieme . 2012

12. Indications for Surgical Management White eye  rectus inferior trap  OCR Diplopia that persists beyond 7 to 10 days. Obvious signs of entrapment. Relative enophthalmos >2 mm. Fracture that involves >50% of the orbital floor. Entrapment that causes an oculocardiac reflex bradycardia and cardiovascular instability. Progressive infra orbital nerve numbness

13. Aim of surgical repair Release of entrapped orbital contents Reconstruction of floor of the orbit Reconstruction of inferior wall of orbit is another important step that should be performed to prevent to further prolapse of orbital content into the maxillary sinus. Autologous bone/cartilage graft, or synthetic meshes can be used for the purpose Ehrenfeld M, Manson PN dan Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and Orthognathic Surgery. AOCMF. Thieme . 2012

14. RECONSTRUCTION MATERIALS Reconstruction Materials Autograft Alloplastic materials Nonabsorbable Absorbable Bone Cartilage Titanium mesh PPE Customised implant Resorbable sheeting

15. 15 Incisi periosteum aspect inferior & elevate w ith periosteal Technique Transcutan approach Ehrenfeld M, Manson PN dan Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and Orthognathic Surgery. AOCMF. Thieme . 2012

16. Tranconjunctival approach Ehrenfeld M, Manson PN dan Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and Orthognathic Surgery. AOCMF. Thieme . 2012

17. A transantral endoscopic approach to the orbital floor Ehrenfeld M, Manson PN dan Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and Orthognathic Surgery. AOCMF. Thieme . 2012

18. Advant ages & Disadvant ages Transcutan eous Easy to learn & offer broad acces to the orbital floor Higher rates of post operative lower lid malposition and visible scraring Can be produced ectropion Advant Disadvant Ehrenfeld M, Manson PN dan Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and Orthognathic Surgery. AOCMF. Thieme . 2012

19. Advant ages & Disadvant ages Transc onjunctiva No visible scarring decrease risk ectropion Decreased incidence lower lid malposition Almost minimal with flawless technique Advant Disadvant Ehrenfeld M, Manson PN dan Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and Orthognathic Surgery. AOCMF. Thieme . 2012

20. Advant ages & Disadvant ages Tr ansantral Improved visibility of the posterior orbit and floor orbit Difficulty in reconstructing the orbital floor lateral Advant Disadvant Ehrenfeld M, Manson PN dan Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and Orthognathic Surgery. AOCMF. Thieme . 2012

21. Diplopia  most common Vision loss  direct injury to the optic nerve or its vascular supply If the patient develops visual changes such as decreased color discrimination or loss of acuity associated with increased intraocular pressure and proptosis  an expanding retrobulbar hematomamust be suspected Lid malposition  28% - 42% of transcutan eous . App, 0,5% in transconjunc tiva COMPLICATIONS Ehrenfeld M, Manson PN dan Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton Trauma and Orthognathic Surgery. AOCMF. Thieme . 2012

22. INTODUCTION Common Orbital Fracture Sites : Inferior and medial walls, thinnest bony areas More common in males, ages 21-31 Causes: falls, motor vehicle accidents, assaults

23. CLINICAL FINDINGS

24. Type Orbital Fracture

25. DIAGNOSTIC Clinical examination : Palpation: step-off and point tenderness along the infraorbital rim Imaging : Gold standard: CT scan without contrast

26. SURGICAL REPAIR Reduction of fracture, repositioning herniating tissues, stabilization with implant/graft Emergent surgery: extraocular muscle incarceration, acute enophthalmos, hypoglobus Observation recommended for resolution of edema before surgery

27. Timing Of Surgery Semi-urgent surgery: within 1-2 weeks Delayed surgery: at least 3 months for tissue healing

28. SURGICAL APPROACHES

29. Age/Gender: 19-year-old female Symptoms: Marked hypoglobus and enophthalmos Incident: Fell from a 5m high fence onto concrete Injuries: Panfacial fractures involving both orbits and surrounding sinuses Timeline: 7 months post-injury with multiple surgical treatments Case Report

30. Initial Findings Panfacial fractures to include both orbits and surrounding sinuses Immediate post-injury ophthalmology exams obtained at bedside while she was in induced coma revealed bilateral periorbital hematoma with edema, conjunctival chemosis, right pupil slightly more dilated, and the impalpable right-side orbital rim. CT scans had shown extensive fracture of both ethmoid and maxillary sinus walls, right orbital medial and inferior wall, with bony fragments dislocation, fat prolapse, and hemorrhagic content in the right maxillary sinus

31. IMAGING RESULT CT Scan Findings : Extensive fractures: ethmoid and maxillary sinus walls, right orbital medial and inferior wall Dislocated bony fragments, fat prolapse, hemorrhagic content in right maxillary sinus

32. INITIAL SURGICAL INTERVENTIONS Maxillofacial Team (MFT) Actions: Stabilized vital functions Repaired facial and orbital fractures Surgical Approaches: Extended lateral canthal incision for orbital roof repair Trans-oral approach for mandibular fracture

33. DETAILED SURGICAL REPAIR

34. Follow Up Examination 7 Months Post-Injury : Best-corrected visual acuity: 20/25 in both eyes Ocular normotension, intact extraocular movement Relative hypoglobus (5 mm) and enophthalmos (4 mm) on right side Right relative afferent pupillary defect (RAPD), slightly pale and decentered right optic nerve head

35. An extension of the orbital fat tissue herniating into the maxillary sinus through the floor fracture. The fractured medial wall of the ethmoid sinus was indented inward by the orbital soft tissue. Both globes and other orbital structures were of regular form and size, with the right globe clearly enophthalmic on the scan IMAGING

36. SURGICAL APPROACH Operation technique : Incision transconjunctiva through inferior fornix, placing the incision 4–6 mm below the tarsus A traction suture was placed to elevate the conjunctiva and retractors over the cornea, using 6–0 nylon suture The dissection was advanced down to the infraorbital rim, elevating the periosteum posteriorly Reduction of herniating orbital tissue Exposing the orbital floor, the size of a fracture was measured to adjust the size and shape of a 0.35 mm thick nylon implant Forced duction test to ensure no restriction

37. CT Scan Findings : Orbital fat herniating into maxillary sinus through floor fracture Indented medial wall of ethmoid sinus by orbital soft tissue Both globes of regular form and size, right globe clearly enophthalmic FOLLOW UP IMAGING

38. POST OPERATIVE CARE Treatment : Systemic antibiotics, pain relief medication, topical antibiotic ointment Head elevation and monitoring Follow-Up : 1-week follow-up: Enophthalmos improved from 4 mm to 2 mm, minimal hypoglobus Long-term: Persistent improvement in globe position, no diplopia, satisfied with aesthetic appearance

39. DISCUSSIONS

40. Name Of Your Section You can enter a subtitle here if you need it POST OPERATIVE MONITORING

41. Goals of Repair : Reduce herniating tissue, restore globe position, motility, and orbital volume Additional surgery can be performed 3 months after the initial one using augmentation implants Case Significance : First use of smooth polyamide sheet implant in Bosnia and Herzegovina Successful transconjunctival approach for orbital floor repair CONCLUSION