Orbital Fracture & Management

Orbital fracture, types, blow in fracture ,blow out fracture ,clinical features ,superior orbital fissure syndrome ,management ,complications ,reconstruction techniques ,Oculocardiac reflex

2. CONTENTS
❑Anatomyof Orbit
❑Classification offracture
❑Pathophysiology
❑Blow In fracture
❑Blow Out Fracture –Pathophysiology & Clinicalfeatures.
❑Superior Orbital Fissure Syndrome -Pathophysiology &
Clinicalfeatures.
❑CLINICALEVALUATION–Forced Duction Test
❑Management
❑Reconstruction
❑Complications

3. Anatomy ofOrbit
❑Orbit –conicalcavity
❑Base –Anteriorly
❑Apex –Directed at OpticForamen.
❑Orbital Volume –30cc ; Globe –7cc
❑Bones –7 (Maxillary, Zygomatic, Frontal, Ethmoid,
Lacrimal, Palatine, and Sphenoid )
❑Four Walls –roof, lateral, medial,floor
❑Medial wall & Floor –Thin
❑Lateral wall & Roof –Stronger.
❑Floor weakened –due to –Infraorbital canal passing
through it.

4. ❑Medial wall –Formed by –Lamina Papyraceaof Ethmoidbone
& Lacrimal bone.
❑6 EXTRAOCULAR MUSCLES –
❑Originate from Common Tendinous fibrousring
❑Annulus of Zinn –Fibrous ring –Common origin of 4 RectiMuscle
❑OPTIC NERVE –direct extension of GrayMatter
❑Very sensitive to Compression and once damaged fails to regenerate.
❑SUPERIOR ORBITALFISSURE
❑Transmits –3
rd , 4
th & 6
th CranialNerves
❑OpthalmicDivision of 5
th CranialNerve
Anatomy ofOrbit

5. Anatomy of BonyOrbit

6. Floor OfOrbit
❑Extends –Rim toapprox.
2/3
rd
of the depth oforbit.
❑Posteromedial aspect of Orbital
floor transitsinto Medial Orbital Wall
–toform
post.medialbulge.
❑Only three of four orbital wall extend
into the apex –Medial, Superior,
Lateral.
❑Ant.3rd –Diameter widens
behindSuperiorInferior margins
‘Post Entry Concavity’ –
Saggital plane–‘Lazy S’shape.
Peterson’s Principles of Oral and Maxillofacial Surgery ; 2
nd
Edition ; Page463-464

7. Surface Landmarks–
❑Infraorbital Groove –
bony sulcus
❑Inferior Orbital Fissure
–converts into canal –
continues to Infraorbital
Foramen.
❑Origin Of Inferior
Oblique Muscle
❑Posterior Lateral
Promontry –Posterior
medial bulge ending in a
raised promontory shaped
lateral plateau.
Floor OfOrbit

9. Medialwall
❑Convex Rectangular shape
❑Runs parallel to saggital
plane
❑Medial wall –paper thin
Laminapaprycea
–(0.2-0.4mm)
Reinforced alongthe Maxillary-
Ethmoidal suture ---forming an
Internal Orbital Buttress.
Peterson’s Principles of Oral and Maxillofacial Surgery ; 2
nd Edition ; Page–465

10. Surface Landmarks
❖Lacrimal Fossa –Anterior 1/3
rd of MedialWall
❖Frontoethmoidal suture –Roof of ethmoid sinus at the level of
cribriform plate.
❖Ant. & Post. Ethmoidal Foramen –along frontoethmoidal suture in
midorbit.
❖Distances:
❖Medial orbital rim –Ant. Ethmoid Foramen –22-25mm
❖Post. Ethmoid Foramen to Ant Ethmoid Foramen –12mm

11. Lateralwall
❑Forms –Triangle with an ant. base.
❑Forms 45
0
angle toitsmedial wall
counterpart.
❑SURFACE LANDMARKS –
❑Whitnall’s tubercle –small bony
projection –actual insertion is
‘Common lateralretinaculum’.
❑Superior & InferiorOrbitalFissure
❑Zygomaticosphenoidsuture –
imp. landmark to verifyproper
reduction of complexZMC fracture.
Peterson’s Principles of Oral and Maxillofacial Surgery ; 2
nd Edition ; Page–465

12. Roof OfOrbit
❑Domedcontour
❑Comprised of –Orbital plate of FrontalBone
❑Extremelythin
❑In apex –Roof terminates into Lesser Wing of Sphenoid
–where Oval shaped Optic foramen forms Opticcanal.
❑SURFACELANDMARKS:
❑Trochlear fossa : Zone of attachment of tendon of
Superior Obliquemuscle
❑Lacrimal GlandFossa

13. Apex ofOrbit
❑Post. 3rd –made by sphenoid
bone
❑Superior Orbital Fissure –
separates the Lesser wing of
sphenoid & GreaterWing of
Sphenoid
❑Optic Canal –within the lesser
wing ofsphenoid
❑Annulus of Zinn –All Extraocular
musclesexcept Inf. Oblique arises
from this tendinousring.

15. Limit ofDissection
❑Inferiorly(Floor) –Upto28-30mm (safe limit) –optic canal
is at around40mm.
❑Laterally–Superior OrbitalFissure
❑Superiorly–Orbital roof dissection is stopped at periorbital
surrounding Recurrent Meningeal Artery –passing through
bony canal within the Sphenofrontalsutureline
❑Medially–Posteriorextent–PosteriorEthmoidalvessels,
runningintheFronto-EthmoidalSuturelineAnteriortoOptic
foramen.

16. Distance of Vital OrbitalStructures
from Bony landmark
STRUCTURE REFERENCE
LANDMARK
MEAN DISTANCE(mm)
Midpoint of
inferior orbital
fissure
Infraorbitalforamen 24
Anterior
Ethmoidal
Foramen
Anterior Lacrimalcrest 24
Superior Orbital FissureZygomaticofrontal
suture
35
Superior orbitalFissureSupraorbitalNotch 40
Optic Canal
(medial aspect)
Anterior LacrimalCrest 42
Optic Canal(Superior
Aspect)
Supraorbitalnotch 45

17. Pathophysiology of Orbital
Fractures
Trauma
Thick Rims protect theEyeball
Absorb shock by Fracturingthemselves
Orbital walls (especially Medial Wall & Floor)fracture
in an isolatedway
Gets displaces Inwards orOutwards
Called as ‘Blow-In’ or ‘Blow-Out’fractures

18. Classification
ORBITAL WALL FRACTURES
1.Blow OutFracture
2.Pure Blow OutFracture
3.Impure Blow OutFracture
4.Blow InFracture
ISOLATED ORBITAL WALL FRACTURE:
1.Roof
2.Floor
3.Medialwall
4.Lateralwall

19. ❑ISOLATED FRACTURES OF THE ORBITAL
RIM:
1.SUPERIORRIM
2.INFERIORRIM
3.MEDIALRIM
4.LATERALRIM
❑COMPLEX COMMINUTED FRACTURES :
Nasoethmoidal and fronto-naso-orbital
fractures

20. ❑PURE BlowOutORBlow In–
OrbitalWalls fracture inIsolation
❑IMPURE Blow Out or Blow In Fracture–
Walls +Rim

21. Blow OutFracture

22. Blow OutFracture
❑Term coined by –Smith and Regan –1957
❑First described by MacKenziein1844
❑PATHOPHYSIOLOGY
❑Buckling Theory–
❑If a force strikesat any part of orbitalrim,
❑it will cause walls to undergo a rippling effect &
the force striking therimwill transfer to weaker
portion especially floor & cause them to distort
& eventuallyfracture

23. Pathophysiology of blow outfracture
of theorbit
❑Hydraulic Theory (Pfeiffer in
1943) –A generalized increase
in orbital content pressure
results in direct compression and
fractureof the thin orbital bone.
❑Therefore direct injury to globe
forcing it into the orbit is
necessary.
❑Medial Wall & Floor –Thin&
Fragile
❑Fracture readily –Provide
natural compensation.

24. ClinicalFeatures
❑Circumorbital Edema
❑Subconjunctival Bleeding –due to fracture →
subperiosteal bleeding →escapes in subconjuctival
plane.
❑Enopthalmous →Increase in size of Orbit→
Eyeballsinks
❑Periorbital fat herniates through fracturedwalls-‘Hanging-
drop’Appearance
❑Unilateral Epistaxis –bleeding intoantrum
❑Numbness in area of distribution of Infraorbital Nerve
❑Diplopia or Vertical gage –Inferior Rectus or Inferior
Obliqus gets entrapped in fracture →Inability of eyeball
to move in verticaldirection.

25. Enopthalmus followingBlow-Out
Fracture
❑Retracting action of
extraocular muscles
–Enopthalmus.
❑Diplopia –
Entrapment of
Inferior Rectus &
InferiorObliqus

26. Superior Orbital Fissure
Syndrome
k/a –‘Rochon DuvigneaudSyndrome’
Hirschfeld –first describedit.

27. Pathophysiology
Raised Intraorbital Pressure (due to
Hematoma/Displaced fracturedsegments)
Compression ofcontents ofSup. OrbitalFissure
Paresis ofNerve
Neurological deficit in theirdistribution

28. ❑Due to paresis of these nerves →all these
extraocular muscles undergo paralysis →
eyeball fails to move →‘External
Opthalmoplegia’
❑As affected eye does not move →whereas
contralateral normal eyeball moves →focal
axis gets disturbed →two images -→
Diplopia

29. ClinicalManifestations
❑External Opthalmoplegia –Eyeball fails tomove
❑Diplopia –Two images of oneobject
❑Internal Opthalmoplegia –Fixed Dilated pupils
(parasympathetic –III cranial nerve –
Occulomotor)
❑Ptosis of Upper Eyelid –upper eyelid drops
down like a curtain –parasympatheticsupply.
❑Orbital Apex Syndrome –If Optic Nerve
involvement ispresent.

30. BLOW INFRACTURE
Fragmented bones of the orbital floor are
displaced into theorbit.
Proptosis –Exopthalmous.
More commonly seen in fractures of orbitalroof.

31. CLINICALEXAMINATION
Initial Opthalmologicalevaluation–
1.PeriorbitalExamination
2.Visual acuity –SNELLENCHART
3.Ocularmotility–FORCED DUCTION TEST
4.Pupillary responses ,-pupillary size,shape & symmetry,
lightreactivity,
5.Visual fields –HESSCHART
6.Fundoscopicexamination -TONOMETRY –to assess Intraocular
pressure (Normal10-20mmHg)
7.Hertel Exopthalmometer–measureexopthalmous

32. Forced DuctionTest
❑Prior to the test, a cotton-
tipped applicatorsoaked
with topical anesthetic
drops and held against
the limbus forfew
minutes.
❑Fine-toothed forceps
are then used to grasp
the conjunctiva and
Tenon’s capsule just
posterior to thelimbus.
❑The patient is then
asked to look in the
direction of restriction of
movement of the eye.

33. Snellen Chart
•To assess visual
acuity of the eye
Tonometer
•Measures IOP
•Greatly increased IOP
causes pulsatile optic
disk
Hess Chart

34. Opthalmoscopy
Examination of the fundus
TYPES:
Direct ---General examination
Indirect---Better view of the eye
Pressure –eye ball –blunt instrument—edges
of fundus --examination
Retinal detachment requires
ophthalmologic attention.

35. Hyphaema
❑Layering of blood in the anterior chamber.
❑Direct blow to eye --fist or squash ball
❑C/F: Pain
Blurred vision
Photophobia
Visual acuity decreased
Pupil dilated
❑Vision worse supine, clears upright
❑Can cause increased IOP

36. ❑Head of bed elevated
❑Atropine –dilates pupil–prevents iris movements
❑Mannitol
❑Anti fibrinolytic agent 50mg/kg every 4 hrsreduces
recurrent bleeding.

37. IMAGING
❑Caldwell view
❑Waters view
❑Lateral skull
❑CT Scan –Orbit
-To visualize the fracturedsegments
-Also helps evaluate theIntraorbitalvolume.
By using a software to compare the normal
orbital volume to theaffected.
❑MRI

38. Imaging
Ultrasound
High resolution CT is used the
management of enophthalmos
Sinuscopy
3D reconstruction volumetric
assessment

39. Management
Management

41. Indications forsurgical
managment
Unresolving soft tissue entrapment with disabling
diplopia
Enopthalmous greater than2mm
CT scan evidence of a largefracture
SURGICAL MANAGEMENT :
1.CLOSED REDUCTION –
Transantrally.-Caldwell LucProcedure
Trannasally –Through inferior turbinate –foley’s
catheter

42. Incisions
❑Existinglacerations
❑Lower Eyelid–
1)Subciliary
2)Subtarsal
3)Infraorbital approaches
❑TransconjuctivalApproach

43. SAGITAL SECTION THROUGH ORBIT&
GLOBE
C-Palpebral
Conjuntiva
IO-InferiorOblique
muscle
IR-Inferior Rectus
Muscle
OO-OrbicularisOculi
OS –OrbitalSeptum
P-
Periosteum/Periorbita TP-
TarsalPlate.

44. Orbicularis OrisMuscle
Innervated by Cranial NerveVII
Upper Eyelid –Levator
Palpebral Superioris –Cranial
NerveIII
Orbicularis Oculi-
Orbitaland
PalpebralPortions
Palpebral Portion is dividedinto
fibers-
Pretarsal Portion
PreseptalPortion

45. Subciliary
Incision
The incision is approximately 2 mm below eyelashes, can be
extended laterally as necessary (top dashed line). Itis made
throughskinonly.

46. Subcutaneous dissection of skin,leaving
pretarsal portion of orbicularis muscle
attached to tarsus. Dissection 4-6mm
inferiorly in this plane isadequate.
Subcutaneous dissection
through lidmargin

47. Usescissors to dissect through orbicularis oculi muscle
over lateral orbital rim to identifyperiosteum.

48. Incision through the bridge of orbicularis
oculimuscle.
Saggitalplane through orbitshowing
incision of the bridge of orbicularis oculi
muscle.

49. ❑Incision through periosteum
along ant.maxilla, 3 to 4 mm
inferiorto infraorbitalrim.
❑Note the pretarsal muscle still
remaining on the inferior tarsus
and orbital septum, which restricts
orbital fat from enteringfield.
❑Subperiosteal dissection of anterior
maxilla and orbital floor.Periosteal
elevator entering the orbit is
placed almost verticallyas
dissection proceeds behind rim.
❑Inant.region,flooroftheorbitisata
lowerlevelthancrestoftherim,
necessitatingdissectioninferiorly.

50. Sagital plane through orbit showing subperiosteal dissection of
the anterior maxilla and orbitalfloor.

51. Transconjuctivalapproach
•Fig.1 -Incision ofconjuctivabelow the tarsalplate.
•Fig 2 -Incision through periosteum. To facilitate this maneuver, a traction
suture is placed through the cut end of conjunctiva to retract the tissueand
maintain the position of cornealshield.
•Small retractors are placed so that lower lid is retracted to the level ofant.
surface of infraorbitalrim.
•Intervening tissue alonginfraorbital rim is the periosteum. Theincision
is made through the periosteum just post.to infraorbitalrim.

52. •Saggitalplanethroughtheorbitandglobedemonstrating
levelandplaneofincision.Theconjunctivaandlowerlid
areincisedwithscissors.

53. SUBPERIOSTEAL DISSECTION OF THE ORBITALFLOOR.
Note the traction suture placed through the cut end of the
conjunctiva, which assists in retracting the conjunctiva and
maintains the corneal shield inplace.

54. SurgicalExposure
❑After periorbital
dissection is performed,
adequate exposureand
illumination of the
fractured area is
imperative.
❑Malleable retractors,
spoons and special
orbital retractors
designed for theglobe.

55. ❑Transition between anterior
mid orbit , the orbital floor
slopes upwards giving rise to
posterior medial bulge &
slightly convex bonyplatform.
❑Elevator passes transversely
along inferior orbitalfissure.
❑Infraorbital neurovascular
bundle can be visualized first
shining through the thin bony
roof of its canal.
❑Thenitbecomesdirectlyvisible
ininfraorbitalgroove.

56. EXTENT OFDISSECTION
❑Taking into account extent of
fracture, the periorbital dissection
stops atmedial border ofthe
inferior orbital fissure leaving
the soft tissue invaginationintact.
❑Laterally, the dissection is
continued to posterior edge of
the floor to orbital processof
the palatine bone. The suture
between the maxilla and the
palatine bone is indistinguishable
in the adultskull.
❑Mediallythe periorbital
dissection extends to the zone
over the internal orbital
buttress.

57. ❑For an EXTENDED ACCESS
to posterior orbital floor, the
contents of the inferior orbital
fissure must be addressed
and transected to allow for
this additionalaccess.
❑The transsection is prepared
with a dissection along the
inferior portion of the lateral
orbital wall in order to create a
second tunnel alongside the
verticalsofttissue.

58. ❑The intervening soft tissue
invagination is transected in a
stepwise fashionusing
bipolar electrocautery and
sharp dissection across the
fissure above the levelof
Müller’s muscle, stripping
the periorbita along the
lateral edge oftheinferior
orbitalfissure.

59. Limit ofDissection
❑Inferiorly –Upto28-30mm.
❑Laterally –Superior OrbitalFissure
❑Superiorly –Orbital roof dissection is stopped
at periorbital surrounding Recurrent Meningeal
Artery –passing through bony canal within the
Sphenofrontal sutureline
❑Medially–Posteriorextent–Posterior
Ethmoidalvessels,runningintheFronto-
EthmoidalSuturelineAnteriortoOptic
foramen.

60. ❑The subperiosteal dissection is
continued using a periosteal or
freer elevator inalateromedial
direction and lifted up and
retracted by and by with the
ribbonretractor until the
entrance ofapex isreached.
❑Closure (layer-by-layer)

61. Reconstruction Material

62. Autogenous Material
•Graft transferred from one part
of patient’s body to another
•Ex. –1. Septal cartilage
2. Ear cartilage
3. Maxillary wall bone
4. Iliac crest
5. Rib
6. Split calvaria

63. BoneGraft
Advantages:
1.Provides strength and stability to the orbital
floor
2.Relative resistance to infection
3.Lack of host response against the graft
4.Lack of concern for late extrusion
5.Long term efficacy and reliability
6.Can be easily accessed and harvested from
same operative area ( cartilage –ear, nose;
bone-maxilla, mandible )

64. Disadvantages:
1.Need for graft donor site
2.Increased operative time
3.Complications related to donor site wound
4.Donor site morbidity ( rib –pneumothorax,
infection; calvarial–duraltears,
subarachnoid haemorrhage, etc)
5.Unpredictable graft resorption
6.Limited ability to contour same type of bone
7.Limited availability

65. Allogenic Materials
Graft transferred from another
person (homogenic/ allogenic) or
from any animal of different
species (xenograft)
Ex. 1. Lyophilized dura
2. Lyophilized cartilage
3. Banked bone
Advantages:
1.No need for graft donor site
2.Decreases operative time
3.Eliminates complications
related to donor site wound
morbidity
4.Inertness
5.Resistant to resorption

66. Alloplastic Materials
Grafts derived from non-living source, synthetic
Ex. 1. Gelfilm
2. Medpor
3. Polytetrafluoroethylene
4. Methylmethacrylate
5. Polyamide mesh
6. Titanium, vitallium, other metallic meshes
7. Hydroxyapatite –block, granular
8. Hydroxyapatite –cement, vicrylmesh

67. Pre-formed OrbitalImplant
ADVANTAGES:
•Radiopacity
•SmoothSurface
•Minimal or no countouringnecessary
DISADVANTAGE:
•Cost

68. Porous Polyethylene
Sheet (PPE)
Disadvantages:
•Not Radiopaque (Not visible on PostOP Radiographs)
•Lack of Rigidity when very thin wafer of PPE is used. When a
more thick rigid wafer is used there is a risk of causing
dystopia.

69. Polyethylene andtitanium mesh
❑By combining titanium mesh with
porous polyethylene–
❑Material becomesradioopaque
❑More rigid than porousPPE.
❑ADVANTAGE:
❑Stability
❑Contouring
❑Adequate in large three wall
fractures
❑Radiopacity
❑No Donor SiteNeeded
❑DISADVANTAGES :Less
drainage from orbit.

70. Resorbablematerials
❑Thermoplastic and Non
thermoplasticmaterials.
❑Advantages:
❑AvailabilityHandling/
❑Contourability (only for
thermoplastics)
❑Smooth surface andsmooth edges
❑Disadvantages:
❑No radiopacity
❑Degradation of material with possible
contour loss Sterile infection /
inflammatoryresponse
❑Difficulttoshapeaccordingtopatients
anatomy(onlyfornon-thermoplastics)
❑Lessdrainagefromtheorbit.

71. COMPLICATIONS
EARLY COMPLICATIONS :
1. Hemorrhagic or orbital hematoma–treatedby
-lateral cathotomy immediately, lateral canthal
Tendonlysis,
Lateral canthotomy –indicated when–
-Decreased visualacuity
-Intarocularpressure more than40mmHg
-Proptosis
-Opthalmoplegia

72. Retrobulbarhemorrhage
❑Rare, rapidly progressive
life threatening emergency
that results inaccumulation
of blood in the retrobulbar
space
❑Increased IOP →stretching
of the optic nerve &
blockage ofocular
perfusion
❑Proptosis , marked
subconjuctivalecchymosis
& edema.

73. Symptoms–Pain , decreasing visual acuity, diplopia.
Treatmentincludes
•I.vmannitol(200 ml of 20% solution)
•i.vacetazolamide 500 mg
•i.vpapaverine 40 mg
•i.vhydrocortisone 100 mg
•Dexamethasone sodium phosphate-3-4mg/kg body
weight followed by 1-3 mg /kg 6
th
hourly.
•If no evidence of improvement stop after 48 hours.
3.Blindness

74. OCULOCARDIAC REFLEX/ TRIGEMINOCARDIAC/
TRIGEMINOVAGAL REFLEX
-The oculocardiac reflex pathway begins withthe
-afferent fibres of the long & short ciliary nerves that
travelwith
-the opthalmic division of the trigeminal nerveto
-the gasserion ganglionvia
-the sensory nucleus of the trigeminalnerve.
-In the floor of the 4
th
ventricle short internuncial
fibres in the reticular formation connect them withthe
efferent pathway from the motor nucleus of the
vagus nerve to the depressor nerve ending in the
mucle tissue of theheart.

75. CLINICAL FEATURES–
-Bradycardia
-Faintness
-Further stimulation can lead tocardiac
dysrhythmias
-Atrioventricularblocks
-Asystole
-Bradycardia has been attributed toTrigeminal
derived vagalreflex

76. LATECOMPLICATIONS
❑Alteredvision
❑Diplopia
❑Ectropion –Lower eyelid turnsoutwards.
❑Epiphora –Overflow of tears onto the face
❑Enopthalmous

77. References
❑Rowe & William’s MaxillofacialInjuries
❑Maxillofacial Surgery-Peter Ward Booth
Vol-1
❑Peterson’s Principles of Oral and
Maxillofacial Surgery ; 2
nd Edition
❑Textbook of Oral & Maxillofacial Surgery –
R.M. Borle