ORBITAL FRACTURES MANAGEMENT AND COMPLO.pptx

Orbit fracture mandible at symphysis transfer in the patients with stand up for surgery

1. ORBITAL FRACTURES Dr. K. DEVIKA SECOND YEAR RESIDENT PLASTIC & RECONSTRUCTIVE SURGERY

2. Orbital cavity– boundary between cranial cavity and face Formed by 7 bones Frontal Ethmoid lacrimal maxillary zygomatic Palatine sphenoid

3. Normal volume 30cc

4. AGE Bimodal age distribution first peak 2 nd ,3 rd decades second in forties MEN>WOMEN Isolated fractures or combined ISOLATED ORBITAL # - 4 to 16%

5. Aetiology – Assaults (blunt trauma penetrating rarely) Accidental falls motor vehicle accidents Inferior wall of orbit (mc) Medial wall(2 nd )

6. CLASSIFICATION For the ease of communication and assessment Based on anatomical considerations, radiological findings , and also on the severity of trauma

7. DINGMAN CLASSIFICATION ANATOMICAL Fractures involving the orbital rim. Intraorbital fractures with no orbital rim involvement. Combined ( intraorbital and orbital rim) fractures

8. Manson et al 3 GROUPS B ased on the comminution and displacement on CT findings L ow, middle or high-energy impact groups.

9. Converse and Smith Pure (blow-out and blow-in) and I mpure (complex and involving the orbital rim).

10. Pure fractures : by a sudden increase in intraorbital pressures from direct blunt trauma to the globe . Impure fractures : by direct trauma resulting in the disruption of the internal orbital walls. Most of the fractures are a result of blunt injury to the orbit

11. BLOWOUT FRACTURES THEORY The hydraulic theory ( Smith and Regan) states that when orbital pressure increases, the orbital content decompresses through the weakest walls.

12. The globe-to-wall contact theory: This theory postulates that when the globe becomes displaced posteriorly, it strikes the wall resulting in a fracture .

13. The theory of buckling: This states that the posterior movement of the orbital rim results in fracture

14. Waterhouse et al (1999) studied the mechanisms by applying force to the cadaveric orbit and described two types of orbital blowout fractures TYPE I TYPE II

15. Type I : A small fracture confined to the mid medial orbital floor with herniation of orbital contents into the maxillary sinus . This fracture results when a direct force is applied to the globe (hydraulic theory). .

16. Type II: A large fracture that involves the floor and medial wall with herniation of orbital contents This type of fracture was caused by force applied to the orbital rim (buckling theory).

17. CLINICAL FEATURES The initial evaluation in orbital fractures is to assess visual acuity, ocular motility, pupillary response, and fundoscopy . Pure orbital fractures are associated with a more serious ocular injury compared to impure fractures.

18. Diplopia Enophthalmos I nfraorbital nerve injury Proptosis Hyphema C onjuntival chemosis , etc.

19. Diplopia :Diplopia (double vision) is a subjective symptom surrounding tissue edema , muscle contusion, or restricted ocular movements due to entrapment of muscles.

20. Enophthalmos - secondary to increase in orbital volume I ndicates disruption of orbital floor or wall of more than 2 cm with an increase of orbital volume by around 1.5 mL.

21. Infraorbital Nerve Injury Numbness of cheek may be seen in orbital rim fractures due to infraorbital nerve involvement.

22. Proptosis - indicates retrobulbar hemorrhage intervention in the form of lateral canthotomy and cantholysis .

23. This is uncommon in pure internal orbital fractures because the majority of the floor defects are posterior to the axis of the globe.

24. Other features may include hyphema (blood in the anterior chamber ), chemosis of conjunctiva, corneal injuries, superior orbital fissure syndrome (SOFS), and orbital apex syndrome.

25. SOFS Rochon-Duvigneaud syndrome occurs due to the involvement of the superior orbital fissure in the fracture Causes : Localised edema or inflammation Direct impingement of fracture segments

26. Diplopia , Paralysis of extraocular muscles (due to paralysis of cranial nerves III, IV, and VI), Exophthalmos , and P tosis , accompanied, often, by proptosis due to increased pressure inside the bony orbit

27. orbital apex syndrome. If the optic nerve is also involved in the fracture or due to localized edema/inflammation- blindness Urgent reduction of the fractured segment, sometimes need to be managed by surgical decompression of optic canal and high-dose corticosteroids .

28. White-Eyed Blow-Out Fracture (Trapdoor Fracture) This is a subtype of orbital fractures where a portion of the floor becomes momentarily displaced and later recoils back to its position, and while doing so, soft tissue (at times, with muscle) gets entrapped leading to restriction in ocular motility and pain on attempted eye movement. Exclusively in children

29. Radiological examination may not reveal fracture in proportion to soft tissue herniation, hence a high index of clinical suspicion is necessary

30. T reatment Prompt reduction of the fracture, usually within 24 hours from diagnosis, is recommended.

31. Gossman et al proposed five-point assessment Visual acuity Pupillary function. Anterior segment. Posterior segment. Ocular motility.

32. CT is the investigation of choice axial , coronal, and sagittal images .

33. In orbital floor fractures, there can be herniation of the inferior rectus muscle and intraorbital fat through the defect leading to entrapment of the muscle. This is known as the teardrop sign on CT

34. MRI soft tissue imaging modality CT - assess lens dislocation, vitreous hemorrhage, ruptured globe, retrobulbar hemorrhage, or avulsion of the optic nerve. CT –localization of metallic and nonmetallic foreign bodies in relation to the globe, muscular cone (area inside the extraocular muscles), and the optic nerve.

35. MANAGEMENT A ssess for any associated injuries ATLS protocols. assessed clinically and radiologically to decide the need for urgent surgical intervention.

36. Aim: To minimize late sequelae such as persistent diplopia and malpositioning of globe.

37. criteria for surgical intervention Persistent diplopia, radiological confirmation, or positive forced duction test suggesting entrapment of the recti. Enophthalmos that is greater than 2 mm 14 days after trauma. A fracture involving one-half or more of the orbital floor, especially when associated with a medial wall defect.

38. Timing Burnstine’s criteria

39. Surgical Approaches Inferior and Lateral Orbital Approaches Trans cutaneous exposure Infraorbital Subciliary subtarsal Patterson ethmoidectomy Trans conjunctival approach – preseptal post septal Endoscopic approaches via a transmaxillary and transnasal route.

40. The subciliary incision was popularized by Converse. The skin incision is made 2 mm below the lid margin, preferably in a skin crease.

41. The skin flap is undermined inferiorly, and orbicularis oculi fibers are split to reach the orbital septum. D issection proceeds preseptally till the periosteum is reached, and the periosteum is incised below the orbital rim and is elevated to provide access to the orbital floor .

42. Transconjuctival approach Transconjunctival approach was first popularized by Tessier. P reseptal approach > retroseptal approach F at herniation Fat atrophy enophthalmos (Postoperatively) .

43. Incision palpebral conjunctiva 2 to 3 mm below the tarsal margin and orbital septum reached. D issection is carried out down several millimeters below the orbital rim, and the periosteum is incised and orbital floor reached

44. Lateral canthotomy and cantholysis have been advocated by McCord and Moses for wider exposure of the orbital floor, lateral and medial walls. S ubciliary approach of ectropion and scleral show T ransconjunctival approach was more prone to cause entropion

45. Extension of a Subciliary or Transconjunctival Incision with a Superior Cantholysis Superior cantholysis helps to free the lateral margin of the upper lid to swing superiorly to approach the zygomaticofrontal suture. The deep limb of the superior canthal tendon is isolated and cut between hemostats.

46. Superior Orbital Approaches Lateral Eyebrow Incision Incision .

47. Upper Blepharoplasty Incision Incision is placed in one of the upper eyelid skin creases The skin incision is then carried down through subcutaneous tissue, retracted somewhat laterally, and extended through the orbicularis oculi and periosteum by sharp dissection

48. Coronal Incision The coronal incision allows access to the entire supraorbital rim, frontal sinus, nasal bone, lateral orbital rim, medial orbital rim, and zygomatic arch Incision is placed at least 2 cm posterior to the hairline paralleling the hairline, and inferiorly into the preauricular region.

49. The incision is carried out through the skin, subcutaneous connective tissue, and galea aponeurotica into the loose areolar tissue in the midline.

50. Endoscopic Approach Endoscopic approach is gaining popularity due to the absence of eyelid complications and improved visibility and hence aids in better reduction of fracture segments. This approach uses 0- and 30-degree endoscopes through a Caldwell–Luc antrostomy window through a sublabial approach.

51. The incision is then extended laterally in the supraperiosteal plane. Dissection is carried out laterally to the superior temporal line and then anteriorly to the frontal bone, and incision is made around 2 cm above the superior orbital rim in the periosteum.

52. Maxillary sinus is reached, and using angled scopes, fractured segments and herniated orbital contents can be accessed, fracture reduced, and implant placed. Advantage is the absence of an external scar.

53. Principles of Surgical Management Fractures supraorbital rim, infraorbital rim, and lateral orbital rim ( zygomaticofrontal suture) are fixed in accordance with the principles of craniofacial osteosynthesis using miniplates and screws. .

54. Blow-out fractures of the floor and the medial wall, however, require reconstruction of the lost structures with either an implant or autologous grafts

55. Complications Infraorbital Nerve Disorders 18 to 83%. Enophthalmos . A difference of more than 3 mm compared to the unaffected side (measured by Hertel’s exophthalmometer ) is considered significant. (An increase in orbital volume, due to incomplete reduction of the fracture segment)

56. P revention of postoperative enophthalmos is by accurate reduction and fixation DIPLOPIA - edema , hematoma, muscle contusion, entrapment of the extraocular muscles and orbital tissue, and injury to cranial nerve III, IV, or VI. posttraumatic fibrosis of the extraocular muscles on histological examination

57. Traumatic Hyphema El evation of the head of the bed and patching of the injured eye, and surgical treatment is needed in unresolved cases. Traumatic optic neuropathy - from mild visual deficit to complete visual loss. Treatment varies depending on the cause but may include systemic steroids or surgery with orbital or optic nerve decompression.

58. Periorbital Incision Problems - dehiscence , hematoma or seroma formation, and lymphedema are usually easy to manage Mild and moderate ectropion - resolve with the passage of time and with gentle massage of the lid. Severe ectropion requires surgical correction.

59. Entropion rare –surgical intervention Ectropion lower eye lid>upper eye lid

60. Advances of virtual planning in the preoperative period help in achieving better outcomes.

61. Thank you