Orbital Fractures/Orbital

Blowout Fractures

Christina Gillespie, MD

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Topics for Discussion
 Orbitalanatomy
 Types of fractures
 Signs and symptoms
 Management

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Orbital Anatomy
 The bony orbit refers to the shell of
bone which surrounds and protects the
eye.
 The bony orbit is a pyramidal cavity with
an elliptical base presenting anteriorly
and the apex posteriorly at 22 degrees
lateral from the visual axis.

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Bony Orbit
 Seven bones form the bony orbit
 Maxilla
 Zygoma
 Lacrimal
 Ethmoid
 Palantine
 Sphenoid
 Frontal

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Superior Orbital Wall
 Formed by:
 Frontalbone
 Lesser wing of sphenoid

 Functions as:
 Floor anterior fossa
 Important structures:
 Supraorbitalnotch which transmits the
supraorbital nerve

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Medial Orbital Wall
 Formed by (from anterior to posterior):
 Maxilla
 Lacrimal bone
 Ethmoid
 Sphenoid

 Important structures:
 Lamina papyracea
 Nasolacrimal canal

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Lamina Papyracea
 Thin segment of the medial orbital wall
 Separates the orbit from the ethmoid air
cells

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Nasolacrimal canal
 Contains nasolacrimal duct
 Passes from lacrimal sac to inferior
meatus

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Lateral Orbital Wall
 Formed by:
 Zygomatic bone
 Greater wing of sphenoid

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Orbital Floor
 Formed by:
 Maxilla
 Palatine

 Important structures:
 Infraorbital groove
 Transverses floor from lateral to medial
 Location of infraorbital nerve which supplies

sensation to check and ipsilateral upper

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Orbital Floor
 Forms roof of maxillary sinus
 Location of more blow out fractures due
to inherent weakness of bone overlying
maxillary sinus

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Three important apertures at
the apex of bony orbit
 Optic canal
 Superior orbital fissure
 Inferior orbital fissure

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Optic Canal
 Contains:
 Opticnerve
 Ophthalmic artery

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Superior Orbital Fissure
 Separates lateral wall from roof
 Transmits the following structures:
 Oculomotor nerve (CN II)
 Trochlear nerve (CN IV)

 Abducens nerve (CN VI)

 Ophthalmic division of trigeminal nerve

 Ophthalmic vein

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Inferior orbital Fissure
 Connects to pterygopalantine fossa
 Located between floor and lateral wall
 Transmits:
 Infraorbital
branch V2
 Orbitalis muscle

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Blowout Fractures of Orbit
 Originally defined as orbital floor
fractures without fracture orbital rim, but
with entrapment one or more soft tissue
structures

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Blowout Fractures
 Blowout fractures now refer to fractures of the:
 Orbital floor
 Medical wall
 Lateral wall
 Superior wall
 “pure” blowout fractures – trapdoor rotation to
bone fragments involving central area of bone
 “impure” fracture – fracture line extends to
orbital rim

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Physiology of Blowout
Fracture
 The bony defect is filled with soft tissue
and fat from the orbit
 Alters support mechanisms for EOM
 EOM can become entrapped
 Direct muscle damage can result

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Common causes of orbital
fractures
 Falling
 Aggression
 Sporting events
 MVAs

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Initial Evaluation
 History
 Time and mechanism of injury
 Change in appearance of eye
 State of vision immediately after injury
 Immediate loss of vision – severe damage to retina
 Loss of light perception - vascular occlusion or optic
nerve compression
 Initial good vision – compression optic neuropathy

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Initial Evaluation
 Physical Exam
 Cranial nerve examination
 EOM
 Numbness check
 Palpation orbital rim
 Papillary function
 Visual acuity
 Fundus examine
 Ophthalmologic evaluation

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Visual Acuity
 Lightperception
 Finger counting
 Visual acuity

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Consultation
Do not hesitate to obtain an
ophthalmologic consultation

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Common physical signs
 Periorbital eccyhmosis
 Impaired extraocular muscles
 Hypoesthesia in V2 distribution
 Intraorbital emphysema

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Common Symptoms
 Diplopia
 Pain with eye movement

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Radiographic Evaluation
 CT scan of the orbits
 Plain films not useful due to a high rate
of false negatives and non-diagnostic
studies

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Injuries associated with blow
out fractures
 Ruptured globe
 Retroorbital hemorrhage
 Vitreous hemorrhage
 Hyphema
 Anterior chamber angle recession
 Dislocated lens
 Secondary glaucoma
 Retinal detachment

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Treatment Options
 Nonsurgical
 Surgical

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Initial Management
 Ice affected area for 48 hours
 Elevation HOB
 Use of nasal decongestants
 Broad spectrum antibiotics like Augmentin
 Oral steroids to prevent fibrosis
 No ASA
 No nose blowing

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Absolute Indications for
Surgical Repair
 Diplopia
 Enophthalmos >2 mm

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Relative Indications for
Surgery
 CONTOVERSIAL AREA
 Substantial soft tissue herniation into
maxillary sinus
 Intraoribital emphysema
 Hypoestheia in V2 distribution

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Contraindications to surgery
 Hyphema
 Retinaldetachment
 Globe perforation
 Only seeing eye
 Medically unstable patient

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Timing of Surgery
 Usually seven to ten days after trauma

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Surgical Approaches
 Transconjunctival approach
 Transcutaneous
 Subciliary
 Trasantral

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Factors to consider for surgery
 Site
 Location
 Severity
 What needs to be corrected

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Surgical procedures for orbital
floor fractures
 Incision
 Subtarsal dissection
 Skin-muscle flap
 Incision of maxilla
 Floor dissection
 Placement of Marlex mesh
 Periosteal closure
 Skin closure

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Orbital Implants
 Use of implants based on degree of
comminution and size of fracture
 Various implant material used
 Autogenous bone and cartilage
 Alloplastic material
 Teflon
 Marlex

 PDS

 Etc.

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Complications of Surgery
 Ectropion
 Lidretraction
 Persistent diplopia
 Malposition of eye
 hypoesthesia
 Extrusion of orbital floor implant

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Rare complications
 Ipsilateral
fourth cranial nerve palsy
 Post-op mydriasis
 Blindness (1/1,500)

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Conclusions
 Assessment of orbital fractures is an
area that requires a high index of
suspicion

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