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Orbital Floor Fractures Jacques Peltier MD Francis Quinn MD Grand Rounds Presentation Department of Otolaryngology University of Texas Medical Branch at Galveston April 11, 2007 Divine Design

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Orbital Floor Fractures

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Orbital floor fractures l.jpg

Orbital Floor Fractures

Jacques Peltier MD

Francis Quinn MD

Grand Rounds Presentation

Department of Otolaryngology

University of Texas Medical Branch at Galveston

April 11, 2007


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Divine Design

  • Important in the design of the orbit is its inherent ability to protect vital structures by allowing fractures to occur. Because the globe is surrounded by fat and the medial wall and floor of the orbit are thin, force that is transmitted to the globe allows fracture of the orbit without significant globe injury. This accounts for the significantly higher incidence of fractures of the orbit as compared to open globe injuries.


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Bone conduction theory “buckling”

Less energy

Small fractures limited anterior floor

Hydraulic theory

More energy

Larger fracture involving entire floor and medial wall

Should suspect more extensive orbit involvement with associated injuries (globe rupture)

Pathophysiology


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Mechanism of injury

Double vision, blurry vision

Epistaxis

V2 numbness

Malocclusion

Nausea and vomiting (especially in children)

Abuse? Repeated falls? Frequent ER visits? (children)

History


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  • Ali vs. sonney liston

  • Maya Kulenovic


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Physical Exam

  • Full Head and Neck exam

  • Cardiac exam

    (Bradycardia, low BP)

  • Facial asymmetry

  • V2 exam

  • Exam of canthal stability (Bowstring Test)

  • Entrapment

  • Pupillary exam (Marcus Gunn pupil)

  • Retinal exam

  • Hurtel exophthalmometry


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C-Spine X-rays

Plain Films of limited use

MRI if retinal, optic nerve, or intracranial concerns

CT Facial bones (most useful)

Imaging


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Indications for Repair

  • Diplopia that persists beyond 7 to 10 days

  • Obvious signs of entrapment

  • Relative enophthalmos greater than 2mm

  • Fracture that involves greater than 50% of the orbital floor (most of these will lead to significant enophthalmos when the edema resolves)

  • Entrapment that causes an oculocardiac reflex with resultant bradycardia and cardiovascular instability

  • Progressive V2 numbness


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Nonresolving oculocardiac reflex with entrapment

Bradycardia, heart block, nausea, vomiting, syncope

Early enophthalos or hypoglobus causing facial asymmetry

“White-eyed” floor fracture with entrapment

Immediate repair

Clinical Recommendations for Repair of Isolated Orbital Floor Fractures, An Evidence-based Analysis, Michael A Burnstine, MD, Ophthalmology 2002; 109: 1207-1210.


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Repair Within Two Weeks

  • Symptomatic diplopia with positive forced duction test

  • Large floor fracture causing latent enophthalmos

  • Significant hypoglobus

  • Progressive infraorbital hypesthesia

  • Clinical Recommendations for Repair of Isolated Orbital Floor Fractures, An Evidence-based Analysis, Michael A Burnstine, MD, Ophthalmology 2002; 109: 1207-1210.


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Observation

  • Minimal diplopia

    • Not in primary or downgaze

  • Good ocular motility

  • No significant enophthalmos

  • No significant hypoglobus

Clinical Recommendations for Repair of Isolated Orbital Floor Fractures, An Evidence-based Analysis, Michael A Burnstine, MD, Ophthalmology 2002; 109: 1207-1210.


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Trapdoor fractures with entrapment differ in children and adults

Children repaired within 5 days of injury do better that those repaired within 6-14 days or those repaired > 14 days

There is no difference in early timing of adults (1-5 days or 6-14 days)

Adults repaired less than 14 days from injury have less long term sequela than those repaired greater than 14 days from injury

The Differences of Blowout Fracture of the Inferior Orbital Wall Between Children and Adults, Kwon et al. Archives Oto head & Neck.

Trapdoor Fractures


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Transconjunctival, Subciliary, Subtarsal Approaches


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Transconjunctival Approach

  • Transconjunctival

    • No visible scar

    • Less incidence of ectropion and scleral show

    • Poorer exposure without lateral canthotomy and cantholysis

    • Better access to the medial orbital wall

    • Risk of entropion


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Transconjunctival Approach


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Subciliary Approach

  • Subciliary advantages

    • Easier approach

    • Scar camouflage

    • Skin necrosis

    • Highest incidence of ectropion

    • Highest incidence of scleral show


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Subtarsal Approach

  • Subtarsal Advantages

    • Easiest approach

    • Direct access to floor

    • Good exposure

    • Postoperative edema the worst

    • Visible scar


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Stay below orbital septum

24/12/6mm rule

Remove entrapped inferior rectus muscle

Slightly overcorrect if possible

Avoid V2 injury

Picture of dissection here

Dissection


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Materials for reconstruction

  • Autogenous tissues

    • Avoid risk of infected implant

    • Additional operative time, donor site morbidity, graft absorption

    • Calvarial bone, iliac crest, rib, septal or auricular cartilage


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Enophthalmos

Maxillary sinus Ostia obstruction

Deviated Septum

Septoplasty, MMA, floor repair with septal cartilage

Septal Cartilage repair


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Floor reduced

Maxillary Sinus Clear

Septum Straighter

Endophthalmos improved

Septal Cartilage repair


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Conchal cartilage repair

  • Curve of concha can approximate curve of orbit

  • Can place with concave surface down for overcorrection

  • Two site surgery

  • Entire concha needed for significant floor fractures


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Materials for reconstruction

  • Alloplastic implants

    • Decreased operative time, easily available, no donor site morbidity, can provide stable support

    • Risk of infection 0.4-7%

    • Gelfilm, polygalactin film, silastic, marlex mesh, teflon, prolene, polyethylene, titanium


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Materials for reconstruction

  • Ellis and Tan 2003

    • 58 patients, compared titanium mesh with cranial bone graft

    • Used postoperative CT to assess adequacy of reconstruction

    • Titanium mesh group subjectively had more accurate reconstruction


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Wide MMA

Insert Foley and inflate

Leave in place for 7-10 days

Best for large trapdoor fractures without entrapment

Broad spectrum antibiotics

Endoscopic Balloon catheter repair


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Caudwell Luc approach

Large MMA will allow larger working space

Endoscopic reduction of floor contents

May secure with antral wall bone, synthetic material, or Foley

Endoscopic Orbital Floor Repair


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Complications

  • Blindness

  • Orbital Hematoma

  • Infection of hardware

  • Entropion

  • Endophthalmos

  • Diplopia


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Orbital Hematoma

  • Poor Vascular perfusion of the optic nerve and retina

  • Early recognition

  • “Gray Vision”

  • Proptosis

  • Ecchymosis

  • Subconjunctival hemorrhage

  • Afferent pupil defect

  • Hard globe


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Orbital Hematoma

  • Treatment

    • Lateral Canthotomy (immediately)

    • Lateral canthal tendon lysis (immediately)

    • IV acetazolamide 500mg

    • IV mannitol 0.5 g/kg

    • Surgical decompression of the orbit


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Abscess over implant

Requires Implant removal

More common with synthetic floor implants

Complications


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Pyogenic granuloma

Entropion

Complications


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Late left proptosis

Hemorrhage into implant

Complications


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Lagniappe

  • Medial orbital wall fractures

    • Most common orbital wall fracture

    • Weakest area of the orbit

    • Very commonly asymptomatic

    • Can have entrapment of medial rectus

    • Can get orbital emphysema with nose blowing

    • Approach through Lynch or Transcaruncular/Medial fornix incision


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Lagniappe


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Lagniappe


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Lagniappe

  • Orbital dystopia-The bony orbital cavities do not lie in the same horizontal plane (Horizontal Dystopia) or the same vertical plane (Vertical Dystopia`).


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Questions?


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References

  • Clinical Recommendations for Repair of Isolated Orbital Floor Fractures, An Evidence-based Analysis, Michael A Burnstine, MD, Ophthalmology 2002; 109: 1207-1210.

  • Cummings: Otolaryngology Head and Neck Surgery 4th ed. Chapter 26, Maxillofacial Trauma, Robert M. Kellman, Mobsy, Inc. 2005.

  • Buckling and Hydraulic Mechanisms in orbital Blowout Fractures: Fact or Fiction?, Ahmad et al, Journal of Craniofacial surgery, vol 17, 438-441

  • The Effect of Striking Angle on the Buckling Mechanism in Blowout Fracture, Nagasao et al, Journal of Plastic and Reconstructive Surgery, Vol 117, number 7, March 05


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