ORBITO-FACIAL

FRACTURES
Dr . Pravallika
ANATOMY OF ORBIT
 Each orbit is formed by 7 bones.
namely: 1)Frontal
2)Ethmoid
3) lacrimal
4) Palatine
5) maxilla
6) zygomatic
7) Sphenoid.
WALLS OF ORBIT:
 MEDIAL WALL:
quadrilateral in shape
Boundaries:
frontal process of maxilla
lacrimal bone
orbital plate of ethmoid bone
body of sphenoid.
RELATIONS:
 medial to medial wall:
Anterior ethmoidal air sinuses,
Middle meatus of nose,
Middle and posterior ethmoidal sinuses
sphenoid air sinuses.
 orbital surface of medial wall:
upper part superior oblique ant and post ethmoidal nerve,
middle part medial rectus infra trochlear nerve ,
terminal part of ophthalmic
artery.
 Inferior orbital wall( floor):
triangular in shape , shortest of all the walls.
thinnest of all the walls, most commonly involved in
“blow - out –fractures” of orbit.
Boundaries :
formed by 3 bones
orbital surface of the maxillary bone – Medially
orbital surface of zygomatic bone – laterally
palatine bones – posteriorly.
RELATIONS:
 Below – maxillary air sinus
palatine air cells.
 Above – inferior rectus
inferior oblique
nerve to inferior oblique.
 Lateral wall:
thickest and strongest .
triangular in shape.
Boundaries :
Anteriorly : zygomatic bone
posteriorly: greater wing of sphenoid bone.
Relations:
laterally:
it separates the orbit from temporal fossa – Anteriorly
middle cranial fossa – Posteriorly
Medially:
lateral rectus
lacrimal nerve and vessels,
zygomatic nerve.
 Roof:
triangular in shape,
formed mainly by - orbital plate of the frontal bone
lesser wing of sphenoid.
 roof slopes backward and downward towards the apex ,where it ends at
the optic canal and superior orbital fissure.
RELATIONS:
 Above : frontal lobe of cerebrum , meninges and frontal sinuses.
 Below : periorbita , frontal nerve, LPS, superior rectus, superior oblique
trochlear nerve and lacrimal gland.
 junction of roof and medial wall: anterior and posterior ethmoidal canal
 Junction of roof and lateral wall: superior orbital fissure.
ORBITO-FACIAL TRAUMA:
 Orbito-facial trauma including blunt and penetrating trauma to
the eyelids and orbit.
Orbital fractures , orbital haemorrhage ,intra-orbital foreign
bodies are all common sequelae of facial trauma.
10% of all facial fractures are isolated orbital wall fractures.
30-40% of all facial fractures involves orbit.
PREOPERATIVE EVALUATION:

 systemic evaluation : complete and thorough

examination should be done to assure any life threatening
injuries are present or not.
 History : 1) time of injury.
2) mechanism of injury.
 Traumatic
history +/-

yes

Accidental non-accidental

1) injury d/t -??? h/o abuse +/-

2) any signs of
head injury +/-
 Any h/o of injury from high speed projectile particles +/-
Examination in detail:
ocular examination:
1) visual acuity: Best corrected visual acuity.
2) skin and subcutaneous tissue : if any lacerations +/-
site, size , and depth.
3) eye brows :
4) eye lids and lid margins, and both canthal regions should be
examined.
5) ecchymosis , edema of periorbital tissues +/-
 slit lamp examination :
conjunctiva, sclera, cornea , anterior chamber, iris, pupil, lens, extra ocular
movements,
IOP, and fundus examination should be done in detail.
 Examination of orbit:
superior ,inferior , and lateral orbital margins along with nasal side
walls should be palpated. To R/O any orbital fractures.
 Examination of cranial nerves:
all cranial nerves should be examined carefully.
ORBITAL FRACTURES

 CLASSIFICATION:
classified mainly:
1) fractures involving orbit:
- orbital floor, medial wall, roof of orbit.

2) fractures involving orbit and facial skeleton.

- Zygomatico-maxillary fracture.
- Naso - orbito-ethmoid fracture.
BLOW-OUT FRACTURES
 Definition:
fracture of one or more of its internal walls caused by blunt trauma
to orbit.

• Fracture of orbital floor, medial wall

Pure blow out or both with intact bony margin.
fracture.

• Fractures that occur in conjugation

Impure blow out with a fracture of the orbital rim.
fracture.
 Mechanism of injury :

fracture at
backward Increased
the weakest
Blunt injury displacement intraocular
of eyeball point of
pressure
orbital bone
 Hydraulic theory:
elevation in intra orbital
pressure transmits force to the
orbital walls creating a fracture
at the weakest point.
Energy required: 71mj
 Buckling theory:
Direct trauma to the thick
infraorbital rim transmits the
force posteriorly and creates
compression fracture at the
floor’s weakest point.
SYMPTOMS:
1) Eyelid ecchymosis/haematoma.
2) Unable to move eyes.
3) Diplopia
4) Numbness in certain regions of face
5) Subcutaneous emphysema
6) Blindness
7) Intraocular pain.
 SIGNS:
1) Enophthalmos
2) Edema
3) Haematoma
4) Globe displacement
5) Restriction of eye movements
6) Infraorbital anaesthesia.
 EXAMINATION:
 thorough ocular examination should be done , vision and pupillary
response for optic neuropathy
 Assess extra ocular motility : to r/o for any extra ocular muscle
entrapment, ischaemia, haemorrhage or any orbital compartment
syndrome.
 globe position – Hertel’s exophthalmometry.
Eyelids and periorbital tissues should be palpated – r/o any sub
cutaneous emphysema ,or any orbital rim fractures.
 patient should be asked to open and closed his mouth
– r/o pain or trismus which may be associated with
zygomatic complex fracture.
Slit lamp examination and fundus examination.
Assessing severity of diplopia – Diplopia charting ,
Hess charts/Lees scree
INVESTIGATIONS:
 CT ( coronal and sagittal ) : GOLD STANDARD
 MRI
X-RAY ORBITS:
water’s view:
1) “tear drop opacity.”
2) fragmentation and irregularity of orbital
floor.
 MANAGEMENT:
 Medical management : for 5-7 days
1) ice packs.
INDICATIONS: 2) elevation of head.
3) use of nasal
1) No/minimal diplopia
2) Good ocular motility. decongestants.
3) No significant enophthalmos
4) Absence of entrapped muscle 4) broad spectrum oral
or tissue.
5) Fracture involving <50% of antibiotics
orbital floor. 5) oral steroids

NOSE
BLOWING IS
NOT ALLOWED
SURGICAL MANAGEMENT:
Indications:
1) unresolved diplopia in primary and downgaze
2) early enophthalmos
3) large fracture size(> 50% of the orbital floor on CT scan)
4) significant hypoglobus
5) infra orbital nerve hypesthesia.
Aim of surgery:
1) disengage entrapped structures.
2) restore oculo-rotatory functions.
3) replace orbital contents in anatomical positions
4) restore orbital size and volume.
Surgical approaches:
subciliary (preffered)
1) transcutaneous: subtarsal
orbital rim- one stroke incision.
2) trans conjunctival
3) transantral
TRANS CONJUNCTIVAL APPROACH
 a curvilinear incision is given approximately 3 mm below the tarsal
plate parallel to lower lid punctum

 this surgical plane is carried posterior to orbicularis oculi muscle , and

anterior to lower lid retractors and orbital septum.

 after reaching orbital septum, approach inferior orbital rim and incise
periosteum at the medial aspect of anterior border of inferior orbital rim

Elevate periosteum separating it from its bony attachments , starting

nasally and moving temporally until adequate exposure is obtained.
 release the entrapped tissue and repair the fracture defect with
appropriate reconstructive material.

 the periosteum with a 4/0 absorbable suture.

 Place a suture at the angle of incision

 Muscle is closed with 6/0 long acting absorbable suture.

 Skin is closed with 6/0 absorbable suture.

Reconstructive materials:
 Alloplastic implants:
porous polythelene , silastic, Teflon, silicone,
PMMA, tantalum ,ePTFE, hydroxyapatite.
 Autologous materials:
bone or cartilage
 Dissolvable alloplastic materials:
gelfilm, lactosorb
 Allogenic materials:
banked bone or lyophilized cartilage.
 Silicone blocks/sheets:

ADVANTAGES DISADVANTAGES

1) inexpensive 1) Migration.

2) Easily available. 2) Extrusion

3) Inert and stable

4) Block implants help in volume

replacement
5) Long life

6) No additional surgical site

7) Can be cut into desired size.

TITANIUM:

ADVANTAGES DISADVANTAGES

1) Easily available 1) Migration.

2) Inert and stable 2) release of aluminium into adjacent

structures and regional lymphnodes.
3) Good healing and osteointegration

4) Long life

5) No additional surgical site

6) Fixate complex shapes of facial

skeleton
7) Good for larger fractures.
e-PTFE/PorousPolyethylene/Hydroxyapatite:
 Non- antigenic.
Biologically, chemically inert.
Stable and durable.
Resistant to infection
Easily incorporated into host tissue.
Autologous implants:
cancellous bone/cartilage

Advantages Disadvantages.

1) Biologically and chemically inert 1) Requires knowledge of special

harvesting methods.

2) Non antigenic 2) More time consuming

3) Resistant to infection 3) Resorption of graft possible over

time.

4) Easily incorporated into host tissue. 4) Difficult to trim to a shape suitable

for the complex areas of the orbit.

5) Can be used to replace volume in

enophthalmos.
 Newer resorbable implants:
Polydiaxone:
 is a biodegradable material,doesnot need to be removed once placed.
It doesnot have any osteoconducting properties,used extensively in
orbital defects.
The bone growth within the torn periosteum will occur and follow the
shape of the fragments and it leads to increase in orbital volume.
Disadvantages: lead to sinus/excessive scar formation.
It is used in <2cm defects.
Complications of surgery:
1) diplopia
2) lowerlid retraction
3) implant extrusion: due to infection
oversized implant
4) infection
5) infraorbital sensory loss
6) undercorection of enophthalmos
POST-OP MANAGEMENT:
 Nose blowing is not allowed
 IV antibiotics are recommended at the time of
surgery if implant is placed
 Postoperative antibiotics given for 5-7 days.
 Oral steroids
 Antibiotic ointment is applied in the fornices or at the
site of wound twice daily for 1-2 weeks.
WHITE EYED BLOW OUT FRACTURE:
 sub group of orbital blow out fracture with little visible external soft
tissue injury usually effecting orbital floor.
 urgent repair is required to avoid permanent neuromuscular damage.
Usually seen in < 18 yrs of age.
 it involves the acute incarceration of herniated tissues in a “trap- door
effect” and occurs because of the greater elasticity of bone in young
children
 acute nausea, vomiting, headache, and persistent activation of
Oculocardiac reflex.
 SURGICAL APPROACH:
surgical repair is done through transconjunctival/sub ciliary incision
through the maxillary sinus

Periosteum is elevated from the orbital floor

freeing of trapped orbital contents

repair of the bony defect with a synthetic implants.

MEDIAL WALL FRACTURE:
 Medial wall orbital fractures usually associated with orbital
floor fractures.
 Signs:
periorbital echymosis
subcutaneous emphysema that develops on blowing the
nose
defective ocular motility involving abduction and
adduction
Investigations:
x ray orbit
CT and MRI
Treatment:
repair involves release of incarcerated tissue and repair of the
bony defect using reconstructive materials
 ORBITAL ROOF FRACTURE
 orbital roof fractures are relatively uncommon orbital fractures
accounting 1-9% of all facial fractures.
 30% of all orbital roof fractures are in paediatric population.

Etiology :
in adults : high –energy blunt trauma like
RTA , assault or fall
in children: low energy blunt trauma.
 Isolated orbital roof fractures:
Mainly associated with craniofacial injuries including frontal sinus,
naso orbito ethmid fracture, and lefort fractures.
most common presentation is “csf rhinorrhea”
Classification:
mainly into 3 types
1) non displaced fracture
2) Isolated blow-in fracture
3) Isolated blow-up fracture.

• Inferior displacement of orbital roof

Blow in without involvement of the superior
orbital rim
fractures
• Displacement of orbital roof
Blow up superiorly into the anterior cranial
fossa without involvement of the
fractures superior orbital rim.
Examination:

1) decreased vision , colour vision, pupillary defects – r/o

traumatic optic neuropathy.
2) decreased extraocular motility – r/o EOM entrapment.
3) Eyelid haematoma
4) Any lacerations on eye brow or upper eyelid
5) CSF rhinorrhea +/-
Management:
conservative, surgery not indicated.
urgent surgical repair:
Indications: 1) direct optic nerve compression
2)Expanding orbital haemorrhage.
3) perforating eye injury
4) early evidence of meningitis.
Delayed repair:
Indications: 1) enophthalmos
2) persistent csf fistula
3) bony impingement causing diplopia or ptosis.
 Surgical approach:
multiple approaches are there like extracranial , intracranial,
endonasal endoscopic approaches .
Extracranial approaches: upperlid crease incision , brow incision, lynch,
bicoronal incisions
Intracranial approaches: craniotomy
Endonasal endoscopic approach: decompression of optic canal
not used for reduction of fracture.
NASO ORBITO ETHMOIDAL
FRACTURES:
 most commonly due to high impact trauma.
NOE fracture refers to a delicate three-dimensional structure
involves frontal process of maxilla , and may involve ethmoid
bone, lacrimal bone, nasal bone or frontal bone.
It may occur isolated or along with other fractures including
high Le Fort -2 and Le fort -3 fractures.
 Classification:
comminution of the fracture NOE fracture divided
+ into 3 types.
Involvement of medial canthal tendon

• Minimal comminution with the medial canthal tendon

Type-I attached to large bone segment.

• More severe comminution of the bone fragments with the

medial canthal tendon remaining attached to a bone
Type-II fragment.

• Severe comminution with disruption of medial canthal

Type-III tendon.
Clinical findings:
1)telecanthus
2)flattened nose with widened nasal dorsum
3)nasal bone instability
4)Upturned nasal tip
5)epistaxis or rhinorrhea on intranasal examination
6) mobility of medial canthal tendon
7) signs of NLD obstruction.
MANAGEMENT:
 Surgical reduction with internal fixation with microplates.
 TYPE-1:
Plating of the unstable fracture.
 TYPE-2 & 3 :
transnasal wiring for stabilization of the medial canthal tendon

During repair of NOE fractures nasolacrimal duct is injured

Initially: bony fragments are repaired

after 3 months

Dacrocystorhinostomy ( if indicated)
LE-FORT FRACTURES:
 caused by high velocity trauma.
May be isolated or in conjugation with other facial fractures.
 based on extension of fracture through pterygoid plates, and
their association with maxillary trauma and craniofacial
dysfunction Le fort fractures classified into 3 types.
 CLASSIFICATION:

Le-Fort -1 Le-Fort –II Le Fort –III

 Guerin fracture  Pyramidal fracture.  Craniofacial dysfunction
 Low transverse  Fracture through the  Fracture through the
fracture through the nasal bridge, lacrimal, nasal bridge , entire orbit,
maxillary alveolus and maxillary bones and laterally through the
separating teeth from extending through the frontozygomatic suture.
the upper face. medial orbital floor and  This completely detaches
from the lower facial
 No orbital inferior orbital rim near skeleton.
involvement. the infra orbital canal.
 EXAMINATION:
 includes dental occlusion abnormalities,
 BATTLE SIGN( bruising over the mastoid),
 CSF rhinorrhea,
 Mid face segment mobility,
 Retrusion assessment.
ORBITAL HAEMORRHAGE:
 orbital haemorrhage is one of the oculoplastic surgery emergencies
as bleeding with in the orbit can quickly cause vision loss as a result of
orbital compartment syndrome.
 most commonly occurs following trauma with or without bony orbital
injury.
Iatrogenic orbital haemorrhage may result from peri-or retro bulbar
local anaesthetic block .
Rare causes include bleeding from vascular anomalies.and bleeding d/
t poor clotting.
 Diagnosis:
increased IOP,proptosis, eyelid edema, ecchymosis, ocular
motility dysfunction,haemorrhagic chemosis, decreased visual
acuity.
 Treatment:
treatment should be started immediately.
CANTHOTOMY:
at the angle of lateral canthus.after clamping the
incision site for 60 sec,a horizontal full thickness
incision under local anaesthesia is given.
 Cantholysis:
Following canthotomy ,lower lid is retracted downwards and the inferior
crus of the lateral canthal tendon is cut using blunt tipped scissors,
directed inferiorly and inserted adjacent and parallel to the lateral orbital
rim b/w conjunctiva and skin and angled away from eye ball.
Blood is drained slowly.
INTRA ORBITAL FOREIGN BODIES:
 a foreign body in orbit may be metallic, inert materials like glass
or vegetative matter.
 mostly d/t high-velocity injuries, including projectiles, occupational
trauma, or d/t blast injuries, can also occur from organic materials like
tree branches.
CLINICAL FEATURES:
1) Orbital edema
2) Ecchymosis
3) Recurrent orbital infections,
4) Abscess,
5) Fistula formation. If a sharp or unstable foreign body it may damage
optic nerve.
 Investigations;
plain X-ray- demonstrates radio opaque /metallic fb.
MRI – C/I in metallic fb is suspected.
helpful in detecting wooden fb
CT: goldstandard , it can detect even small fb.
 Management:
 magnetic removal of iron fb involves creation of
Sclerotomy adjacent to fb, with application of magnet
followed by cryotherapy to retinal break.
 Non magnetic fb- forceps removal
 broad spectrum antibiotics are given prophylactically.