orbit floor fx slides
TRANSCRIPT
Orbital Floor FracturesOrbital Floor Fractures
Divine DesignDivine Design
Important in the design of the orbit is its inherent Important in the design of the orbit is its inherent ability to protect vital structures by allowing ability to protect vital structures by allowing fractures to occur. Because the globe is fractures to occur. Because the globe is surrounded by fat and the medial wall and floor of surrounded by fat and the medial wall and floor of the orbit are thin, force that is transmitted to the the orbit are thin, force that is transmitted to the globe allows fracture of the orbit without significant globe allows fracture of the orbit without significant globe injury. This accounts for the significantly globe injury. This accounts for the significantly higher incidence of fractures of the orbit as higher incidence of fractures of the orbit as compared to open globe injuries. compared to open globe injuries.
PathophysiologyPathophysiology
Bone conduction theory Bone conduction theory “buckling”“buckling” Less energyLess energy Small fractures limited Small fractures limited
anterior floor anterior floor
Hydraulic theoryHydraulic theory More energyMore energy Larger fracture involving Larger fracture involving
entire floor and medial wallentire floor and medial wall Should suspect more Should suspect more
extensive orbit involvement extensive orbit involvement with associated injuries with associated injuries (globe rupture)(globe rupture)
HistoryHistory
Mechanism of injuryMechanism of injury Double vision, blurry visionDouble vision, blurry vision EpistaxisEpistaxis V2 numbnessV2 numbness MalocclusionMalocclusion Nausea and vomiting Nausea and vomiting
(especially in children)(especially in children) Abuse? Repeated falls? Abuse? Repeated falls?
Frequent ER visits? Frequent ER visits? (children)(children)
Ali vs. sonney listonAli vs. sonney liston Maya KulenovicMaya Kulenovic
Physical ExamPhysical Exam
Full Head and Neck examFull Head and Neck exam Cardiac examCardiac exam (Bradycardia, low BP)(Bradycardia, low BP) Facial asymmetryFacial asymmetry V2 examV2 exam Exam of canthal stability Exam of canthal stability
(Bowstring Test)(Bowstring Test) EntrapmentEntrapment Pupillary exam Pupillary exam
(Marcus Gunn pupil)(Marcus Gunn pupil) Retinal examRetinal exam Hurtel exophthalmometryHurtel exophthalmometry
ImagingImaging
C-Spine X-raysC-Spine X-rays Plain Films of limited Plain Films of limited
useuse MRI if retinal, optic MRI if retinal, optic
nerve, or intracranial nerve, or intracranial concernsconcerns
CT Facial bones CT Facial bones (most useful)(most useful)
Indications for RepairIndications for Repair
Diplopia that persists beyond 7 to 10 days Diplopia that persists beyond 7 to 10 days Obvious signs of entrapment Obvious signs of entrapment Relative enophthalmos greater than 2mm Relative enophthalmos greater than 2mm Fracture that involves greater than 50% of the Fracture that involves greater than 50% of the
orbital floor (most of these will lead to significant orbital floor (most of these will lead to significant enophthalmos when the edema resolves) enophthalmos when the edema resolves)
Entrapment that causes an oculocardiac reflex Entrapment that causes an oculocardiac reflex with resultant bradycardia and cardiovascular with resultant bradycardia and cardiovascular instability instability
Progressive V2 numbnessProgressive V2 numbness
Immediate repairImmediate repair
Nonresolving oculocardiac Nonresolving oculocardiac reflex with entrapmentreflex with entrapment– Bradycardia, heart block, Bradycardia, heart block,
nausea, vomiting, syncopenausea, vomiting, syncope
Early enophthalos or Early enophthalos or hypoglobus causing facial hypoglobus causing facial asymmetryasymmetry
““White-eyed” floor fracture White-eyed” floor fracture with entrapmentwith entrapment
Clinical Recommendations for Repair of Isolated Orbital Floor Fractures, An Evidence-based Analysis, Michael A Burnstine, MD, Ophthalmology 2002; 109: 1207-1210.
Repair Within Two WeeksRepair Within Two Weeks
Symptomatic diplopia with positive forced Symptomatic diplopia with positive forced duction testduction test
Large floor fracture causing latent Large floor fracture causing latent enophthalmosenophthalmos
Significant hypoglobusSignificant hypoglobus Progressive infraorbital hypesthesiaProgressive infraorbital hypesthesia
Clinical Recommendations for Repair of Isolated Orbital Floor Fractures, An Evidence-based Analysis, Michael A Burnstine, MD, Ophthalmology 2002; 109: 1207-1210.
ObservationObservation
Minimal diplopiaMinimal diplopia– Not in primary or downgazeNot in primary or downgaze
Good ocular motilityGood ocular motility No significant enophthalmosNo significant enophthalmos No significant hypoglobusNo significant hypoglobus
Clinical Recommendations for Repair of Isolated Orbital Floor Fractures, An Evidence-based Analysis, Michael A Burnstine, MD, Ophthalmology 2002; 109: 1207-1210.
Trapdoor FracturesTrapdoor Fractures
Trapdoor fractures with entrapment differ in Trapdoor fractures with entrapment differ in children and adultschildren and adults– Children repaired within 5 days of injury do Children repaired within 5 days of injury do
better that those repaired within 6-14 days or better that those repaired within 6-14 days or those repaired > 14 daysthose repaired > 14 days
– There is no difference in early timing of adults There is no difference in early timing of adults (1-5 days or 6-14 days)(1-5 days or 6-14 days)
– Adults repaired less than 14 days from injury Adults repaired less than 14 days from injury have less long term sequela than those have less long term sequela than those repaired greater than 14 days from injuryrepaired greater than 14 days from injury
The Differences of Blowout Fracture of the Inferior The Differences of Blowout Fracture of the Inferior Orbital Wall Between Children and Adults, Kwon et Orbital Wall Between Children and Adults, Kwon et al. Archives Oto head & Neck.al. Archives Oto head & Neck.
Transconjunctival, Subciliary, Transconjunctival, Subciliary, Subtarsal Approaches Subtarsal Approaches
Transconjunctival ApproachTransconjunctival Approach
TransconjunctivalTransconjunctival– No visible scarNo visible scar– Less incidence of ectropion and scleral showLess incidence of ectropion and scleral show– Poorer exposure without lateral canthotomy and Poorer exposure without lateral canthotomy and
cantholysis cantholysis – Better access to the medial orbital wallBetter access to the medial orbital wall– Risk of entropionRisk of entropion
Transconjunctival ApproachTransconjunctival Approach
Subciliary ApproachSubciliary Approach
Subciliary advantagesSubciliary advantages– Easier approachEasier approach– Scar camouflageScar camouflage– Skin necrosisSkin necrosis– Highest incidence of ectropionHighest incidence of ectropion– Highest incidence of scleral showHighest incidence of scleral show
Subtarsal ApproachSubtarsal Approach
Subtarsal AdvantagesSubtarsal Advantages– Easiest approachEasiest approach– Direct access to floorDirect access to floor– Good exposureGood exposure– Postoperative edema the worstPostoperative edema the worst– Visible scarVisible scar
DissectionDissection
Stay below orbital Stay below orbital septumseptum
24/12/6mm rule24/12/6mm rule Remove entrapped Remove entrapped
inferior rectus muscleinferior rectus muscle Slightly overcorrect if Slightly overcorrect if
possiblepossible Avoid V2 injuryAvoid V2 injury
Picture of dissection Picture of dissection herehere
Materials for reconstructionMaterials for reconstruction
Autogenous tissuesAutogenous tissues– Avoid risk of infected implantAvoid risk of infected implant– Additional operative time, donor site morbidity, Additional operative time, donor site morbidity,
graft absorptiongraft absorption– Calvarial bone, iliac crest, rib, septal or auricular Calvarial bone, iliac crest, rib, septal or auricular
cartilagecartilage
Septal Cartilage repairSeptal Cartilage repair
EnophthalmosEnophthalmos Maxillary sinus Ostia Maxillary sinus Ostia
obstructionobstruction Deviated SeptumDeviated Septum Septoplasty, MMA, Septoplasty, MMA,
floor repair with septal floor repair with septal cartilagecartilage
Septal Cartilage repairSeptal Cartilage repair
Floor reducedFloor reduced Maxillary Sinus ClearMaxillary Sinus Clear Septum StraighterSeptum Straighter Endophthalmos Endophthalmos
improvedimproved
Conchal cartilage repairConchal cartilage repair
Curve of concha can Curve of concha can approximate curve of approximate curve of orbitorbit
Can place with Can place with concave surface down concave surface down for overcorrectionfor overcorrection
Two site surgeryTwo site surgery Entire concha needed Entire concha needed
for significant floor for significant floor fracturesfractures
Materials for reconstructionMaterials for reconstruction
Alloplastic implantsAlloplastic implants– Decreased operative time, easily available, no Decreased operative time, easily available, no
donor site morbidity, can provide stable supportdonor site morbidity, can provide stable support– Risk of infection 0.4-7%Risk of infection 0.4-7%– Gelfilm, polygalactin film, silastic, marlex mesh, Gelfilm, polygalactin film, silastic, marlex mesh,
teflon, prolene, polyethylene, titaniumteflon, prolene, polyethylene, titanium
Materials for reconstructionMaterials for reconstruction
Ellis and Tan 2003Ellis and Tan 2003– 58 patients, compared titanium mesh with 58 patients, compared titanium mesh with
cranial bone graftcranial bone graft– Used postoperative CT to assess adequacy of Used postoperative CT to assess adequacy of
reconstructionreconstruction– Titanium mesh group subjectively had more Titanium mesh group subjectively had more
accurate reconstructionaccurate reconstruction
Endoscopic Balloon catheter repairEndoscopic Balloon catheter repair
Wide MMAWide MMA Insert Foley and inflateInsert Foley and inflate Leave in place for 7-10 daysLeave in place for 7-10 days Best for large trapdoor fractures Best for large trapdoor fractures
without entrapmentwithout entrapment Broad spectrum antibioticsBroad spectrum antibiotics
Endoscopic Orbital Floor RepairEndoscopic Orbital Floor Repair
Caudwell Luc Caudwell Luc approachapproach
Large MMA will Large MMA will allow larger working allow larger working spacespace
Endoscopic Endoscopic reduction of floor reduction of floor contentscontents
May secure with May secure with antral wall bone, antral wall bone, synthetic material, synthetic material, or Foleyor Foley
ComplicationsComplications
BlindnessBlindness Orbital HematomaOrbital Hematoma Infection of hardware Infection of hardware EntropionEntropion EndophthalmosEndophthalmos DiplopiaDiplopia
Orbital HematomaOrbital Hematoma
Poor Vascular perfusion of Poor Vascular perfusion of the optic nerve and retinathe optic nerve and retina
Early recognitionEarly recognition ““Gray Vision”Gray Vision” ProptosisProptosis EcchymosisEcchymosis Subconjunctival Subconjunctival
hemorrhagehemorrhage Afferent pupil defectAfferent pupil defect Hard globeHard globe
Orbital HematomaOrbital Hematoma
TreatmentTreatment– Lateral Canthotomy Lateral Canthotomy
(immediately)(immediately)– Lateral canthal tendon Lateral canthal tendon
lysis (immediately)lysis (immediately)– IV acetazolamide IV acetazolamide
500mg 500mg – IV mannitol 0.5 g/kgIV mannitol 0.5 g/kg– Surgical decompression Surgical decompression
of the orbitof the orbit
ComplicationsComplications
Abscess over implantAbscess over implant Requires Implant Requires Implant
removalremoval More common with More common with
synthetic floor implantssynthetic floor implants
ComplicationsComplications
Pyogenic granulomaPyogenic granuloma EntropionEntropion
ComplicationsComplications
Late left proptosisLate left proptosis Hemorrhage into Hemorrhage into
implantimplant
LagniappeLagniappe
Medial orbital wall fracturesMedial orbital wall fractures– Most common orbital wall fractureMost common orbital wall fracture– Weakest area of the orbitWeakest area of the orbit– Very commonly asymptomaticVery commonly asymptomatic– Can have entrapment of medial rectusCan have entrapment of medial rectus– Can get orbital emphysema with nose blowingCan get orbital emphysema with nose blowing– Approach through Lynch or Approach through Lynch or
Transcaruncular/Medial fornix incisionTranscaruncular/Medial fornix incision
LagniappeLagniappe
LagniappeLagniappe
LagniappeLagniappe
Orbital dystopiaOrbital dystopia-The -The bony orbital cavities do bony orbital cavities do not lie in the same not lie in the same horizontal plane horizontal plane ((Horizontal DystopiaHorizontal Dystopia) ) or the same vertical or the same vertical plane (plane (Vertical Vertical DystopiaDystopia`).`).
Questions?Questions?
ReferencesReferences
Clinical Recommendations for Repair of Isolated Orbital Clinical Recommendations for Repair of Isolated Orbital Floor Fractures, An Evidence-based Analysis, Michael A Floor Fractures, An Evidence-based Analysis, Michael A Burnstine, MD, Burnstine, MD, OphthalmologyOphthalmology 2002; 109: 1207-1210. 2002; 109: 1207-1210.
Cummings: Otolaryngology Head and Neck Surgery 4th Cummings: Otolaryngology Head and Neck Surgery 4th ed. Chapter 26, Maxillofacial Trauma, Robert M. ed. Chapter 26, Maxillofacial Trauma, Robert M. Kellman, Mobsy, Inc. 2005.Kellman, Mobsy, Inc. 2005.
Buckling and Hydraulic Mechanisms in orbital Blowout Buckling and Hydraulic Mechanisms in orbital Blowout Fractures: Fact or Fiction?, Ahmad et al, Journal of Fractures: Fact or Fiction?, Ahmad et al, Journal of Craniofacial surgery, vol 17, 438-441Craniofacial surgery, vol 17, 438-441
The Effect of Striking Angle on the Buckling Mechanism The Effect of Striking Angle on the Buckling Mechanism in Blowout Fracture, Nagasao et al, Journal of Plastic in Blowout Fracture, Nagasao et al, Journal of Plastic and Reconstructive Surgery, Vol 117, number 7, March and Reconstructive Surgery, Vol 117, number 7, March 0505