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