orbit-floor-fx-slides-070411 - Orbital Floor Fractures...

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Unformatted text preview: Orbital Floor Fractures Orbital Jacques Peltier MD Francis Quinn MD Grand Rounds Presentation Department of Otolaryngology University of Texas Medical Branch at University Galveston Galveston April 11, 2007 Divine Design Divine Important in the design of the orbit is its inherent Important 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. Pathophysiology Pathophysiology Bone conduction theory Bone “buckling” “buckling” Less energy Small fractures limited Small anterior floor Hydraulic theory Hydraulic More energy Larger fracture involving Larger entire floor and medial wall entire Should suspect more Should extensive orbit involvement with associated injuries (globe rupture) (globe History History Mechanism of injury Double vision, blurry vision Epistaxis V2 numbness Malocclusion Nausea and vomiting Nausea (especially in children) (especially Abuse? Repeated falls? Abuse? Frequent ER visits? (children) (children) Ali vs. sonney liston Maya Kulenovic Physical Exam Physical Full Head and Neck exam Cardiac exam (Bradycardia, low BP) (Bradycardia, Facial asymmetry V2 exam Exam of canthal stability Exam (Bowstring Test) (Bowstring Entrapment Pupillary exam Pupillary (Marcus Gunn pupil) (Marcus Retinal exam Hurtel exophthalmometry Imaging Imaging C-Spine X-rays Plain Films of limited Plain use use MRI if retinal, optic MRI nerve, or intracranial concerns concerns CT Facial bones CT (most useful) (most Indications for Repair Indications Diplopia that persists beyond 7 to 10 days Diplopia Obvious signs of entrapment Obvious Relative enophthalmos greater than 2mm Relative Fracture that involves greater than 50% of the Fracture orbital floor (most of these will lead to significant enophthalmos when the edema resolves) Entrapment that causes an oculocardiac reflex Entrapment with resultant bradycardia and cardiovascular instability Progressive V2 numbness Immediate repair Immediate Nonresolving oculocardiac Nonresolving reflex with entrapment reflex – Bradycardia, heart block, Bradycardia, nausea, vomiting, syncope nausea, Early enophthalos or Early hypoglobus causing facial asymmetry asymmetry “White-eyed” floor fracture White-eyed” with entrapment with 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 Weeks Repair Symptomatic diplopia with positive forced Symptomatic duction test duction Large floor fracture causing latent Large enophthalmos 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. Observation 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. Trapdoor Fractures Trapdoor Trapdoor fractures with entrapment differ in Trapdoor children and adults children – Children repaired within 5 days of injury do Children better that those repaired within 6-14 days or those repaired > 14 days those – There is no difference in early timing of adults There (1-5 days or 6-14 days) (1-5 – Adults repaired less than 14 days from injury Adults have less long term sequela than those repaired greater than 14 days from injury repaired The Differences of Blowout Fracture of the Inferior Orbital Wall Between Children and Adults, Kwon et al. Archives Oto head & Neck. al. Transconjunctival, Subciliary, Subtarsal Approaches Transconjunctival Approach Transconjunctival Transconjunctival – No visible scar – Less incidence of ectropion and scleral show – Poorer exposure without lateral canthotomy and Poorer cantholysis – Better access to the medial orbital wall – Risk of entropion Transconjunctival Approach Transconjunctival Subciliary Approach Subciliary Subciliary advantages – Easier approach – Scar camouflage – Skin necrosis – Highest incidence of ectropion – Highest incidence of scleral show Subtarsal Approach Subtarsal Subtarsal Advantages – Easiest approach – Direct access to floor – Good exposure – Postoperative edema the worst – Visible scar Dissection Dissection Stay below orbital Stay septum septum 24/12/6mm rule Remove entrapped Remove inferior rectus muscle inferior Slightly overcorrect if Slightly possible possible Avoid V2 injury Picture of dissection Picture here here Materials for reconstruction Materials Autogenous tissues – Avoid risk of infected implant – Additional operative time, donor site morbidity, Additional graft absorption graft – Calvarial bone, iliac crest, rib, septal or auricular Calvarial cartilage cartilage Septal Cartilage repair Septal Enophthalmos Maxillary sinus Ostia Maxillary obstruction obstruction Deviated Septum Septoplasty, MMA, Septoplasty, floor repair with septal cartilage cartilage Septal Cartilage repair Septal Floor reduced Maxillary Sinus Clear Septum Straighter Endophthalmos Endophthalmos improved improved Conchal cartilage repair Conchal Curve of concha can Curve approximate curve of orbit orbit Can place with Can concave surface down for overcorrection for Two site surgery Entire concha needed Entire for significant floor fractures fractures Materials for reconstruction Materials Alloplastic implants – Decreased operative time, easily available, no Decreased donor site morbidity, can provide stable support donor – Risk of infection 0.4-7% – Gelfilm, polygalactin film, silastic, marlex mesh, Gelfilm, teflon, prolene, polyethylene, titanium teflon, Materials for reconstruction Materials Ellis and Tan 2003 – 58 patients, compared titanium mesh with 58 cranial bone graft cranial – Used postoperative CT to assess adequacy of Used reconstruction reconstruction – Titanium mesh group subjectively had more Titanium accurate reconstruction accurate Endoscopic Balloon catheter repair Endoscopic Wide MMA Insert Foley and inflate Leave in place for 7-10 days Best for large trapdoor fractures Best without entrapment without Broad spectrum antibiotics Endoscopic Orbital Floor Repair Endoscopic Caudwell Luc Caudwell approach approach Large MMA will Large allow larger working space space Endoscopic Endoscopic reduction of floor contents contents May secure with May antral wall bone, synthetic material, or Foley or Complications Complications Blindness Orbital Hematoma Infection of hardware Infection Entropion Endophthalmos Diplopia Orbital Hematoma Orbital Poor Vascular perfusion of Poor the optic nerve and retina the Early recognition “Gray Vision” Proptosis Ecchymosis Subconjunctival Subconjunctival hemorrhage hemorrhage Afferent pupil defect Hard globe Orbital Hematoma Orbital Treatment – Lateral Canthotomy Lateral (immediately) (immediately) – Lateral canthal tendon Lateral lysis (immediately) lysis – IV acetazolamide IV 500mg – IV mannitol 0.5 g/kg – Surgical decompression Surgical of the orbit of Complications Complications Abscess over implant Requires Implant Requires removal removal More common with More synthetic floor implants synthetic Complications Complications Pyogenic granuloma Entropion Complications Complications Late left proptosis Hemorrhage into Hemorrhage implant implant Lagniappe 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 Approach Transcaruncular/Medial fornix incision Transcaruncular/Medial Lagniappe Lagniappe Lagniappe Lagniappe Lagniappe Lagniappe Orbital dystopia-The -The bony orbital cavities do not lie in the same horizontal plane (Horizontal Dystopia) or the same vertical plane (Vertical plane Vertical Dystopia`). Dystopia Questions? Questions? References References Clinical Recommendations for Repair of Isolated Orbital Clinical Floor Fractures, An Evidence-based Analysis, Michael A Burnstine, MD, Ophthalmology 2002; 109: 1207-1210. Ophthalmology Cummings: Otolaryngology Head and Neck Surgery 4th Cummings: ed. Chapter 26, Maxillofacial Trauma, Robert M. Kellman, Mobsy, Inc. 2005. Mobsy, Buckling and Hydraulic Mechanisms in orbital Blowout Buckling Fractures: Fact or Fiction?, Ahmad et al, Journal of Craniofacial surgery, vol 17, 438-441 Craniofacial The Effect of Striking Angle on the Buckling Mechanism The in Blowout Fracture, Nagasao et al, Journal of Plastic and Reconstructive Surgery, Vol 117, number 7, March 05 05 ...
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This note was uploaded on 12/28/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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