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Toronto Notes 2019 Craniofacial Injuries
Orbital Floor Fractures
• seeOphthalmology,OP40
Definition
• fractureofflooroforbit:maybea“pureblow-outfracture”,whichhasanintactorbitalrim,orcanbe associated with other fractures (orbital rim fracture and/or zygoma)
Etiology
• bluntforcetoeyeball→suddenincreaseinintraorbitalpressure(e.g.baseballorfist)
Clinical Features
• checkvisualfieldsandvisualacuityforinjurytoglobe
• periorbitaledemaandbruising,subconjunctivalhemorrhage
• ptosis,exophthalmos,exorbitism,enophthalmos,orhypoglobus
• orbitalrimstep-offswithpossibleinfraorbitalnerveanesthesia
• verticaldystopia(abnormaldisplacementoftheentireorbitalconeintheverticalplane)–assessed
by comparing the symmetry of the two pupils by a horizontal line running through the pupil of the
unaffected eye
• orbitalentrapment
■ clinical diagnosis that is a surgical emergency
■ diplopia with straight gaze: unable to look up or down (entrapment of inferior rectus), limited EOM ■ severe pain or nausea and vomiting with upward globe movement
■ requires urgent ophthalmology evaluation if there are associated visual acuity changes
Investigations
• CT(diagnostic):axialandcoronalviews–withfinecutsthroughorbit;roundingofinferiorrectusisa sign of orbital entrapment
• diagnosticmaneuverforentrapmentisforcedductiontest(pullingoninferiorrectusmusclewith forceps to ensure full ROM) under local anesthesia in the OR
Treatment
• surgicalrepairindicatedif:entrapment(urgent),anysizedefectwithenophthalmos(ifpatientis bothered by it) or persistent diplopia (>10 d)
• reconstructionoforbitalfloorwithbonegraftoralloplasticmaterial
• afterrepair,assessfordiplopia(mayrequireadditionalsurgeryforstrabismus)
Complications
• persistentdiplopia • enophthalmos
Superior Orbital Fissure Syndrome
• fractureofSOFcausingptosis,proptosis,anesthesiainV1distribution,andpainfulophthalmoplegia (paralysis of CN III, IV, VI)
• uncommoncomplicationseeninLeFortIIandIIIfractures(1/130)
• recoverytimereportedas4.8-23wkfollowingoperativereductionoffractures
Orbital Apex Syndrome
• fracturethroughopticcanalwithinvolvementofCNIIatapexoforbit
• symptomsarethesameasSOFsyndromeplusvisionloss
• treatmentisurgentdecompressionoffractureinopticcanal(posteriorcraniotomyfordecompression)
or steroids
Plastic Surgery PL33
Frontozygomatic Zygomatic arch Zygomatico-maxillary
Figure 30. Blow-out fracture
© Aimée Worrell