3.

3 ORBITAL FRACTURES Often occur in conjunction with zygomatic fractures, nasoethmoid, high le Fort #s Isolated orbital # from pressure to the globe. Orbit fractures at its weakest point the inferomedial floor (lamina papyracea = paper layer) Floor and Medial most common in adults Roof most common in kids - "white eye blow out" - emergency - minimal CT changes - marked motility in both up and down gaze - emergency surgery much better Blow-out a poor term according to Ken Sneddon (East Grinstead MaxFacs) CT needs to be thin-slice, high resolution, esp. for 3D Recon Enophthalmos more ignored by ophthalmologists cf MaxFacs/Plastics Relatively small (5%) changes in orbital vol can lead to significant enophthalmos Immediate enophthalmos usually means 2 point fractures Timing of repair controversial - essentially in adults - fix big defects sooner. Kids - see above.

Symptoms and signs Bruising and swelling Subconjunctival haematoma with no posterior limit Palpable steps in orbital margin Enophthalmus (may be caused by volume of orbit, volume of contents as they fall through the floor, tethering posteriorly in the # line, late sign if atrophy of intraorbital fat) Diplopia (Entrapment of fat, fascial attachments or muscles within fracture lines, contusion of the recti or oblique muscles). Usually on upward gaze as most # and tethering occur inferiorly. Radiology Site, extent and displacement PA, OM (teardrop sign fat herniating into maxillary sinus) CT scan 3D CT reconstruction.

Indications for surgery Symptomatic diplopia

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Significant enophthalmos Radiological evidence of orbital content entrapment Large bony defects Other fractures requiring fixation

Surgery Access Lower eyelid incision explore and delineate # Release any trapped structures Reduce fractures Reconstruct orbital floor Autologous (Split calvarium, rib, iliac crest, superficial segment of anterior maxilla). Alloplastic ( Titanium mesh, GoreTex, Silicone, Medpore wafers) Approaches Cutaneous - subciliary vs subtarsal vs orbital rim Skin vs skin & muscle Transconjunctival with/without lateral canthotomy Pre-septal (avoid fat) vs post septal Medial floor - Bicoronal vs Lynch (incision medial to medial canthus Materials Bone - Calvarial/Iliac crest/Rib/Antral wall/Mandible Cartilage - Septal/Ear Allogenic - banked bone/lyolysed cartilage Alloplastic - resorbable (titanium etc) vs non-resorbable (e.g. medpore, Inion membrane (still experimental) Secondary Reconstruction Bloody difficult Customised implants Moss Theory Eye socket expands if contents enlarged irrelevant here, but worth knowing

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