Orbital Floor Fracture

Abstract

The medial wall and floor of the bony orbit are frequently fractured because of the delicate anatomy. To optimize functional and aesthetic results, reconstructive surgeons should understand the anatomy and pathophysiology of orbital fractures. Appropriate treatment involves optimal timing of intervention, proper indications for operative repair, incision and dissection, release of herniated tissue, implant material and placement, and wound closure. The following review will discuss the management of orbital floor fractures, with the operative method preferred by the author. Special considerations in operation technique and the complication are also present in this article.

Keywords: Blow-out fractures; Complications; Orbital fractures; Surgery.

Fig. 1. The orbital wall consists of frontal, ethmoid, lacrimal, maxilla, zygoma, sphenoid, and palatine bones.

Fig. 2. Common fracture sites of blowout fracture of orbit (red line). Most thin portions of the orbit is medial to the infraorbital groove.

Fig. 3. Forced duction test should be performed to evaluate extraocular muscle entrapment. The examiner uses forceps to grasp the conjunctiva near the attachment of the inferior rectus muscle and attempts to move the globe through a full range of motion. Because of potential significant discomfort, this should be performed under sedation or anesthesia.

Fig. 4. Types of accesses used to expose the orbital floor: (1) subciliary, (2) subtarsal, (3) infraorbital, (4) transcaruncular, (5) tranconjuctival, and (6) transconjunctival with lateral canthotomy.

Fig. 5. Transconjunctival access to orbital floor (author's preferred technique). (A) Transconjunctival incision 1mm below inferior margin of tarsal plate. (B) After the preseptal dissection and release of arcus marginalis, subperiosteal dissection is carried out posteriorly. (C) A periosteal elevator in combination with a small malleable retractor is used to identify the margins of the fracture to free an impinged or herniated tissue. Gentle manipulation is essential to avoid intraoperative bleeding. (D) Identification of posterior shelf. The elevator is placed in the maxillary sinus and swept upward to reveal the posterior shelf. (E) Implant is usually secured with a single screw. (F) The forced duction test is repeated after implant placement.

Fig. 6. Subperiosteal dissection in the posterior area usually starts from lateral to medial side (red arrow) to allow for ready identification of the important structures (blue arrows): infraorbital nerves and vessels, origin of inferior oblique muscle, and orbital process of palatine bone, which is usually the posterior shelf.

Fig. 7. A patient with persistent diplopia for 11 months following orbital floor reconstruction. (A) At the time of the initial operation, the left medial wall and floor were repaired with an absorbable plate. (B) Diplopia test shows diplopia zone (red zone). Absorbable plates were removed and scar tissue was released in periorbital tissue during the secondary operation. The orbital floor was reconstructed with a titanium plate (C). Diplopia zone was markedly decreased in diplopia test (D).

Fig. 8. Various implants available for orbital floor reconstruction.