Blow-out Fracture

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M Rinaldi Dahlan

Cicendo Eye Hospital Bandung Department of Ophthalmology Faculty of Medicine Universitas Padjadjaran

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Introduction

 Orbital fracture is the most common type of fracture of the orbital walls

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Introduction

 Medial wall

 Orbital floor  most vulnerable

 The term Blow-out fracture refers specifically to the fracture of an orbital wall in the presence of an intact orbital rim

 The thin part of the maxillary bone ( 0,5 mm thick in this area)

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Introduction

 Mc Kenzie (1844)  describe floor fracture

 Smith and Converse (1956)blow out fracture

 Mechanism:

Blunt traumapushes the orbital tissue

posteriorlyincrease in intraorbital pressurethe orbital bones to break at their weakest point posterior medial aspect of the orbital floor

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Clinical Presentation

 External sign: Lid edema, subcutaneous or orbital emphysema, Ecchymosis, Subconjunctival

hemorrhage, enophthalmos, globe ptosis

 on some occasions, there may be little or no signs of external injury

 Ocular injury  anisocoria can occur with inferior floor fracture

 Diplopia

 Infraorbital nerve hypesthesia

 Ocular Motility, small fracture incarcerate

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Evaluation

 Visual acuity, pupil, intraocular pressure, biomicroscopy and fundus.

 Globe position  hertel exophthalmometry

 Ocular motility  injury to the extra ocular muscle or cranial nerve palsy

 Diplopia visual fields

 Photographs  as documentation  for patients to appreciate an acceptable operative result

 Force duction test  paretic and restrictive motility patterns

 X ray , CT scans

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Cicendo 102, Cares for Vision

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Management

 Smith and Converse: early surgical correction

 Putterman et al: 4-6 months surgical and non surgical

 Dutton: early repair symptomatic persistent

diplopia with positif force ductions, CT evidence of orbital tissue or muscle entrapment, no clinical

improvement over 1-2 weeks, enophthalmos of 3mm or more, significant globe ptosis, floor defect > 50%

 Conservative/ observation: minimal diplopia with good motility, no CT evidence of tissue entrapment, absence enophthalmos or globe ptosis.

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 The goal of blowout # repair :

- Free entrapped orbital tissue

- Return orbital volume to normal

 In children: early surgery ( 2-4 days) has been advocated trapdoor defect  cause

ischemic damage and tissue fibrosis

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Treatment and repair

 Surgical: 7-10 days to allow swelling and hemorrhage to subside

 Anesthesia: general, neurolepsia

 Approached: subcilia or transconjunctival  orbital rim periosteum elevated off the orbital floor until the fracture site is

identified entrapped tissue is freed

carefully and elevated from the defect insert material for floor reconstruction

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Postoperative Care

 Ice packs +/- 48 hours

 Broad spectrum antibiotics: 5-7 days

 Patients are advised not to blow their nose

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Complications

 The result of injury itself or the surgical repair

 Optic nerve injury

 Retrobulbar hemorrhage  immediate surgical exploration and drainage is

necessary

 Implant migration and extrusion

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Another technique:

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Blow-out Fracture - perpustakaan rs mata cicendo