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Floor Orbital Fracture Treatment & Management

  • Author: Geoffrey M Kwitko, MD, FACS, FICS; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Jun 28, 2016
 

Medical Care

When orbital edema is severe, steroids may be used to decrease orbital edema. However, most cases do not require any medical intervention. In addition, most cases are managed on an outpatient basis.[8, 5] Elderly patients may require antibiotics given preoperatively and continued for 2 weeks postoperatively. Patients should be advised to avoid nose blowing for several weeks after the injury to prevent orbital emphysema and possible visual compromise.

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Surgical Care

The criteria for surgical intervention in blowout fractures are controversial; however, 3 general guidelines exist for surgical intervention.[9]

  • Diplopia due to limitation of upgaze and/or downgaze with a positive forced duction test and radiologic confirmation of an orbital floor fracture is an indication of entrapment of the inferior rectus or the perimuscular tissues surrounding the inferior rectus. If diplopia is still present 10-14 days after trauma, a need for release and repair is indicated. Diplopia may be present initially after trauma but may resolve as the neuropraxia and/or orbital edema subsides.
    • A subclass of orbital fracture with entrapment is the so-called white-eye fracture in children.[10]
    • Several studies have shown that children may be more prone to pure trap door fractures than adults and incarceration of the muscle in such fractures can lead to permanent damage of the neuromuscular complex.[11]
    • Several studies have demonstrated more complete resolution of diplopia if these cases are operated on very early or as soon as the diagnosis is made. Careful examination of the CT scan is essential since there is often no loss of the floor and a lack of blood in the maxillary sinus.
  • Enophthalmos of greater than 2 mm 10-14 days after trauma is cosmetically significant and is an indication for surgery. Orbital edema that is present initially may mask any enophthalmos. Therefore, measurements must be rechecked once the orbital edema has subsided. This usually occurs 10 days to 2 weeks after injury.
  • A fracture involving one third or more of the orbital floor usually leads to a cosmetic and/or functional deformity. If left unattended, these fractures tend to result in significant enophthalmos.

When surgery is indicated, it is usually best performed as close to 2 weeks from the trauma date as possible. This allows the swelling to subside and a more accurate examination of the orbit to be performed. Additionally, the scarring usually has not advanced enough to prohibit adequate surgical correction.

Access to the orbital floor usually is made through an inferior fornix approach. This allows the surgeon to avoid a cutaneous incision and scar. Alternatively, a lower eyelid subciliary incision can be used but will result in a cutaneous scar. Both approaches allow easy elevation of the periorbita along the floor and release of entrapped orbital contents. An implant (eg, MEDPOR, calvarial bone, Supramid, silicone) is placed over the fracture site. The surgeon must ensure that adequate ledges of stable bone are present for the implant to sit on. Then, the periorbita is closed over the implant along the orbital rim. If the orbital rim is involved and unstable, microplates may be screwed directly into the floating bone segment to anchor it to stable bone.

  • Multiple implant options are available for the repair of orbital floor fractures. Some surgeons harvest split-thickness calvarium for an implant, although this significantly lengthens the surgical time and increases the potential complications.
  • Allograft materials, such as Supramid or silicone sheets, have been commonly used and are easy to work with. However, these implants can migrate or form capsules and may need to be removed later.
  • More recently, many surgeons are using porous polyethylene (MEDPOR) because of its ease of use (moldable and easily shaped) and its ability to become incorporated in the soft tissue. Its porosity, like other integrated implants such as hydroxyapatite, allows this material to remain firmly fixated in the position that the surgeon places it. [12]
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Activity

Physical activity is limited for about 3-6 weeks after surgery to prevent re-injury. This may involve restricting gym class for students. Any contact sports should be avoided for this period.

Nose blowing should also be avoided for about 4-6 weeks to prevent orbital emphysema.

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Contributor Information and Disclosures
Author

Geoffrey M Kwitko, MD, FACS, FICS Clinical Associate Professor, Department of Ophthalmology, University of South Florida College of Medicine

Geoffrey M Kwitko, MD, FACS, FICS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, International College of Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Ron W Pelton, MD, PhD Private Practice, Colorado Springs, Colorado

Ron W Pelton, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, AO Foundation, American Society of Ophthalmic Plastic and Reconstructive Surgery, Colorado Medical Society

Disclosure: Nothing to disclose.

References
  1. Della Rocca RC, Nassif JM. Blowout fractures. Linberg JV, ed. Oculoplastic and Orbital Emergencies. Appleton & Lange; 1990. 155-165.

  2. Green RP Jr, Peters DR, Shore JW, et al. Force necessary to fracture the orbital floor. Ophthal Plast Reconstr Surg. 1990. 6(3):211-7. [Medline].

  3. Kersten RC. Blowout fracture of the orbital floor with entrapment caused by isolated trauma to the orbital rim. Am J Ophthalmol. 1987 Feb 15. 103(2):215-20. [Medline].

  4. Bansagi ZC, Meyer DR. Internal orbital fractures in the pediatric age group: characterization and management. Ophthalmology. 2000 May. 107(5):829-36. [Medline].

  5. Rubin PAD, Bilyk JR, Shore JW. Management of orbital trauma: fractures, hemorrhage, and traumatic optic neuropathy. Focal Points: Clinical Modules for Ophthalmologists. 1994. 12:7.

  6. Gilbard SM, Mafee MF, Lagouros PA, et al. Orbital blowout fractures. The prognostic significance of computed tomography. Ophthalmology. 1985 Nov. 92(11):1523-8. [Medline].

  7. Tan Baser N, Bulutoglu R, Celebi NU, Aslan G. Clinical management and reconstruction of isolated orbital floor fractures: The role of computed tomography during preoperative evaluation. Ulus Travma Acil Cerrahi Derg. 2011 Nov. 17(6):545-53. [Medline].

  8. Smith B, Regan WF. Blow-out fractures of the orbit: mechanism and correction of internal orbital fracture. Am J Ophthalmol. 1957. 44:733.

  9. Piombino P, Iaconetta G, Ciccarelli R, Romeo A, Spinzia A, Califano L. Repair of orbital floor fractures: our experience and new technical findings. Craniomaxillofac Trauma Reconstr. 2010 Dec. 3(4):217-22. [Medline]. [Full Text].

  10. Jordan DR, Allen LH, White J, et al. Intervention within days for some orbital floor fractures: the white-eyed blowout. Ophthal Plast Reconstr Surg. 1998 Nov. 14(6):379-90. [Medline].

  11. Egbert JE, May K, Kersten RC, et al. Pediatric orbital floor fracture : direct extraocular muscle involvement. Ophthalmology. 2000 Oct. 107(10):1875-9. [Medline].

  12. Magaña FG, Arzac RM, De Hilario Avilés L. Combined use of titanium mesh and resorbable PLLA-PGA implant in the treatment of large orbital floor fractures. J Craniofac Surg. 2011 Nov. 22(6):1991-5. [Medline].

 
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Coronal CT scan of orbits demonstrating loss of orbital floor on the left in contrast to the normal orbital floor on the right.
 
 
 
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