Orbital Fractures

Orbital fractures are breaks that occur in the bones surrounding the eyes.

THERE ARE TWO TYPES:

Orbital rim fractures, which are breaks in the rim of the orbit. Blow-out fractures, which affect only an inner wall or the floor of the orbit and maintain a healthy rim Fractures of the orbit are completely different from those that can occur in a hand or leg. The main difference is that the bones surrounding the eyes support the structures and muscles that operate the eyes, but have no movement. Therefore, not all fractures need to be repaired.

SYMPTOMS

Orbital fractures may produce the following symptoms:
Double vision
Sinking of the eye or Enophthalmos
Pain associated with eye movements
Anesthesia or decreased sensation in the cheek and teeth

DOUBLE VISION

Double vision occurs when a muscle that moves the eye is trapped inside the fracture and affects its movement. This is very common in children but highly unlikely in adults. It is important to perform an early repair of fractures in children to release the trapped muscle. If repair is delayed, the orbital muscles and fat may be damaged by compression of the bones and surgery is less likely to correct double vision.

SINKING OF THE EYE (ENOPHTHALMOS)

Sinking of the eye or eyeball is called enophthalmos and occurs when the fractured bones cause the volume of the orbit to increase significantly. In the first few days following trauma, there is usually edema within the orbit and the degree of sinking may not be noticeable to its full extent. Fortunately, CT scans of the orbit help to assess the degree of involvement and to predict whether a person is likely to develop significant enophthalmos. Approximately 50 % of fractures do not cause double vision or significant enophthalmos and therefore do not require surgical repair. In that case, it is advisable to simply administer antibiotics and avoid straining in order to achieve spontaneous healing. Pain associated with eye movements.
Occasionally, the muscles trapped within a fracture may cause pain on movement, a situation which also typically occurs in children.

ANESTHESIA OR DECREASED SENSATION IN THE CHEEK AND TEETH

The infraorbital nerve is the nerve that carries sensation to the cheek and teeth. This nerve runs along the floor of the orbit through a canal that is often involved in fractures. This causes trauma to the nerve. There is usually a spontaneous recovery of sensation after a few weeks or months.

What does the surgery consist of?

It involves elevating with extreme care the displaced contents of the orbit, and placing a plate to replace the broken bone. When there is a fracture of the orbital rim, it is necessary to implant titanium screws and microplates.

Does the surgery leave scars?

The orbital bones can be accessed fully through incisions hidden inside the eyelid, that is, through the conjunctiva. This prevents visible scars.

Is it possible for the plates used in the repair to become infected?

There is always a possibility that a foreign material or graft can become infected. Fortunately, this risk is extremely low –less than 1 %– thanks to the use of antibiotics during surgery, and the use of sterile surgical techniques.

Will it be necessary to remove the plates in the future?

The removal of an orbital plate is very rare. The plate becomes incorporated into the tissues as the arteries and veins grow inside them and it becomes part of the body. In children, and sometimes in adults, reabsorbable plates can be used, which broken down by the body after several months.

What happens with orbital rim fractures?

These fractures must be repaired when they are displaced from their normal position. This is detected by palpating a protrusion, or through a CT scan. Titanium microplates with small screws are usually used to align and fix the fragments of the fractured orbital rim.

Is it urgent to repair an orbital fracture?

The only case in which it is necessary to repair it urgently, is the “Trapdoor Fracture” which is seen in kids when a muscle is trapped inside the fracture. The sooner it is resolved, the better. In the other cases, there isn’t matter of urgency, and it can wait until the inflammation is reduced or it can even be done later in time, if side-effects appear (eye sinking).

BEFORE AND AFTER

case 1

BEFORE:

Patient with trapdoor fracture or trapping, presenting with inability to look up with the left eye and permanent double vision.

after:

Following urgent surgery, the patient regained full movement and corrected her double vision.

case 2

BEFORE:

This patient had a history of a motorcycle crash against a wall 9 years before. He had been treated and undergone surgery in a neighboring country. He presented with marked inferior displacement of the left eyeball and inability to look up. A CT scan of the orbit showed a large foreign body located above the eye.

Surgery:

An incision was made in the upper eyelid crease and the foreign body was removed. It turned out to be a tile fragment that still had paint on one side.

after:

Recovery was very favorable in both eye position and eyelid elevation.