Blowout Fracture

Hadijah

Blowout Fracture
Terminologi : fraktur dasar orbita m. Rektus inferior terjebak dalam sinus maksilaris pergerakan bola mata terhambat
1.

Direct fractures (Unpure Blowout fractur)

2.

Indirect fractures (Pure Blowout fractur)

History

Mechanism of injury Double vision, blurry vision Epistaxis V2 numbness Malocclusion Nausea and vomiting

Clinical Features

Intraocular pain Diplopia Inability to move eye ball Epistaxis Blindness (rarely) Enopthalmos Oedema Globe displacement Infraorbital anesthesia Pupillary dysfunction

Signs of orbital floor blow-out fracture

Periocular ecchymosis and oedema Infraorbital nerve anaesthesia

Ophthalmoplegia typically in up- and down- gaze (double diplopia)

Enophthalmos - if severe

X- ray paranasal sinuses

Prolapsed orbital contenx classic tear drop sign

Hemosinus hazy maxillary sinus

Investigations of orbital floor blow-out

Coronal CT scan

Right blow-out fracture with tear-drop sign

Management for blowout fracture :

Blowout fracture (edema +, orbital hemorrhage +) Oral steroids (1 mg/kg/day) for 7 days

Edema (-)
Force duction test (+) Surgery

Force duction test

Indication for surgical repair

Persistent diplopia in the primary position of gaze Symptomatic disturbance of ocular motility Radiological evidence of intraocular muscle entrapment enophthalmos greater than 2mm Large fractures involving the floor of the orbit (more than 50%) Infraorbital nerve anesthesia/hypoesthesia Presence of oculo cardiac reflex (common in trap door type of fracture) (Bradycardia, heart block, nausea, vomiting, syncope)

Transconjunctival, Subciliary, Subtarsal Approaches

Transconjunctival Approach

Transconjunctival
No visible scar Less incidence of ectropion and scleral show Poorer exposure without lateral canthotomy and cantholysis Better access to the medial orbital wall Risk of entropion

Transconjunctival Approach

Subciliary Approach

Subciliary advantages Easier approach Scar camouflage Skin necrosis Highest incidence of ectropion Highest incidence of scleral show

Subciliary Approach...

a. Subciliary incision b. Periosteum elevated and entrapped orbital contents freed Defect repaired with synthetic material Periosteum sutured

Subtarsal Approach

Subtarsal Advantages Easiest approach Direct access to floor Good exposure Postoperative edema the worst Visible scar

Orbital Hematoma

Poor Vascular perfusion of the optic nerve and retina Proptosis Ecchymosis Subconjunctival hemorrhage Afferent pupil defect Hard globe

Orbital Hematoma

Treatment

Lateral Canthotomy (immediately) Lateral canthal tendon lysis (immediately) IV acetazolamide 500mg IV mannitol 0.5 g/kg Surgical decompression of the orbit

Complications

Decreas visual acuity/blindness Diplopia Undercorection/overcorrection enoftalmus Lower eyelid retraction Infection Extrusion of implant

Terimakasih

trap door type of fracture