Introduction:
Orbital floor fractures can involve either single or multiple bones that are present within the orbit, leading to a possibility of diverse fracture patterns when traumatized. The complications associated with orbital fractures arise because of the close proximity of the orbit and the surrounding tissue to many vital intracranial structures, making surgical treatment and facial reconstruction challenging. Orbital fractures are usually considered to be a globally more common incidence in males compared to females, with the mean age of affliction in between the individuals of age group between 21 to 30 years, according to global medical statistics. The orbital floor and medial orbital wall are the most likely to be involved or fractured sites in all orbital fractures. Interdisciplinary collaboration is further required among other subspecialists to ensure good long-term function, esthetics, and post-surgical outcomes with minimal postoperative complications.
Why Orbital Fractures Are Challenging to Treat?
There are mainly six extraocular muscles (muscles that control eye movements) connected to the part of the orbit (the bony cavity in the skull that contains the eye) and attached to the globe (eyeball). The extraocular muscles include mainly the four rectus and the two oblique muscles that are responsible for all eye movements. The fat and connective tissue (tissue that supports, binds, or separates other tissues and organs) that are present surrounding the globe have the function of aiding in the reduction of extraocular muscle pressure. It is important to note for clinicians that the orbital bones in the body are not only competitively very thin and delicate in comparison to other bones in the system, but they can also be of varying shapes from individual to individual. This makes the orbit the weakest and thinnest part of the body that can be easily prone to fractures, even from relatively minor trauma. Further, because of the presence of the maxillary sinus (a large hollow space located below the orbit in the face) below in the face, the largest of the four facial paranasal sinuses that help in the resonance of the skull, a severe orbital fracture can often involve the paranasal sinuses of the face as well (a fracture that extends from the orbit to the facial sinuses) or even be a mixture of maxillary bone and orbital bone fractures that can pose a diagnostic and surgically challenging task to the maxillofacial surgeon or the plastic surgeon.
A blowout fracture is a subset of the orbital fractures or a sub-classification of these fractures that usually involves an isolated fracture of the orbital walls of the skull without compromising the orbital rims. When the fractures involve intracranial structures (structures within the skull) as well, these fractures can be easily life-threatening and require that a professional surgeon, maxillofacial surgeon, and plastic surgeon thoroughly understand the orbital anatomy in and out preoperatively using a potent diagnostic technique such as modern-day CBCT (cone beam computed tomography) or CT (computed tomography) scan, in the management of all patients with minor or moderate to severe orbital fractures.
What Are the Causes of Orbital Fractures?
The pathology of the blow-out (superficial) fractures is related to an increased hydraulic mechanism that leads to fracture without involving the orbital rim. In comparison, the orbital fractures (deep fractures) may involve intense or extreme intraorbital pressure that may increase post-fracture to the structures surrounding intracranial counterparts near the orbital rim of the individual. Examples of such common orbital fractures or blowout fractures that may not involve intracranial complications are minor falls, high-velocity sports hits to the orbit, traffic accidents, interpersonal or domestic violence, etc. Even when a blunt force is directed or often aimed at the eye, such as in acts of violence, there is more likely to be a blowout fracture that does not involve a pressure component towards the eye rim of the individual.
Orbital and blowout fractures typically usually result only from trauma, with the forces being transmitted directly towards an increase in intraorbital symptoms like pressure, pain, diplopia (double vision), optic nerve compression, visual disturbances, impaired orbital circulation, and possible ischemic damage (tissue damage caused by a lack of blood supply) of the orbital muscles, which are common clinical features reported in moderate to severe injuries.
How Are Orbital Fractures Diagnosed?
Computed tomography scan is the preferred gold standard diagnostic imaging modality of choice preoperatively for surgeons when trying to mount a full evaluation and analysis of the affected individual orbital or blowout fracture. A CT scan usually reveals that in most orbital fractures, the orbital fat or inferior rectus muscle would be often herniated into the maxillary sinus located below this and further detect if any retained foreign bodies are present as well post the fracture.
Preoperative blood work is usually an investigation that should include several parameters to be analyzed commonly, such as the CBC (complete blood count), electrolytes, and coagulation profile (tests that assess the blood's ability to clot properly). In the case of females who are affected in the age group between 21 and 30, a pregnancy test would also be needed to ensure that no postoperative complications exist if surgery is considered as per the current surgical guidelines.
How Are Orbital Fractures Managed?
The primary goal of craniofacial, maxillofacial, and plastic surgeons in treating any orbital fracture is to ensure that the aesthetics and function are restored with as conservative management as possible. However, when intracranial structures are involved, then the need for invasive surgical intervention alongside prophylactic antibiotics (to prevent oral cavity or orofacial or paranasal sinus infections) and corticosteroid therapy in reducing edema may be recommended or initiated by the surgeon. When treated on time, patients reporting mild or moderate orbital bone fractures usually heal well with appropriate conservative and antibiotic treatment. In severe cases, facial reconstruction (surgery to rebuild the face) is required post-surgery, and rehabilitation is needed to advance the patient's visual recovery and functions. Endoscopic techniques are also currently available by surgeons for treating patients with orbital fractures who have visual issues.
Conclusion:
The causes of orbital injuries would be many, ranging from moderate to severe incidents of falls, motor vehicle accidents, and domestic or mid-face or orbital assaults that, in turn, contribute to a major proportion of all mid-face fractures in the world. The presence of other injuries alongside orbital fractures may necessitate the need for surgeons and physicians to initiate emergency surgery to prevent life threats. The maxillofacial or the plastic surgeon needs to note that just like in any other conditions that are caused by head trauma, patients with suspected orbital or blowout fractures of the orbit are most likely to report to the emergency department in the hospital in either a conscious or unconscious state of mind. Unconscious individuals are at the highest risk of mortality because their condition can become life-threatening if left untreated or if they are not resuscitated immediately.
