Facial Orbital Fracture Repair

Introduction

Traumatic facial injuries might result in orbital fractures, injuring the bones surrounding the eye socket. These fractures can cause various symptoms, such as double vision, enophthalmos (sunken eye look), and pain with eye movements. These fractures are divided into two types: hydraulic fractures, which occur due to increased orbital pressure, and buckling fractures, which occur by the displacement of the orbital rim. In many situations, the fracture is caused by a mixture of these factors. Understanding the anatomy, clinical findings, and treatment choices for orbital fractures is critical for optimal healing and restoration of the eye's aesthetic look and functional skills.

What Is an Orbital Floor Fracture?

Orbital floor fractures are most commonly caused by blunt eye socket or midface trauma. The orbital floor is prone to fracture due to its morphology, particularly the thin portion covering the infraorbital neurovascular bundle. This bundle, which includes the infraorbital nerve and artery, runs within the orbital floor.

In orbital floor fractures, the inferior orbital rim is usually intact. Two theories can explain the mechanism of orbital floor fractures: the hydraulic hypothesis and the buckling theory. According to hydraulic theory, direct trauma to the eyeball raises intraorbital pressure, resulting in a "blowout" fracture of the thin orbital floor.

This fracture causes bone fragments and orbital structures to be displaced into the maxillary sinus. The buckling theory proposes that blunt trauma to the face presses the orbit, causing the weakest point in the orbital floor to bend and break, resulting in a fracture.

How to Examine and Diagnose Orbital Fractures?

The clinical examination is critical in identifying orbital floor fractures. Numerous findings may be related to an inferior orbital wall fracture. A step-off across the inferior orbital rim might detect an anterior extension of the fracture. If the inferior rectus muscle becomes entrapped in the fracture site, upward movement of the eyes may be restricted.

Damage to the infraorbital neurovascular bundle, usually linked with infraorbital groove fractures, can result in hypesthesia in the area supplied by the infraorbital nerve. In situations of considerable loss of support due to a large inferior orbital wall fracture, enophthalmos may occur, which involves the displacement of the globe into the orbit. Furthermore, blood in the maxillary sinus can indicate the potential for an orbital floor fracture. Notably, orbital blowout fractures in children might look differently than in adults. Children may have minor periorbital edema, subconjunctival bleeding, injections, and reduced eye movement during the upward movement of the eyes due to inferior rectus muscle entrapment. Prompt diagnosis and treatment are critical for avoiding long-term consequences such as persistently restricted eye movement.

How to Manage Orbital Fractures?

When there is a risk of extraocular muscle entrapment, restricted strabismus, or substantial globe malposition, surgical treatment for orbital fractures is indicated. General anesthesia and various incisions and procedures to reach and fix the fracture site are commonly used in orbital fracture repair surgery.

General anesthesia is generally used for orbital fracture healing. A forced duction test may be performed before surgery to evaluate globe limitation owing to entrapment. This test can also be done following surgery to assess restriction release. The primary measurement is the direct sight of soft tissue release from the fracture site's perimeter.

• Incision Techniques: A swinging eyelid incision, a lateral canthotomy, or inferior cantholysis, is a frequent technique for orbital floor fractures. This method requires cutting an incision with a No. 15 blade and then removing the inferior ramus of the lateral canthal tendon. The conjunctiva and lower eyelid retractors are then incised between the inferior fornix and the inferior portion of the tarsus. The dissection proceeds below the infraorbital rim, raising the periosteum and exposing the fracture site. Alternative incision approaches, such as external subciliary or direct rim incisions, are linked with complications such as eyelid malposition and visible scars. In some circumstances, transnasal and transantral endoscopic methods are used.

• Exposure of the Fracture Site: After the incision is made, the fracture site is carefully dissected to expose it. A Freer or Cottle elevator gently elevates the periosteum posteriorly into the orbit. At the same time, a pliable retractor covers the globe and improves the visibility of the orbital tissues. The orbital soft tissues are delicately lifted from the fracture site using a hand-over-hand method. A muscle hook or forceps can retrieve fragments of the fractured bone. To assure the release of all herniated or entrapped tissue, the orbital floor fracture must be completely exposed, particularly the posterior margin.

• Placement of an Orbital Floor Implant: Various orbital implants are available to correct orbital floor fractures. Nonporous alloplastic thin implants, such as nylon foil implants, are frequently used. These implants may adjust to the orbital walls while providing appropriate support for the orbital contents. The implant size is carefully chosen to avoid issues such as globe displacement or interference with extraocular muscle function. The implant is carved to fit the orbital floor, with enough overlap over the fracture margins. Visualizing the fracture and verifying that the implant is positioned correctly is critical.

• Closure and Postoperative Care: Sutures seal the conjunctiva and lower eyelid retractors once the implant has been placed. Ophthalmic antibiotic ointment may be used, and postoperative globe observation is required to identify any hemorrhage. Patients with orbital fracture repair surgery might suffer bruising and edema around the eye for several weeks. Cold compresses and head elevation can help minimize edema. Pain relievers may be prescribed. Patients should clean around the eye during healing, remove stitches within five to 10 days, and use antibiotics to avoid infection. Keeping a close eye on your vision to discover issues is critical. Recovery can take several months, and follow-up sessions with the surgeon are required to ensure the best possible results.

Conclusion

Orbital fractures can cause serious functional and cosmetic consequences. Understanding the anatomy and clinical manifestations of orbital floor fractures is critical for precise diagnosis and therapy. To restore stability and function, orbital fractures are surgically repaired with careful dissection, exposure of the fracture site, and implantation of an orbital floor implant. Individuals with orbital fractures can regain visual acuity and facial appeal with correct surgical intervention and postoperative care, enhancing their quality of life.