Orbit blow out fractures

Tavishi Bishnoi
1622059
Blow-out fractures are isolated comminuted fractures which
occur when the orbital walls are pressed indirectly. These
mainly involve orbital floor and medial wall.
Blow-out orbital fractures generally result from trauma to the orbit by
a relatively large, often rounded object, such as
tennis ball, cricket ball, human fist or part of an automobile.

The force of the blow causes a backward displacement of the eyeball

and an increase in the intraorbital pressure; with a resultant fracture at
the weakest point of the orbital wall. Usually, this point is the orbital
floor, but this may be the medial wall also.
The orbital wall is formed by several bones of the skull. The orbit
(eye socket) has four walls — roof, floor, medial wall, and lateral
wall — and each is formed by different bones:
1. Roof (superior wall):
• Frontal bone
• Lesser wing of sphenoid
2. Floor (inferior wall):
• Maxilla
• Zygomatic bone
• Palatine bone (orbital process)
3. Medial wall:
• Maxilla (frontal process)
• Lacrimal bone
 • Lacrimal bone
• frontal bone
• Ethmoid bone
• Sphenoid bone
(body)
4. Lateral wall:
• Zygomatic
bone
• Greater wing of
 The orbit is pyramidal in shape, with a base (not body) anteriorly and
an apex posteriorly. The thinnest wall of the orbit is the medial wall, not
the floor.
Mechanism of injury

There are two Main theories that

explain mechanism of injury
1)Hydraulic theory
2)Buckling theory
Hydraulic theory:

When a blunt object (like a ball) hits the

eye directly, it causes a sudden rise in
intraorbital pressure.
• The globe (eyeball) pushes backward
and compresses the orbital contents.
•This pressure is transmitted equally in
all directions, leading to fracture of the
weakest part of the orbital wall — usually
the floor or medial wall
Buckling theory :
The force of the impact is transmitted through the
orbital rim, especially the inferior rim (lower border
of orbit).
•This force travels like a shockwave through the
bones (like a buckle), causing the orbital floor to
“bend” and fracture at a point distant from the
impact
 Types
• a) Pure blowout fracture: Fracture of the
orbital floor with
intact orbital rim
• b) Impure blowout fracture: Associated
fracture of the orbital
rim.
These are associated with other fractures
about the middle third of the facial
skeleton
 Pure blow Impure blow
out out
fractures fractures
Orbital Intac Fracture
rim t d
Orbital floor Fractured Fractured

Indirect
Mechanis Direct trauma to
trauma (force
m of orbital rim/face
injury through globe)
 Clinical features :
1. Periorbital edema and blood extravasation in
and around the orbit (such as subconiunctival ecchymosis immediately. This may mask
certain signs and symptoms seen later.
•2. Emphysema ofthe eyelids occurs more frequently
with medial wall than floor fractures. It may be made
I• worse by blowing of the nose.
. 3. Paraesthesia and anaesthesia in the distribution of
infraorbital nerve (lower lid, cheek, side of nose,
upper lip and upper teeth are very common.

• 4. Ipsilateral epistaxis as a result of bleeding from

maxillary sinus into the nose is frequently noted in
early stages.
 5. Proptosis of variable degree may also be present
• initially because of the associated orbital oedema
• and haemorrhage.

6. Enophthalmos and mechanical ptosis. After about

10 days, as the oedema decreases, the
eyeball
sinks backward and somewhat inferiorly resulting
° in enophthalmos and mechanical ptosis.
Clinically significant enophthalmos (22 mm) occurs wILl increase in
the bony orbital volume of 1.5-2 ml.
 Three factors responsible for producing
enophthalmos are:
• escape of orbital fat into the maxillary
sinus;
• backward traction on the globe by entrapped
inferior rectus muscle;
and
enlargement of the orbital cavity from
displacement of fragments.
 7.Diplopia also becomes evident after the decrease
in oedema.
• It typically occurs in both up and down
gaze (double diplopia) due to entrapment of soft tissue structures in
the area of the blowout fracture.
•Due to restriction of ocular motility. With the entrapment of
inferior orbital tissue and inferior rectus muscle, vertical diplopia is
more prominent in upgaze.
 Force duction test :

•The forced duction test is a clinical test used to determine if restricted eye
movement is due to mechanical restriction (like in orbital blowout fractures) or due
to nerve/muscle paresis (like in cranial nerve palsy)

In orbital blowout fractures:

• A forced duction test is usually positive.
• This means resistance is felt when the examiner tries to passively move the eye
(especially upward).
• The restriction is due to entrapment of the inferior rectus muscle or orbital fat in the
fracture site (usually the floor of the orbit)
 Interpretation:
•Positive forced duction test = Mechanical
restriction (like entrapment in blowout fractures).
• Negative test = Likely a nerve palsy or
muscle weakness rather than a physical
entrapment
The presence of muscle restriction can be
confirmed
by a positive 'forced duction test'.
 8. Severe ocular damage associated with blow-out
fracture is rare. This is because a 'blow-out fracture' is
nature's way of protecting the globe from injury.
Nevertheless, the eye should be carefully examined to
exclude the possibility of intraocular damage.
White eye fracture :
• signs of injury can be absent (white-eyed
blowout).
It is a condition in which blow out fracture is
only detectable on X ray no other
symptoms are present
• Diplopia can be present on upward gaze
 Orbital
imaging:

1)Plain X-rays. The most useful projection for detecting an orbital

floor fracture is a nose-chin (Water's) view.
The common Roentgen findings are:
• fragmentation and irregularity of the orbital floor; •depression of

bony fragments and

• 'hanging drop' opacity of the superior maxillary antrum from
orbital contents herniating through the floor
 2. Computerised tomography scanning and magnetic
resonance imaging (MRI). These are of greater value for
detailed visualisation of soft tissues. Coronal sections
are particularly useful in evaluating the extent of the
fracture and herniation of contents into maxillary
antrum (hanging drop or tear drop sign).
Management:
1. Initial Assessment & Stabilization
:Rule out globe rupture, optic
nerve injury, and other facial
fractures
2. Indications for Urgent Referral
• Entrapment of extraocular muscles (especially
inferior rectus) causing diplopia
 3. Conservative Management (for minor fractures):
If there is no cosmetic /functional problem then
conservative management is done that includes :
• Ice packs for 24–48 hours.
• Head elevation to reduce swelling.
• Analgesics and anti-inflammatory drugs.
• Antibiotics (if sinus involvement).
• Avoid nose blowing (to prevent orbital emphysema).
• Monitor for diplopia or vision changes
4. Surgical Management (usually after 1–2 weeks
unless urgent):

Indications:
• Persistent diplopia with positive forced duction
test.
• Enophthalmos >2 mm.
• Large floor defects >50% on CT.
• Muscle entrapment
 Contraindication:
• Retinal detachment
• Globe perforation
• Only seeing eye
• Medically unstable patient
 5. Follow-Up
• Monitor for:
• Visual acuity
• Eye movements
• Enophthalmos
• Diplopia