Residency · Residency · Ophthalmology
Orbital Fractures and Surgical Repair
Introduction
Orbital fractures are common sequelae of facial trauma and can result in functional and cosmetic deformity. The orbit is composed of seven bones, with the floor (maxillary bone) and medial wall (lamina papyracea) being the thinnest and most frequently fractured. Timely evaluation and appropriate surgical intervention are essential to prevent permanent diplopia and enophthalmos.
Anatomy of the Orbital Walls
Roof: frontal bone (thick anteriorly, thins at orbital plate) Floor: maxillary bone (0.5 mm thick); contains the infraorbital nerve and canal. Medial wall: lamina papyracea of the ethmoid (0.2-0.4 mm, thinnest wall) Lateral wall: greater wing of sphenoid and zygoma (thickest wall) Orbital rim: dense cortical bone providing structural support.
Classification of Orbital Fractures
Blowout Fractures
Pure blowout: fracture of an orbital wall without rim involvement. Most common locations: floor > medial wall > combined floor and medial wall. Mechanism: hydraulic theory (globe transmits force to walls) and buckling theory (direct force on orbital rim causes wall buckling)
Other Fracture Types
Blow-in fractures: wall fragments displaced into the orbit (associated with roof fractures) Tripod (zygomaticomaxillary complex) fractures: involve lateral wall, floor, and infraorbital rim. Le Fort fractures: types II and III involve the orbit. Trapdoor fractures: linear fracture with periosteal hinge; common in children (white-eyed blowout); tissue entrapment with minimal radiographic findings. Naso-orbito-ethmoidal (NOE) fractures: involve medial wall, nasal bones, and medial canthal tendon.
Clinical Evaluation
History
Mechanism and timing of injury. Diplopia (especially in upgaze), pain, numbness, visual change. History of epistaxis (do not blow nose -- risk of orbital emphysema)
Examination
Visual acuity and pupillary exam -- rule out associated globe injury. Forced duction testing -- differentiate entrapment from muscle edema/hemorrhage. Hertel exophthalmometry -- document enophthalmos (may be masked initially by edema) Infraorbital nerve sensation -- hypesthesia in V2 distribution. Extraocular motility -- restriction (especially upgaze in floor fractures, lateral gaze in medial wall fractures) Oculocardiac reflex -- bradycardia, nausea, and syncope suggest tissue entrapment (especially in pediatric trapdoor fractures)
Imaging
CT orbit and face (thin-cut axial and coronal): gold standard. Evaluate fracture location, size, degree of herniation, muscle position. Look for associated injuries: globe rupture, retrobulbar hemorrhage, intracranial injury.
Indications for Surgical Repair
Urgent (Within 24-48 Hours)
Pediatric trapdoor fracture with muscle entrapment and oculocardiac reflex. Non-resolving oculocardiac reflex with tissue incarceration. Early enophthalmos with large fracture.
Semi-Urgent (Within 1-2 Weeks)
Persistent diplopia in functional gaze positions with positive forced ductions. CT evidence of muscle or periorbital tissue entrapment. Large floor fracture (>50% of floor or defect >2 cm) predicting late enophthalmos. Significant enophthalmos (>2 mm)
Observation
Minimal diplopia resolving with conservative management. Small fractures without entrapment or significant herniation. Isolated medial wall fractures with minimal symptoms.
Surgical Techniques
Approaches
Transconjunctival (preseptal or retroseptal) -- preferred; lower rate of lid retraction and ectropion. Subciliary -- good exposure but higher risk of lower lid malposition. Transantral (Caldwell-Luc) -- rarely used; endoscopic-assisted approach gaining popularity. Transcaruncular -- for medial wall fractures.
Implant Materials
Titanium mesh -- strong, thin, easily contoured; risk of implant palpability. Porous polyethylene (Medpor) -- tissue integration; difficult to remove if infected. Resorbable plates (PDS, PLLA) -- avoid permanent implant; limited structural support. Autologous bone (split calvarial, iliac crest) -- gold standard for large defects but donor site morbidity. Nylon foil (Supramid) -- thin, flexible; used for small defects.
| Implant Material | Advantage | Disadvantage | Best Use |
|---|---|---|---|
| Titanium mesh | Strong; easily contoured; radiopaque | Palpability; thermal conductivity | Medium-large defects |
| Porous polyethylene (Medpor) | Tissue integration; stable | Difficult removal if infected | Medium-large defects |
| Resorbable plates (PDS, PLLA) | No permanent implant | Limited structural support | Small defects; pediatric |
| Autologous bone | Biocompatible; gold standard | Donor site morbidity; resorption | Large defects |
| Nylon foil (Supramid) | Thin; flexible; inexpensive | Limited strength | Small defects |
Complications
Persistent or new-onset diplopia. Lower lid retraction or ectropion (especially with subciliary approach) Infraorbital nerve injury. Implant infection, extrusion, or migration. Retrobulbar hemorrhage (rare, vision-threatening) Residual enophthalmos.
Key Clinical Pearls
Pediatric trapdoor fractures are surgical emergencies -- muscle necrosis occurs within hours. The "white-eyed blowout" in children can have minimal external signs but severe entrapment. Never instruct a patient with orbital fracture to blow their nose. Enophthalmos may be masked by acute edema; reassess at 1-2 weeks. Forced duction testing under anesthesia is essential to confirm entrapment before repair.
References
- Burnstine MA. Clinical recommendations for repair of orbital facial fractures. Curr Opin Ophthalmol. 2003;14(5):236-240.
- Jordan DR, et al. Intervention within days for some orbital floor fractures: the white-eyed blowout. Ophthalmic Plast Reconstr Surg. 1998;14(6):379-390.
- Boyette JR, et al. Management of orbital fractures: challenges and solutions. Clin Ophthalmol. 2015;9:2127-2137.
- American Academy of Ophthalmology. Orbit, Eyelids, and Lacrimal System. BCSC Section 7. 2023-2024.