![]() ![]() There are several reasons to repair blowout fractures: 1) mobilize obviously entrapped extraocular muscles in cases presenting with positive forced ductions and severe subjective diplopia, 2) mobilize a large volume of herniated orbital fat back into the orbit in order to return the globe to its preinjury location in cases where greater than 2mm of enophthalmos and or diplopia are present and 3) restore orbital floor integrity and reduce herniated fat in cases with a large defect seen on CT scan but without acute evidence of entrapment or enophthalmos, in order to prevent late post traumatic enophthalmos. If there is evidence for an orbital hematoma soft tissue windows should also be obtained. While the coronal cuts are most important in demonstrating the magnitude of the blowout injury, axial cuts allow better visualization of the distance between the posterior extent of the fracture and orbital apex structures. The coronal cuts are essential as they allow a straight on cross sectional view of the orbital walls. Fine cut, noncontrast, bone windows through the orbits should be obtained in both the axial and coronal plane. The appropriate radiologic work up for an orbital blowout fracture or suspected blowout fracture is a high resolution CT scan. The patient should also be started on high dose steroids (Decadron 3/4mg/kg body weight initially followed by 1/3mg/kg every 6 hrs.) This can be done rapidly and easily at the bedside. If there is evidence for an orbital hematoma with rapidly increasing intraocular pressure (proptosis, decreased visual acuity, severe orbital pain, decreased EOM's and chemosis) a lateral canthotomy or cantholysis may need to be performed. As with malar complex fractures these patients should be given a 7 day course of antibiotics. Most of these patients will be seen, evaluated and given follow up for definitive care. The patient should be seen by an ophthalmologist prior to being discharged home from the emergency room. This is accomplished with a meticulous physical exam and an emergent CT scan if decreased vision is present. Palpate for orbital rim fractures and compare facial symmetry to exclude the possibility of an associated malar fracture.Īs with malar complex fractures the most important emergency management is to ensure that no significant ocular injury exists. Examine the eye carefully for enophthalmos or exophthalmos and ask the patient about double vision (diplopia) in all fields of gaze.ģ. Positive forced ductions suggest the eye cannot be rotated manually in one or more directions and indicate a mechanical entrapment, as opposed to decreased motion due to pain, swelling or a neurologic injury.Ģ. This involves anesthetizing the sclera and attempting to rotate the globe through full extraocular movements. An Ophthalmology consult should be obtained in all cases to evaluate the posterior chamber and to perform forced ductions if decreased EOM's are present. Head and neck trauma exam with special attention to:ġ. For example, a fracture might be described as a pure inferior blowout fracture with likely entrapment of the inferior rectus muscle resulting in severely limited up gaze. The most common muscle to be entrapped by the fracture is the inferior rectus muscle. The most commonly entrapped material following a blowout fracture is orbital fat, this alone may lead to decreased up gaze if the orbital floor is involved. A second level of differentiation is between blowout fractures with or without entrapment of orbital contents. It is important to differentiate pure blowout fractures, which do not have an associated fracture of the orbital rim, from malar complex fractures associated with orbital floor fractures. In many cases blowout fractures are associated with other fractures of the orbital rim, usually a malar complex fracture. This injury most frequently results from an impact to the anterior orbit such as with a baseball or closed fist. True blowout fractures result from a rapid increase in intraorbital pressure resulting in a herniation of orbital contents out through the thin bony orbital walls. Inferior blowout fractures involving the floor of the orbit (maxillary sinus roof) are the most common followed by medial wall blowout fractures. Gerry Funk see also: Facial Fracture Management Handbook Orbital Blowout Fractures Anatomy and Mechanism of injuryīlowout fractures of the orbit most frequently affect the middle third of the orbit where the orbital walls are the thinnest. ![]()
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