Orbital fracture – Orbital floor fracture
An orbital fracture occurs when one of the bones surrounding the eyeball (called the orbit) breaks. This type of injury is usually caused by a violent compression trauma: a punch, a gunshot wound, etc. In the event of a fracture, the eyeball collapses, creating a communication between the sinuses and the orbit. There is a risk of compression of an eye muscle and a risk of infection. If you suspect an orbital fracture following trauma, avoid blowing your nose and consult an ophthalmologist immediately. A CT scan will be performed, and surgery may be necessary to reduce the fracture.
What is an orbital fracture?
In the event of trauma, all the bones surrounding the eye can be fractured or broken. Here are the three most common types of orbital fractures:
Orbital floor fracture
This is the most common type of orbital fracture. It occurs when a blow or trauma is inflicted on the rim of the orbit, pushing the bones backwards.
This mechanism causes the bones of the orbital floor to break, causing them to collapse downwards.
This fracture can also affect the muscles and nerves around the eye, preventing it from moving properly.
The patient will complain of diplopia that worsens when looking upwards.
Fracture of the inner wall of the orbit
The inner surface of the orbit is the second thinnest bone in the orbital cavity after the floor.
A sudden and violent ocular compression can therefore cause the inner surface of the orbit to rupture, with or without damage to the associated floor.
Orbital rim fracture
This fracture affects the outer bony edges of the orbit. Since the rim is made of very thick and solid bone, only a very violent trauma can cause it.
Road accidents and blunt force trauma are among the main causes.
A fracture of the orbital rim should prompt a search for other associated fractures and for cerebral contusions or bleeding.
Blowout fracture
A burst fracture is a rupture of the floor and/or the inner wall of the orbit.
These fractures usually cause sudden diplopia, without entrapment of a muscle or nerve because the orbital bones are completely collapsed.
Symptoms of an orbital fracture
The symptoms of an orbital fracture depend on the type of fracture and the severity of the injury. The main symptoms are:
Hematoma – Presence of bruising, edema and a black eye.
Edema – Swelling of the forehead, cheek and eyelid.
Hypoesthesia – Numbness on the injured side of the face.
Blurred vision or a severe decrease in vision.
Diplopia – Double vision, which is exacerbated in extreme gazes.
Subconjunctival hemorrhage – Blood in the white of the eye.
Pain upon eye movement or palpation around the eye.
Exophthalmos or endophthalmos – Presence of a bulging or sunken eyeball.
Emphysema – Crackles when touched due to air under the skin.
ATTENTION !
If crepitus is felt under the skin upon palpation, it is certain that you have a fracture of the orbital floor with communication to the sinus.
Do not blow your nose, as air will enter your sinuses and could compress the optic nerve. Such an action can cause sudden blindness.
Diagnosis
To check for an orbital fracture, an ophthalmologist will examine the eye and the surrounding area. They will assess vision, eye movement, and the fundus of the eye.
Since the ophthalmological examination is generally limited, he will then refer you to a radiologist who will analyze the bone, fat and muscle structures of the orbit using a facial scan.
To assess the visual impact, the surgeon may request a Lancaster test . This test helps to detect diplopia (double vision).
Causes
Orbital fractures are caused by violent trauma. The main types are:
The punches.
Road accidents.
Projectiles: tennis ball, golf ball, champagne cork, flashball,…
Blunt force trauma: bat, …
How are orbital fractures treated?
Most often, a fracture of the orbit does not require surgery.
If the orbital fracture is small and will not affect your vision in the long term, medical treatment will be recommended. Typical treatment includes:
Contraindication to blowing one's nose.
Nasal washes and, if necessary, decongestants.
Icing the eye with a mask placed in the freezer or with ice cubes 2 to 3 times a day.
Pain relievers such as paracetamol, with or without codeine.
Antibiotic prophylaxis, not Amoxicillin.
In cases of displaced fracture with oculomotor disturbance, intervention will be recommended.
Orbital fracture surgery
Orbital fractures fall within the scope of expertise of ophthalmologists specializing in oculoplastic surgery and maxillofacial surgeons. Surgery is indicated:
In an emergency if a muscle is trapped in a bone fragment.
Delayed treatment may be given once the swelling has subsided if you experience diplopia or an eye movement disorder.
Orbital floor fracture surgeries are most often performed on an outpatient basis, under general anesthesia.
The procedure lasts approximately 1 hour.
Steps in the operation
During this procedure, the surgeon will follow these steps:
An incision is made below the eyelash line or at the level of the conjunctiva to avoid any unsightly scarring.
Release of collapsed tissues adjacent to the fracture.
Installation of a biological fabric support plate.
Closing.
After the procedure, you will be monitored for a few minutes in the recovery room and then you can return to the outpatient unit before going home accompanied.
Your eye will be covered with a bandage to be removed the next day.
Follow-up and recovery
With or without surgery, a work stoppage of 7 to 15 days will be necessary to allow the edema to subside and the vision to stabilize.
Regular ophthalmological follow-up will be scheduled and adapted to your healing process.
Complications
Fractures of the orbital floor are found in cases of severe facial trauma. Therefore, it is not uncommon to find:
An injury to the eyeball.
A hemorrhage from the eye socket.
A sinus and orbital infection.
Incarceration and necrosis of an extraocular muscle.
Avulsion of a sensory nerve, motor nerve, or optic nerve.
A residual diplopia even after healing.
Surgical complications
Surgical complications are specific to the surgical procedure. All the complications listed above can occur. In addition, the following may also occur:
Muscle fibrosis against the reinforcement plate.
The increase in diplopia.
The persistence of a protrusion or retraction of the globe.
Conclusion
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Orbital fractures, and in particular fractures of the orbital floor, are not uncommon following ocular trauma.
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The scan confirms the diagnosis, but the presence of diplopia will determine whether or not surgery is necessary.
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The procedure takes place under general anesthesia and allows a flexible plate made of biological tissue to be inserted to reinforce the fractured bone.