Orbital fracture is one of the common types of craniofacial injuries, which can occur alone or in combination with other craniofacial fractures. The orbit protects the eyeball, and the orbit or the bones around the orbit are hit by external force, which may lead to orbital fracture.
Surgical anatomy
The orbit is a bone cavity for accommodating the eyeball, similar to a quadrangular pyramid, and the tip of the orbit is located at the top of the cone. The orbit consists of seven bones, such as maxilla, zygomatic bone and ethmoid bone. The orbital floor is mainly composed of maxilla, zygomatic bone and palatine bone. The inner wall of the orbit is composed of maxilla, lacrimal bone, ethmoid bone and sphenoid bone from front to back, and the main structure is extremely thin cardboard (0.2-0.4mm). The anatomy of orbital inner wall is the most complicated. Orbital floor and orbital inner wall are the most commonly involved parts of fractures.
Fault classification
Simple orbit: the orbital margin is intact and only the orbital wall is broken; Non-simple orbital fracture: combined fracture of orbital margin and orbital wall, mostly orbital fracture combined with zygomatic complex, nasoorbital ethmoid and frontal bone fracture.
[1] Fracture reason
Simple orbital fractures are mainly boxing injuries or falls, while non-simple orbital fractures are mostly traffic accidents.
[2] Disease diagnosis
In addition to checking whether there are functional and appearance defects caused by orbital fractures, we should also carry out basic ophthalmic examinations, including visual acuity, eye movement, pupil reflex, visual field and fundus examination.
Medical/medical records
Ask the patient or other witnesses about the nature, size and direction of the injury, and whether there is a history of coma after injury. The diagnosis can be made by combining clinical examination with imaging examination.
Disease symptoms
(1) Acute manifestations of fracture: intraorbital hemorrhage, periorbital edema, periorbital ecchymosis, subconjunctival hemorrhage and subcutaneous emphysema.
(2) Eyeball invagination: Fracture often causes the orbital cavity to expand, leading to downward and backward displacement of eyeball. It may not be obvious or exophthalmos in the early stage. 5? After 7 days, the swelling subsided and enophthalmos could appear.
(3) Eye movement disorder: It can be caused by displacement, traction or incarceration of extraocular muscles.
(4) diplopia can be caused by eyeball subsidence/invagination, extraocular muscle injury and oculomotor nerve injury.
(5) Visual impairment: Corneal trauma, penetrating eyeball injury, optic canal fracture and optic nerve contusion were the main causes in the early stage.
Injury or retinopathy. Later stage can be caused by glaucoma, corneal leukoplakia, cataract, optic atrophy and so on.
(6) Periorbital numbness: Most of them are caused by infraorbital nerve or supraorbital nerve injury.
[3] Auxiliary inspection
(1) Plain film: Fahrenheit film can show the orbital floor and ceiling. Indirect signs of rupture, such as teardrop appearance or gas-liquid level, can be observed through this film position. Plain film can't show the fracture of orbital inner wall well and can't locate foreign bodies.
(2)CT: The combination of axial and coronal CT images and 3D reconstructed CT images can clarify the specific situation of orbital rim and orbital wall fractures and soft tissue injuries, select surgical indications and guide the formulation of surgical plans.
(3) MRI: MRI can be used to evaluate the soft tissue injury of orbital trauma. [1-2] Edit the treatment of this disease.
Surgical therapy
If clinical examination and CT examination find that there are risk factors leading to enophthalmos and diplopia, surgery should be performed as soon as possible.
Traumatic diplopia can occur in the early stage of fracture. If the soft tissue and extraocular muscle are not impacted by CT examination, and the extraocular muscle traction test is negative, no special treatment is needed. If diplopia symptoms are obvious, eye movement is limited, and the extraocular muscle traction test is positive, CT examination shows that the extraocular muscle and its surrounding tissues are incarcerated, which requires timely surgical treatment.
When the fracture of orbital floor or orbital inner wall is simple, the fracture area of orbital wall is carefully explored through the incision under the eyelid margin or the incision of eyelid conjunctiva and the incision of outer canthus, and the orbital contents embedded in maxillary sinus and ethmoid sinus are returned, and then the edge of the defect area of orbital wall, especially the posterior boundary, is fully exposed and repaired with autogenous bone or bone replacement pad. The normal orbital floor is arched behind the ball and protrudes into the orbit. This structure is difficult to recover and can be made up by filling implants.
Matters needing attention after operation
It is recommended to use antibiotics 3 days after operation. The antibiotic can be penicillin, cephalosporin or clindamycin. According to postoperative periorbital edema and orbital contents, hormone can be used for about 3 days. Check and record your eyesight in time. Postoperative CT examination confirmed the effect of orbital wall reconstruction. It is recommended to review 3 months after operation.