Key points
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Orbital fractures are among the most common facial fractures sustained among adolescents and adults.
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The surgical decision making in management of orbital fractures is largely dependent on patient-specific and surgeon-specific factors.
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Although many approaches to the orbit have been described, the armamentarium of a surgeon should include at least 3 of those outlined in this article.
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Postoperative complications in management of orbital fractures can be largely avoided with meticulous surgical technique.
Introduction: nature of the problem
Epidemiology
Orbital fractures are exceedingly common, encompassing up to 16% of all facial fractures. These fractures are more common in adults, with a mean age of 32 years old, with the most common mechanism of injury being motor vehicle collision in adults and sport-related trauma in adolescents/children. The lower incidence in the adolescent population is likely because of the larger proportion of cancellous to cortical bone providing more elasticity and protective malar buccal fat pads. Although less common, orbital floor fractures in children are more likely to present with diplopia, extraocular muscle entrapment ,and nausea/emesis.
Orbital anatomy, pattern of injury
The orbit is composed of 7 bones and is quadrilateral pyramidal shaped with an average volume of 30 cm 3 . Important surgical landmarks to recognize are the optic canal, which is 40 to 45 mm from the medial wall, as well as the anterior and posterior ethmoidal foramen, which are 24 mm and 36 mm from the anterior lacrimal crest, respectively. Orbital injuries may be either blow-in or, more commonly, blowout patterns. The blow-in pattern results from high-velocity injuries to anterior cranial base and lead to decreased orbital volume with downward and forward displacement of the globe. The blowout pattern may lead to increased orbital volume and a posterior/inferior displacement of the globe, likely secondary to the compression forces buckling the orbital floor as force is transferred along the inferior orbital rim ( Fig. 1 ).
Surgical technique
Preoperative planning
The history and physical examination are essential portions of preoperative planning. The findings from the clinical examination directly influence your surgical treatment planning and outcome. The complete assessment is beyond the scope of this text, but all patients with facial trauma should have a complete primary and secondary survey completed per advanced trauma life support (ATLS) guidelines to rule out any life-threatening trauma. Changes to visual acuity or pupillary reactivity and dysfunction of the extraocular muscles are first assessed to determine the severity of the orbital trauma and need for surgical intervention. Based on the findings, orbital trauma can be categorized into operative or nonoperative injuries and further defined based on urgency of repair as absolute (less than 24 hours), relative (within 24 hours, if possible), or delayed (within 2 weeks). Computed tomography (CT) without contrast is the standard imaging for orbital trauma evaluation ( Fig. 2 ).
Indications and contraindications
See Table 1 .
| Operative Management | Indications |
| Absolute indication for immediate repair (<24 h) |
|
| Relative indication for immediate repair (within 24 h, if possible) |
|
| Indication warranting delayed repair (within 2 wk) |
|
| Nonoperative Management | Contraindications |
| Observation |
|
Reconstruction and implant selection
See Table 2 .
| Advantages | Disadvantages | Indications | |
|---|---|---|---|
| Alloplastic | |||
| Titanium |
|
|
|
| Titanium-reinforced porous polyethylene |
|
|
|
| Patient specific |
|
|
|
| Resorbable polymerized poly l -lactide (PLLA) |
|
|
|
| Resorbable poly l -lactide-co-glycolide |
|
|
|
| Autogenous | |||
| Calvarial bone |
|
|
|
| Cartilage |
|
|
|
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