Download Blow out fracture

‫‪ORBIT‬‬
‫المحجر‬
Bony Orbit
Seven bones, arranged to form a pyramidal shaped
space (orbit) which contains eye ball, EOM, Optic N.,
vessels, nerves and other connective tissue components.
 It has Base (anterior) & Apex (posterior)

Medial
Wall
Ant. back
1. Maxillary b. +  ant. Lac. Crest
Frontal b.
2. Lacrimal
 post. Lac. Crest
3. Ethmoidal (lamina paperacya)
* very thin, * blow out fracture,
* ethmoidal sinus orbital cellulitis
4. Body of sphenoid
lacrimal
fossa
Floor
Lateral
Wall
1. Maxillary bone (medially)
2. Zygomatic bone (laterally)
3. Palatine
(posteriorly)
• Infraorbital n. runs in groove, canal, foramen  lower lid
• Maxillary sinus below
* Blow out Fracture
1. Frontal bone
(above)
2. Zygomatic bone (below)
3. Greater wing of sphenoid (posteriorly)
It separates the orbit from:
1. Temporal fossa (anterior)
2. Middle cranial fossa & temporal lobe (posterior)
* Thickest wall
Roof
Frontal bone, Lesser wing of sphenoid
1. Frontal sinus (within supraorbital rim)
2. Anterior cranial fossa & frontal lobe
- Trochlea / Supra orbital notch / Fossa of
lacrimal gland.
The bony orbit Walls
Superior Orbital Fissure
Between roof & lateral wall
 Transmits structures passing between middle cranial fossa
and the orbit
1. Oculomotor n.
2. Trochlear n.
3. Ophthalmic n. branches
4. Abducens nerve
5. Superior & inferior ophthalmic vein

Inferior Orbital Fissure
Between floor & lateral wall
 Transmits branches of maxillary nerve (infraorbital nerve,
zygomatic nerve) from pterygopalatine fossa.

The Bony Orbit
Optic Canal
Transmits: 1. Optic nerve (+ CRA)
2. Ophthalmic artery
Between orbit & middle cranial fossa
The periosteum of the orbital wall is called:
Peri orbita .. At the orbital rim (margin)
It extends downward (up) within the lids until if fuse with the
tarsal plate and called:
Orbital Septum
the orbital septum limits the orbit anteriorly..
Optic canal
Apex:
Posterior part of whore the 4 walls converge.. Near the optic
canal and posterior part of superior and inferior orbital
fissures
The 4 recti arise from a common tendinous ring at the apex
& run forward along corresponding walls in the form of
Cone around the optic nerve..
Orbital Apex & Tendinous Ring
Orbital Symptoms
1. Proptosis.
2. Pain.
3. Ophthalmoplagia (EOM motility disorder).
4. Periorbtal changes (swelling, redness, chemosis).
Orbital Investigations:
1. Orbital examination
2. Exophthalmometry
3. U/S
4. C.T.
5. MRI
Exophthalmometry
Proptosis (Exophthalmos):
Forward protrusion of the eye ball..
(normally the corneal apex does not protrude in front
of the orbital margins..)
Differentiate it from pseudoexophthalmos
E.g.:
• lid retraction
• contralateral enophthalmos
• large eye ball  buphthalmos
Exophthalmos
Examination:
• Inspection
• Ruler
• Hertel exophthalmometer
Aetiology of the Proptosis:
1. Endocrine
 thyrotoxicosis
2. Inflammatory  orbital cellulitis
3. Tumors  *cyst *benign or malig. 1ry tumor
* metastasis
4. Traumatic
 retrobulbar hemorrhage
5. Vascular
 * AV malformation *orbital varix
*caroticocavernus fistula
Analysis of Proptosis:
1.  Axial  intraconal
 Non axial (displaced)  extraconal  …
2. Bilateral proptosis  thyrotoxicosis
3. Unilateral proptosis  1.Thyrotoxicosis
2.Orbital Cellulitis
3.Tumours… etc
4. Rapid onset proptosis  Trauma  emphysema
 hemorrhage
5. Intermittent exo. (positional)  orbital varicosity
Commonest cause of exoph.  Thyrotoxicosis
Commonest cause of exoph. In child orbital cellulitis
Unilateral Proptosis
Orbital Cellulitis
Suppurative inflammation of the orbital soft tissue
behind the orbital septum.
 It is either Extension from neighboring str. (sinuses)
Trauma
 Comm. Micro.: *Strept. * Staph. * Pneumococci

Orbital Cellulitis
Orbital Cellulitis
Clinical features:
1. Swelling & redness of the lids.
2. Conjunctival chemosis
3. Exophthalmos
4. Pain
5. Diplopia
6. Constitutional symptoms
7. Vision may be impaired (optic neuritis)
Complications:
1. Orbital abscess
2. Panophthalmitis
3. Meningitis
4. Brain abscess
5. Cavernous sinus thrombosis
Treatment: ( Admission)
1. Systemic antibiotics
child  Ampicillin + Cloxacillin
adult  3rd generation cephalosporin +
Metronidazole
2. Monitoring of optic nerve function (VA, pupils)
3. Investigation *WBC count
*CT of orbit, brain & sinuses
*LP if suspect meningitis
4. Surgical drainage, if:
a. no response to antibiotics
b. orbital abscess
N.B. Preseptal cellulitis
Rhabdomyosarcoma
The most common primary malignant orbital tumor
in children
 Highly malignant, in its early stages may be mistaken
as orbital cellulitis
 7 years
 Present as rapidly progressive proptosis, other signs
include:
1. palpable mass
2. ptosis
3. swelling & injection of overlying skin (but not hot)

Rhabdomyosarcoma
Investigations:
1. Biopsy for diagnosis
2. Systemic assessment for metastasis by CXR,
LFT, BMA, LP, skeletal survey..
Treatment:
Local radiotherapy + chemotherapy
IF no response  Exentration
Blow out fracture
Floor  medial wall
 Trauma by an object whose size is larger than the
diameter of the orbital inlet.
 ↑ intraorbital pressure
 transmitted force
These will affect weak areas..

Signs & Symptoms:
1. Surgical emphysema, edema, echymosis
2. Diplopia (tethering of orbital contents, e.g.: inferior
rectus) with restricted up movement.
3. enophthalmos, orbital fat necrosis
4. Anesthesia along the infra orbital n. distribution
5. Hypotropia
6. Intraocular damage (e.g.: hyphema)
Investigations:
CT of the orbit & maxillary sinus
Treatment:
1. Systemic antibiotics
2. Not blow the nose
3. Surgery  timing
 indications
 procedure
Blow out Fracture
Blow out Fracture
Blow out Fracture