Up to 30% of orbital fractures have concomitant globe injury; therefore, a complete ophthalmologic examination is necessary.

Ocular injuries must be managed first.

Orbital computed tomography (CT) for confirmation of floor fracture defect

Observation

Surgical repair is often indicated to prevent late sequelae of enophthalmos and/or double vision. Preoperative antibiotics, avoiding nose blowing, and oral corticosteroids are often employed.

Double vision, usually in upgaze or downgaze, but could be in any direction depending on what tissues are entrapped.

Orbital CT with axial, coronal, and sagittal views with thin cuts demonstrating fracture defect greater than 50% of floor (Figure 33.1)

Enophthalmos greater than 2 mm due to fracture

Primary indication for immediate surgical repair is significant muscle entrapment, which could be in a narrower fracture defect, causing marked double vision and possible vasovagal effects.

Preoperative selection of floor repair implant. Many alloplastic options including resorbable sheets, thin plastic sheeting, titanium mesh, porous polyethylene sheets, combination titanium and porous polyethylene sheets, preformed titanium or combination implants, and autografted calvarial bone

Selection based on size of fracture, area of stable bone, degree of support needed, and surgeon comfort with various materials

Preoperative oxymetazoline nasal spray to decongest sinus passages on both sides

General anesthesia with endotracheal intubation generally safer due to risk of blood in the airway

Preoperative antibiotics are often used.

Intraoperative intravenous (IV) corticosteroids can reduce postoperative edema.

Inject local infiltrative anesthesia into the surgical area.

Make a transconjunctival incision 5 mm below the inferior border of the tarsus and dissect to the arcus marginalis remaining preseptal, if possible, to keep the fat posterior.

Using a Freer elevator, open the periosteum widely along the inferior orbital rim lateral to medial for exposure, and dissect posteriorly along the floor to identify the anterior, medial, and lateral extent of fracture defect.

Gently reduce the soft tissue back into the orbit, taking care to avoid infraorbital neurovascular structures. Retract the orbital contents under a malleable retractor to
identify the posterior edge of the fracture and isolate the posterior ledge. Consider herniated bone fragment removal from underlying maxillary sinus, especially if the bone flap is obstructing sinus outflow.

Contour and place an implant to cover the fracture site on all edges, especially the posterior ledge.

Confirm hemostasis with bipolar cautery and/or injectable hemostatic matrix. Avoid bipolar over or near nerves.

Perform forced duction testing of globe to confirm full movement and no residual impingement.

Consider anterior fixation of implant along the inferior rim with one to two titanium mini screws if using a titanium mesh based implant or over a large fracture defect.

Close the periosteum over the inferior rim with 4-0 polyglactin sutures.

Remove all instruments and any packing.

Steroid antibiotic ointment to incisions three times per day for 1 week and then daily for 1 week

Cool compresses for 48 hours

Elevate head of bed.

Avoid driving for 1 week.

Avoid bending, lifting, and strenuous activity for 2 weeks.

Avoid nose blowing for 3 weeks.

Follow up at 1 week, 3 weeks, 2 months, and sooner as needed.

Resolution of double vision and enophthalmos is good for early to medium term repairs with minimal scarring.

Prognosis for resolution guarded if late repair with scarring and/or impingement of inferior rectus muscle or perimuscular fascia/fat

Postoperative V2 numbness usually resolves with time, but can be long term or permanent.

Small risk of vision loss or blindness from surgery should be discussed during preoperative informed consent.

Must rule out concomitant globe injury; therefore, a complete ophthalmologic examination is necessary.

Ocular injuries must be managed first.

Orbital CT for confirmation of medial wall fracture defect

Observation

Surgical repair is sometimes indicated to prevent late sequelae of enophthalmos and/or double vision. Preoperative antibiotics, avoiding nose blowing, and oral corticosteroids are often employed.

Orbital CT with axial and coronal thin cuts showing moderate to large fracture greater than 50% of medial wall area and herniation of orbital soft tissue into defect (Figure 33.2).

Marked enophthalmos due to fracture

Horizontal double vision

Preoperative selection of alloplastic medial wall implant. Options include resorbable sheets, thin plastic sheeting, titanium mesh, porous polyethylene sheets, and combination titanium and porous polyethylene sheets. Selection depends on size of defect and need for anterior fixation.

Preoperative oxymetazoline nasal spray to decongest sinus passages on both sides

General anesthesia with endotracheal intubation is generally safer due to risk of blood in the airway.

Preoperative antibiotics are often used.

Intraoperative IV corticosteroids can reduce postoperative edema.

Inject local infiltrative anesthesia into the surgical area.

Consider intranasal packing of cottonoid sponges soaked in oxymetazoline.

Use a transconjunctival postcaruncular approach to the medial orbital rim remaining posterior to the lacrimal structures and immediately subconjunctival, if possible, to keep fat out of the operative field.

Using a Freer elevator, open the periosteum widely along the medial orbital rim for exposure, and dissect posteriorly along the medial wall to identify the anterior, superior, and inferior extent of the fracture defect.

Gently reduce the soft tissue back into the orbit, taking care to avoid the ethmoidal vascular structures.

Identify and isolate the posterior ledge of the fracture. Consider herniated bone fragment removal from ethmoids if interfering with insertion and correct placement of implant.

Contour and place an implant to cover the fracture site on all edges, especially the posterior ledge.

Confirm hemostasis with bipolar cautery and/or injectable hemostatic matrix. Avoid bipolar over or near nerves.

Perform forced duction testing of the globe to confirm full movement and no residual impingement.

Close the medial conjunctival incision with 6-0 plain gut sutures.

Remove all instruments and any packing.

Steroid antibiotic ointment to incisions three times per day for 1 week and then daily for 1 week

Cool compresses for 48 hours

Elevate head of bed.

Avoid driving for 1 week.

Avoid bending, lifting, and strenuous activity for 2 weeks.

Avoid nose blowing for 3 weeks.

Follow up at 1 week, 3 weeks, 2 months, and sooner as needed.

Resolution of double vision and enophthalmos good for early to medium term repairs with minimal scarring.

Prognosis for resolution guarded if late repair with scarring and/or impingement of medial rectus muscle or perimuscular fascia/fat

A small risk of damage to anterior lacrimal structures should be discussed preoperatively with patients.

A small risk of vision loss or blindness from surgery should be discussed during preoperative informed consent.

Up to 30% of orbital fractures have concomitant globe injury; therefore, a complete ophthalmologic examination is necessary.

Ocular injuries must be managed first.

Orbital and facial bone CT for confirmation of displaced zygoma and concomitant orbital floor defect

Observation

Surgical repair is usually indicated to prevent late sequelae of facial and adnexal deformity, globe displacement, and/or double vision. Preoperative antibiotics, avoiding nose blowing, and oral corticosteroids are often employed.

Sequencing of treatment options with stabilization of concomitant ophthalmic injuries may be required first.

Facial deformity

Lateral canthal dystopia

Double vision, usually in upgaze or downgaze, but could be in any direction depending on which tissues are entrapped

Orbital and facial CT with axial, coronal, and sagittal views with thin cuts demonstrating zygoma displacement at three or more locations (Figure 33.3)

Preoperative selection of titanium implant plating set. Many options including size, curve, and thickness of plates (usually small to medium sized)

Preoperative oxymetazoline nasal spray to decongest sinus passages on both sides. General anesthesia with endotracheal intubation generally safer due to risk of blood in the airway.

Preoperative antibiotics are often used.

Intraoperative IV corticosteroids can reduce postoperative edema.

Inject local infiltrative anesthesia to surgical areas, anticipating multiple sites of exposure. Consider intranasal packing of cottonoid sponges soaked in oxymetazoline.

Make a transconjunctival incision 5 mm below inferior border of tarsus and dissect to the arcus marginalis remaining preseptal, if possible, to keep the fat posterior.

Perform a lateral canthotomy with inferior cantholysis to expose the thickest portion of the malar eminence. Using a Freer elevator, open the periosteum widely along the inferior orbital rim lateral to medial for exposure and dissect posteriorly along the
floor to identify the anterior, medial, and lateral extent of the fracture defect. Next, from the arcus marginalis, dissect anteriorly and laterally to expose the fracture site and inferior orbital rim portions of the maxilla and zygoma for reduction and plating.

Place a threaded reduction screw, such as a Carroll-Girard screw, in the thickest portion of the zygoma for bony reduction (Figure 33.4).

Next, make an incision in the lateral upper eyelid crease or in an existing traumatic laceration for access to the zygomaticofrontal suture line. Dissect down to the lateral orbital rim and use a Freer elevator to open the periosteum from the external lateral orbital rim and the lateral orbital wall to identify the zygomaticosphenoid suture line.

Use a reduction tool to fully reposition the zygoma, confirming proper alignment along the inferior orbital rim, lateral orbital rim, and exposed lateral orbital wall.

Before plating the zygoma, perform a subperiosteal dissection posteriorly along the orbital floor to identify the anterior, medial, and lateral extent of the fracture defect, if present.

Gently reduce any soft tissue back into the orbit as needed, taking care to avoid infraorbital neurovascular structures.

Confirm all bony and soft tissue reduction.

Plate the zygoma to the surrounding stable bone at two or more points of fixation. Secure at least two screws through the plate holes on either side of the fracture and one to two plate holes over the fracture site as needed (Figure 33.5).

For the orbital floor portion, identify the posterior edge of the fracture and isolate the posterior ledge. Contour and place an implant to cover all edges of the fracture site, especially the posterior ledge.

Confirm hemostasis with bipolar cautery and/or injectable hemostatic matrix. Avoid bipolar over or near nerves.

Perform forced duction testing of the globe to confirm full movement with no residual impingement.

Close the periosteum over the inferior and lateral orbital rims with 4-0 polyglactin sutures.

Perform midfacial soft tissue resuspension for proper postoperative midfacial support as discussed elsewhere in this text.

Perform lateral canthal resuspension and skin closure as discussed elsewhere in this text.

Remove all instruments and any packing.

Steroid antibiotic ointment to incisions three times per day for 1 week and then daily for 1 week

Cool compresses for 48 hours

Elevate head of bed.

Avoid driving for 1 week.

Avoid bending, lifting, and strenuous activity for 2 weeks.

Avoid nose blowing for 3 weeks.

Follow up at 1 week, 3 weeks, 2 months, and sooner as needed.

Resolution of facial and adnexal deformity, any double vision, or globe displacement good for early repairs within 2 weeks with minimal scarring

Prognosis for proper reduction and resolution of all defects and deformities guarded if delayed repair with scarring and/or impingement of rectus muscles or perimuscular fascia/fat