The orbit of the eye is the anatomical fossa on the skull. Most often, the fractures are combined, that is, they are found in combination with trauma to other bones of the facial part of the skull, such as, for example, the frontal, temporal, zygomatic, zygomatic, maxillary or bone parts of the root and back tissues of the nose, the walls of the orbit itself.
Injury description
The injury to this zone is very dangerous, because fractures of any of the constituent walls of the orbit are almost always accompanied by a concussion.
In addition to the combined fracture, an isolated orbital fracture is also rare (about 16.1% of all cases), which is usually the result of a direct blow towards the eyeball. And more often the blow falls on the side of the lower or inner wall, that is, those walls that limit the paranasal sinuses from the cavity of the orbit. Hence the name "explosive" injury.
Subcutaneous emphysema is an accumulation of air as a result of traumatic "exposure" and the ingress of gas from the orbit into the adjacent paranasal sinuses. This phenomenon is most often detected after a strong exhalation through the nose, after which the air that has fallen into the subcutaneous masses “crunches” as if under pressure on the periorbital region.
Often there is a pinching of the lower rectus muscle, especially with a fracture of the bottom of the orbit, so there is a restriction of the eye upward movement and causes the development of diplopia (double vision).
In addition, hemorrhage into the muscles or surrounding tissues is possible with limited mobility already down.
The main symptoms of an orbital fracture
This ailment is manifested by the following symptoms:
- the presence of severe edema around the injured eye, the development of subcutaneous emphysema is possible;
- the spread of the process to nearby areas involving the root and back of the nose, upper part of the buccal region, upper and lower eyelids, as well as damage to the gums and teeth of the mainly upper jaw ;
- violation of the innervation of these areas, leading to a decrease in sensitivity to various types of stimuli;
- the patient cannot move the eyeball up due to damage to the lower rectus muscle of the eye;
- the phenomenon of diplopia (bifurcation of objects) due to hemorrhage and edema in the area between the lower oblique and rectus muscles on the one hand and the periosteum on the other;
- Enophthalmos is not so rare, the eyeball in this case is as if pressed into the orbit;
- sounds of crepitus due to the development of subcutaneous emphysema.
Diagnostics
Diagnosis of an orbital fracture:
- determination of the degree and volume of mobility of the outer muscle group of the eyeball;
- conducting an external examination to detect chemosis (conjunctival edema involving the eyelid) and swelling of the soft tissues;
- determination of crepitus during palpation of areas of the zone with subcutaneous emphysema developed in it and displacement of bone fragments (if any);
- the use of neurological examination methods to detect hypesthesia (reduce sensitivity to various types of stimuli) along the infraorbital nerve;
- determination and measurement of proptosis (loss of the eyeball) and enophthalmos (retraction);
- ophthalmic biomicroscopic method for the study of subconjunctival hemorrhages, chemosis and other criteria for traumatic injury.
Additional diagnostics
A significant part of the victims show signs of proptosis and prose, as a result of traumatic hemorrhage in the tissue and muscles and swelling in the facial section of the skull. On examination, foreign bodies of various sizes and structures can be identified. About 30% of all “explosive” orbital fractures are combined with the development of erosion of the cornea of the eye, the phenomena of traumatic hyphema (signs of hemorrhage in the anterior chamber), iritis (inflammation of the iris), rupture of the eyeball, signs of trembling of the retina, its detachment, and finally hemorrhage.
The severity of an orbital fracture is high.
It is preferable to conduct computed tomography (CT), and for a better idea of the state of the walls of the orbit, it is desirable to conduct axial and coronal thin sections.
To identify a fracture and insertion of the contents of the orbit into adjacent sinuses, it is necessary to examine the inner (medial) part of the bottom and the wall adjacent to the nasal bone.
Inspection of the bone top allows you to identify the condition of the posterior edge of the bone, which is performed without fail during surgery.
The main manifestations depend on the strength of the applied blow to the facial part of the skull and the accompanying injuries: for example, during a fracture of the mainly upper wall, the percentage of development of concussion is high. With a fracture of the lower or internal (medial) wall, it is possible to spread mucosal secretions through the lesion sites into the paranasal sinuses with concomitant infection.
How to treat an orbital fracture? Let's consider further.
Principles of Therapy
The goal of treatment is to preserve or restore the structure of the orbit and its contents, that is, the eyeball (restoration of the range of motion of both active and passive muscles, the elimination of such unpleasant concomitant symptoms as diplopia or, for example, strabismus, causing significant discomfort to the victim).
Often, in this situation, they resort to surgery, which at the same time has an adverse effect on the contents of the orbit, which manifests itself in the form of excessive pressure on the eyeball. The danger lies also in the fact that the hemorrhage that occurred behind the eye increases the pressure exerted by the optic nerve several times, and mainly on its disk, which entails not only a deterioration in vision, but also an unfavorable outcome and its complete loss.
Since a lot of other anatomical components of the skull are involved in the injury, so the load on these affected parts is also prohibited, in particular, the pressure exerted on the respiratory tract. A simple effort, even insignificant, for example, when blowing your nose, leads to an increase in pressure inside the cavity of the zygomatic arch, which aggravates edema and can provoke complete closure of the eye, or contribute to the development of subcutaneous emphysema.
Indications for surgical intervention
Consider in which cases the operation is shown:
- diplopia, or in other words, double vision, in the direction of gaze downward (at an angle of 30 degrees from the primary) or directly, provided that these pathological changes are preserved for more than two weeks after the injury with a simultaneous radiologically confirmed fracture and a positive reaction to the traction test;
- Enophthalmos exceeding 2 millimeters;
- a fracture of the bottom of the orbit, comprising more than half of its total area, dangerous in view of the possibility of the rapid development of late hypo- and enophthalmos;
- the omission of the contents of the orbit and the value of enophthalmos more than 3 millimeters with a simultaneously confirmed excess of the volume of the cavity of the orbit by 20% or more.
Types of eye socket fracture surgery
According to the timing of the operation, early surgical intervention is performed, performed in the acute period of the injury, within the first two weeks, that is, in that period of time when there are the most optimal conditions for restoring integrity and ensuring adequate physiological functioning of the affected organ. Also, the operation may be delayed, performed after a two-week period, but until the fourth month after the injury. This is the so-called "gray period." And, finally, the late provision of medical care, requiring mandatory osteotomy.
The most effective methods of treatment include surgical, in which several techniques for correcting bone tissue of the orbit and zygomatic arch are distinguished. All of them are similar in that they are made through small incisions, which then heal, that is, they become completely invisible.
This operation can be performed on the side of one of the walls of the orbit, may include providing increased access to the opening of the fracture area and the subsequent possibility of using various types of prostheses.
The consequences of an orbital fracture
An orbital fracture is a serious injury. Assistance must be provided in a timely manner. Otherwise, dangerous, extremely undesirable complications and consequences may occur. Visual function is impaired, it threatens with an absolute and irreversible loss of vision.
The most common consequences are the development of strabismus, diplopia. Concussion, pain shock, and related injuries are possible. Infectious complications are not excluded. The lack of treatment leads to the formation of fibrous, bone growths.
Thanks to the achievements of modern medicine, the above undesirable effects are prevented, and the visual function of the victim is also fully restored.