Fractures of the orbital roof zygoma and midface

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Fractures of the orbital roof are uncommon and usually accompany major head injury, larger fractures often being comminuted and involving the frontal sinuses, the cribriform plate or intracranial injury; the ophthalmologist is, therefore, unlikely to be in charge of the primary management of these cases. Similarly, midfacial fractures are treated by maxillo-facial surgeons and the ophthalmologist's role is in the assessment of visual function, treatment of the ocular injury and in the late management of associated soft tissue injury and diplopia.

Assessment

Orbital roof injury should be suspected where head trauma is accompanied by a large upper eyelid haematoma, hypoglobus, restricted up gaze and sensory loss over the forehead (Figure 14.7). Late manifestations include deformity of the orbital rim underlying the brow and failure of descent of the upper eyelid during down gaze due to adhesions between the fracture site and the levator muscle.

Tripod fracture of the zygoma, with disarticulation from the neighbouring frontal bone and maxilla, tends to occur with a major blow to the cheek and is manifest by a flattening of the prominence of the cheek (although this may be masked by overlying haematoma), by palpable discontinuity of the orbital rim, by tenderness with upward pressure below the zygomatic arch, and by an ipsilateral buccal haematoma.

Le Fort fractures involve the maxilla and extend posteriorly through the pterygoid plates.The orbit is involved in types II and III Le Fort fractures, both extending across the medial part of the orbit at the level of the cribriform plate, but the type II fracture (the commonest) passes infero-laterally to the level of the inferior orbital fissure, whereas the type III fracture extends laterally higher in the orbit, through the zygomaticotemporal suture line. It is unlikely that the ophthalmologist will be required to identify such fractures, which are characterised by dental malocclusion.

When one of these fractures is identified, adequate CT imaging should be performed to include an area clear of the clinical site of injury; damage at the optic canal should be identified prior to surgery, with particular care being taken to avoid damage to the nerve or its circulation by disturbance of bone fragments near the orbital apex or canal. Treatment of these fractures is by open reduction, microplate fixation and dental stabilisation.

Figure 14.7 Child presenting with a delayed onset of severe compressive optic neuropathy due to a large subperiosteal haematoma along the orbital roof; the child had sustained a blunt orbital injury a week before, with fracture of the orbital roof.

Management

Small fractures of the orbital roof are managed conservatively if they cause no functional deficit and only minimal irregularity of the orbital rim and brow. Small bone fragments that interfere with the function of the levator or superior rectus muscles should be repositioned or removed, either through the open wound at the time of primary repair, or through an incision in the upper eyelid skin crease. Larger bone fragments require reduction and microplate fixation, although most such surgery is beyond the realm of the ophthalmic surgeon and involves a multi-disciplinary approach.

Adherence of the levator muscle or upper eyelid scars to fractures of the orbital rim or

roof may cause lagophthalmos and exposure keratitis. This may be treated by exploration of the orbital roof through an upper eyelid incision, division of any adhesions and placement of a dermis-fat graft sutured inside the orbital rim, to the periosteum of the orbital roof.

Complications

Both the injury itself and the surgery for the repair of these complex fractures may be associated with supraorbital nerve injury, loss of other ocular motor innervation due to damage near the superior orbital fissure, orbital emphysema and pneumocephalus, a subperiosteal haematoma with a secondary compressive optic neuropathy (Figure 14.7) and associated intracranial injuries. Late complications include persistent ptosis, due either to mechanical damage or denervation, lagophthalmos due to scarring and retraction of the upper eyelid or levator muscle and chronic or recurrent sinusitis, particularly that of the frontal sinus.

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