Head Injuries & Orbital Fractures Flashcards
What is the Cribriform Plate?
Part of ethmoid bone, but located in the midline. It transmits CNI (Olfactory nerve). If it is damaged it can lead to CSF leak into the nasal cavity and to loss of smell.
What is a coup injury?
Direct blow to area of impact (closed head trauma)
What is a contrecoup injury?
Blow is to the opposite side (a counter blow; closed head trauma)
What is a cerebral contusion?
Both are focal injuries - a coup and contrecoup injury
What is whiplash? What are the symptoms?
A closed head injury caused by hyperextension and hyperflexion leading to ocular problems
Symptoms:
- Diplopia
- Seeing spots
- Objects receding
- CI
- Reduced accommodation
- Reduced pupil cycle time
What do we need to know for the case history in head injuries?
- History is like but not always
- May present immediately or late
- More likely to be male
- Facial injury; orbital/ocular injury
What is optic atrophy?
A form of optic neuropathy. There are 2 types:
- Direct Optic Neuropathy
Direct damage to optic nerve - Indirect Optic Neuropathy
Damage is non-penetrating such as haemorrhage or oedema (like in Grave’s where the swelling affects the ON)
What are the symptoms of optic atrophy?
- Severely reduced VA
- Pale optic disc
- RAPD
Can be unilateral or bilateral
What might we expect after a head injury?
Need to ask about what their vision was like pre-injury
- Neurogenic palsy
- Supranuclear palsy / skew deviation (3rd Year)
- Myogenic OM defect
- Orbital fracture
- Accommodation / convergence problem
- Weak / loss of suppression
- Weak / loss of fusion
- VF defect
- Damage to ON / globe / periocular structures
What can complicate the orthoptic management of a head injury?
- VA
- Loss of / weakened suppression
- Loss of / weakened fusion
incomitance - Torsion
- Vergence and accommodation defects
- Exophthalmos / enophthalmos
- VF defect
What conservative orthoptic management options do we have for treating head injuries and orbital fractures?
- Fresnel prisms
- Advice AHP / head movements
- Orthoptic exercises
- Occlusion - total / sector
- Bangerter foils / occlusive tape
- Refractive correction
What are the types of orbital injuries?
- Eyelid
- Periorbital
- Retrobulbar – will damage optic nerve if left untreated
- Direct damage to EOM
What types of globe injuries are there? Name some
- Corneal abrasion
- Hyphaema
- Lens Damage
- Choroid Rupture
- Subconjuctival Haemorrhage
- Penetrating Injury
- Retinal Detachment
- ON Damage
What are Le Fort fractures?
A way of classifying facial fractures. Le Fort I, II & III that describe commonly occurring lines of facial fracture.
I - No ophthalmic significance
II - Orbital rim & floor
Blow to mid / lower maxilla
Serious intracranial injury & death
III - Most ophthalmically relevant
Blow to nasal bridge / upper maxilla
Serious intracranial injury
What Le Fort Fracture is most ophthalmically relevant?
III
What is affected in Superior Orbital Fissure Syndrome?
CN III, IV, V or VI
= Palsy
What is affected in Orbital Apex Syndrome?
- CN II, III, IV, V or VI
- Central retinal artery & veins
- Proptosis
- Direct damage ON
What are the 5 types of bone fractures?
- Greenstick
- Transverse
- Comminuted
- Spiral
- Compound
What type of bone fracture is most common paediatrically?
Greenstick fractures in long bones
Orbital fractures are usually linear/transverse in children but in adults are comminuted
What type of fracture are children less likely to sustain? What ones are they more likely to damage? Why?
Less likely -
Orbital fracture
More likely -
Upper face & skull
Superior orbital fractures
Because of the development of their faces
What’s the most common cause of paediatric orbital fractures? Who does it affect the most?
Most common in sports injuries (Egbert et al., 2000)
Mean age of 12.5 years and 92% male (Hatton et al., 2001)
What are supra-orbital fractures and what are they caused by?
- Roof of orbit/superior orbital rim
- Less common amongst adults but more so in children
- Caused by direct blows to the frontal region (coup) or indirect blows to the base of skull (contre-coup)
What symptoms can supra-orbital fractures cause?
- Superior orbital oedema and haemorrhage
- Upper lid oedema
? Ptosis or swelling - SR / SO damage
- Trochlear damage
- Depression of supra-orbital rim (displacement of globe)
- Leakage of CSF (cribriform plate fracture)
- Infection (meningitis)
What can a lateral wall fracture cause?
- Uncommon
- Lateral wall is the most solid wall
- Usually part of a complex fracture opposed to an isolated fracture so likely to have associated facial injuries
What is a zygomatic fracture or displacement?
- Displacement upwards / downwards
- Direction of blow affects the outcome (if from below makes it stick out, if from above displaces it inwards)
- May be associated with orbital fracture (can see this with swelling at the orbit and damage to the eye)
What are the signs and symptoms of zygomatic fracture or displacement?
- Oedema & haemorrhage
- Downward displacement – enophthalmos (back in the socket), pseudoptosis (due to eyelid looking down because the eye is far back in the orbit) & flattened cheekbone
- Upward displacement - exophthalmos (protruding outwards) & accentuated cheekbone
- May have disturbed mobility of lower jaw (temporal mandibular join)
What are naso-orbital fractures?
- Trauma to mid-face causing isolated fracture of nasal bones. Caused by direct trauma to mid 1/3rd of face.
- If nasal fracture need to consider if they have an orbital fracture also or not
What are the signs and symptoms of naso-orbital fractures?
- Flattened nose
- Traumatic telecanthus (gap between medial canthi is wide)
- Oedema - medial canthus
- Epistaxis (nose bleed)
- Nasal obstruction (may sound like they have a blocked nose, don’t want them to sneeze or blow the nose if they have orbital fracture also as it could force air into the orbit)
- Damage lacrimal apparatus
- Emphysema – air in the structure i.e., orbital emphysema is forcing air into the socket
- Damage to IO origin
- CSF leak - ?fracture cribriform plate
What are orbital blow-out fractures?
Maxilla - orbital floor blow-out fracture
Ethmoid - medial wall
What is a pure blow-out fracture and am impure blow-out fracture?
- Pure blow-out fracture
Internal orbital walls only - Impure blow-out fracture
Internal orbital walls + orbital rim
What are orbital blow-out fractures dependent on?
- Mechanism of the injury
- Size of the object
Small = rupture globe
Same size / slightly larger than orbital rim = pure blow out
Much larger than orbital rim = impure blow out (fracture orbital rim and the orbit)
What is buckling theory?
Buckling theory is a proposed theory of blow-out fracture.
Buckling theory - force transmitted from orbital rim through bone to floor of the orbit
(Waterhouse et al., 1999)
What is Hydraulic/Blow out theory?
Hydraulic/blow-out theory is a proposed theory of blow-out fracture.
Hydraulic/Blow-Out Theory -
Force of object displaces globe backwards, increasing intraorbital pressure, resulting in a fracture in the area of least resistance
(Waterhouse et al., 1999)
What does a buckling fracture of orbital floor look like?
- Small
- Only the floor is affected due to the force to the orbital rim and thus the medical wall and roof aren’t affected and there’s no herniation of orbital contents into the fracture
What does a hydraulic fracture of orbital floor look like?
Easier to fracture orbital floor by the hydraulic mechanism
- Large due to force to the globe
- Always affects the medial wall and often the roof
- Always leads to herniation of orbital contents into the fracture
What are the different types of pure orbital blow-out fracture?
- Linear / trap door (need to be most aware of this, orbital floor might drop and then come back and then trap the IO and IR)
- Hanging Drop
- Depressed
- Comminuted
What is a Linear/Drop Door pure orbital blow out fracture?
- Fracture open and closed, no loss of orbital contents
- May be trapped muscle / tissue in fracture
What is a Hanging Drop pure orbital blow out fracture?
Herniation of orbital contents into fracture
What is a Depressed pure orbital blow out fracture?
Piece of orbit punched out
What is a Comminuted pure orbital blow out fracture?
Fracture which shatters into several bony fragments
What are some characteristics of orbital blow-out fractures?
- Ecchymosis
- Enophthalmos (indicates glove sunken into hole) & pseudoptosis
- Anaesthesia / hypoaesthesia (may have lost feeling to face, is there sensation on both sides or unilateral? Is it complete loss of partial loss of sensation?)
- Limitation OM
- Diplopia
During OM - pain / globe retraction / increased IOP - Orbital Emphysema (don’t blow nose or sneeze)
Will someone have a deviation in pp if they have an orbital floor fracture?
- May have no deviation in pp
- May have manifest deviation
- Orbital floor # - limitation of elevation
- May also have limitation of depression
Limitation of movement in opposite direction to the fracture i.e. to the orbital floor get limitation in elevation (IO) but might also get some in depression (IR). Important to test ductions and versions because it’s a limitation.
What type of restriction do we get in orbital fractures?
Limitation of movement in opposite direction to the fracture i.e. to the orbital floor get limitation in elevation (IO) but might also get some in depression (IR). Important to test ductions and versions because it’s a limitation.
How might we see a trap-door orbital blow-out fracture?
More common in children
* nausea and vomiting
* pain on eye movement
* oculo-cardiac reflex
‘white eyed blow-out fracture’
Early surgery!
Can lead to bradycardia (oculocardiac reflex), heart block, nausea, vomiting and syncope (fainting/passing out)
What ophthalmic investigation do we need to do into orbital fracturs?
- VA
- Slit lamp examination of the eye
- Measure globe position
- Measure IOP
- FDT
What radiological investigation do we need to do into orbital fracturs?
- X-ray
- CT
- MRI
What symptoms do we need ask for in orthoptic investigation of orbital fractures and head injuries?
- Diplopia
- Pain
- Anaesthesia
- Orbital emphysema (medical condition that refers to the trapping of air within the loose subcutaneous around the orbit)
- Epistaxis (nose bleed)
What are the signs of orbital fracture?
- Ecchymosis (bruising)
- Oedema
- Enophthalmos
- Exophthalmos
- Facial asymmetry
- Subconjunctival haemorrhage
- Globe damage
- Unequal pupils
- AHP
What is Ecchymosis?
Bruising
Look at expected Hess chart slide 59
What must we differentially diagnose when suspecting orbital fractures?
- Soft tissue injury
- Orbital cellulitis (can look like periorbital oedema which is either a soft issue injury or orbital fracture)
What is periorbital oedema seen in?
Soft tissue injury and orbital fractures
What are the aims of surgical management in orbital fractures?
- Restore full orbital volume
- Restore globe movement
- Restore cosmesis
Minimising and preventing early and late sequelae and complications
When is it urgent to do surgery in orbital fractures?
- Diplopia & imaging evidence of trapped muscle / soft tissue with non-resolving oculo-cardiac reflex
- White-eyed blow-out fracture
(young patient, history suggestive of orbital fracture, white eye, marked OM restriction, imaging evidence of fracture with trapped muscle / tissue) - Early enophthalmos causing facial asymmetry
When should you do surgery within 2 weeks of the orbital fracture?
- Symptomatic diplopia with +ve FDT, evidence of trapped muscle / tissue on imaging, minimal improvement over time
- Large orbital floor fracture causing latent enophthalmos
- Significant hypo-ophthalmos
- Progressive infra-orbital hypoaesthesia
When should we observe in orbital fracture before considering surgery?
- Minimal diplopia - not in primary position or downgaze
- Unaffected OM / minimal OM defect
- No significant enophthalmos or hypo-ophthalmos
What surgical approaches are there to orbital fractures?
A subciliary
B subtarsal
C infraorbital (eyelid approach)
D subciliary extending laterally
Caldwell-Luc
(through maxillary antrum, between canine & 2nd molar teeth)
Transconjunctival
(through inferior fornix of the conjunctiva)
Endoscopic procedures may be used
When do we use orbital implants?
In large orbital fractures where there’s entrapment or enophthalmos (contour of orbital floor S shaped)
What complications can we get from surgery of orbital fractures?
- Migration of implant - extrusion
- Infection
- Ectropion
- OM restriction and persistent diplopia
- Lower lid oedema
- Retrobulbar haematoma (rare)
