What is the recommended approach for managing orbital fractures?

Management of Orbital Fractures

The management of orbital fractures should follow a time-sensitive approach based on specific clinical findings, with immediate surgical repair indicated for muscle entrapment with oculocardiac reflex, white-eyed blowout fractures, and globe subluxation into the maxillary sinus. 1

Initial Assessment and Prioritization

• First priority: Address life-threatening and vision-threatening conditions before treating strabismus or other complications 1

  • Note: Serious ocular injury occurs in 24% of blowout fracture cases 1
  • Complete vision loss can occur in 5.5% of patients in one eye and 0.8% in both eyes 1

• Imaging studies:

  • CT scan is preferred for initial evaluation (avoid MRI if metallic foreign body suspected) 1
  • MRI provides better visualization of extraocular muscles and surrounding tissues when needed 1

Surgical Management Timeline

1. Immediate Repair (Emergency)

• Indications:
  • Entrapped muscle/periorbital tissue with nonresolving oculocardiac reflex 1
  • White-eyed blowout fracture with muscle entrapment (especially in children) 1
  • Globe subluxation into maxillary sinus 1

2. Early Repair (Within 2 Weeks)

• Indications:
  • Symptomatic diplopia with positive forced ductions or CT evidence of entrapment 1
  • Significant fat/periorbital tissue entrapment 1
  • Large floor fractures with hypoglobus 1
  • Progressive infraorbital hypoesthesia 1
  • Early enophthalmos or hypoglobus causing facial asymmetry 1

3. Delayed Repair (After 2 Weeks)

• Indications:
  • Restrictive strabismus not resolving with conservative management 1
  • Unresolved enophthalmos 1

4. Observation (No Surgery)

• Indications:
  • Minimal diplopia (not affecting primary gaze or downgaze) 1
  • Good ocular motility 1
  • No significant enophthalmos or hypoglobus 1

Surgical Approaches and Techniques

• Most common approach: Bicoronal (94.8% of cases) 2

• Alternative approaches:

  • Superolateral orbital rim approach 2
  • Transpalpebral approach (5.1% of cases) 2
  • Transantral approach (may reduce complications in selected cases) 3

• Reconstruction materials:

  • Titanium miniplates (46.2%) 2
  • Bone grafts (37.7%) 2
  • Porous polyethylene (2.8%) 2
  • Silastic implants (2.8%) 2

Conservative Management

• Short burst of oral steroids: Can hasten recovery and reveal persistent strabismus after edema resolution 1, 4

  • Recommended regimen: dexamethasone 8mg on surgery day, 6mg on day 1, 4mg on day 2, 2mg on day 3 4

• For persistent diplopia:

  • Wait 4-6 months after trauma before surgical correction of strabismus (unless entrapment is present) 1
  • Consider temporary measures: occlusion, filters, Fresnel prisms, botulinum toxin injection 1

Monitoring and Follow-up

• Careful monitoring for:

  • Oculocardiac reflex (bradycardia, heart block, dizziness, nausea, vomiting) 1
  • Persistent diplopia (occurs in 37% of patients even after repair) 1, 4
  • Enophthalmos or hypoglobus 1

• Sensorimotor examination including:

  • Versions, ductions, saccades, pursuit, vergence 1
  • Forced duction and forced generation testing 1

Special Considerations

• Pediatric patients: More likely to be managed conservatively 2
• Outpatient management: May be safe for isolated orbital floor fractures in selected patients (theoretical risk of orbital hematoma 0-3.2%) 5
• Strabismus surgery: If needed, should be delayed 4-6 months after injury to ensure stability of misalignment 1

Potential Complications

• Post-repair diplopia: Persists in 37% of patients despite surgical repair 1
• Adhesion syndromes: Particularly problematic with porous implants 1
• Orbital fat entrapment: Can be as challenging as muscle entrapment 1