Fracture of the right orbit. Types of eye orbital fracture and methods of its treatment

Trauma to the orbit with fracture of its bones is not common. To do this, it is necessary that a sufficient mechanical force be applied to the eye socket at a certain angle. However, this is one of the most dangerous injuries. Very often, a fracture of the orbit leads to injury to the eye itself, decreased visual acuity, or even complete removal of the eyeball.

Photo 1. In order to break the eye socket, you need to receive a strong blow. Source: Flickr (Lianna Amber Weidle)

Structure of the eye socket

The orbit is a bony cavity in which the eye and surrounding soft tissues are located. It has the shape of a pyramid, which consists of lower, upper, inner and side walls. They are the faces of the pyramid. It has no base, since at the base there is not bone, but soft tissue.

The eye socket does not consist of a single bone, but of many small bones and processes of large bones of the skull. The orbit is formed by the processes of the frontal, sphenoid, ethmoid, palatine and zygomatic bones, as well as the upper jaw. In addition, it includes a separate small bone - the lacrimal bone.

All bones are connected to each other by sutures. There are five seams in total. These are the thinnest places in the orbit where a fracture can occur.

Vessels and nerves pass through the openings of the orbit, which are directed to the eye and surrounding tissues. There are muscles and connective tissue around the eyeball.

It is worth remembering that when the eye is injured, soft tissues are damaged much more often than the orbit itself.

Note! Most often, the lower wall of the orbit is susceptible to fracture. It consists of several bones and sutures, and under it there is a cavity - the maxillary paranasal sinus. When the bones of the lower wall are fractured, the fragments fall into this sinus. That is why the most dangerous in terms of fracture is considered to be a blow to the eye from top to bottom.

Causes and mechanism of eye orbital fracture

Typically, the cause of an orbital fracture is blunt trauma. For example, a blow received on the steering wheel or seat during an accident or a hit with a tennis ball. Even just a punch to the eye with great force can lead to such consequences. In this case, the eye and orbital tissue are very often injured. It's also worth remembering that fragments of the eye socket can damage the tissue of the eye.

When injured by a sharp object, the bone may be slightly damaged, and symptoms of damage to the eyeball will come to the fore.

Note! The most dangerous type of injury is a gunshot wound. It significantly damages soft tissue, crushes the bones of the orbit and other areas of the skull, and can affect the brain.

Types and classification of fractures

Orbital fractures vary depending on the location of the damage- medial, lower, upper or inner walls of the orbit.

Isolated orbital wall fractures

An isolated fracture is one in which are damaged exclusively inner walls of the orbit. At the same time, its edges, like other parts of the facial skeleton, remain intact. Such damage is quite rare. The cause of an isolated fracture may be a blow to the orbital area with a small diameter object.

Most often, along with the inner surface, the outer edges of the orbit break. Such a fracture can no longer be called isolated.

Photo 2. The main danger with an orbital injury is soft tissue injury. The eye may lose the ability to see. Source: Flickr (Josh)

Fracture of the upper wall of the orbit

This type of damage does not occur often. The fact is that the upper wall of the orbit is formed by the frontal bone - one of the strongest among all the bones of the human skeleton. It is quite difficult to break it. In addition, blows directed from bottom to top are not so common.

The frontal paranasal sinus is located above the orbit. It is into this that the fragments fall when the upper wall is fractured.

Trauma to the inferior wall of the orbit

As already said, This type of fracture occurs more often than others. This is due to both the structure of the bones of the orbit and the biomechanics of most impacts. As a rule, they fall from top to bottom at an angle of 30° just in the area above the maxillary sinus.

Fracture of the medial wall of the orbit

Called medial inner wall. It has a very complex structure, many bones and seams. On the other side of this wall there is also an empty space - the nasal cavity. Fragments fall into it when this part of the orbit is fractured. However, such injuries are not common. This is due to the fact that it is quite difficult to receive an outside-in blow so that it passes through the eye socket.

Signs of an orbital fracture

Regardless of the type of fracture, the following are observed:

Intense pain in the area of the affected eye socket;
Significant swelling of the surrounding tissues;
Severe subcutaneous hemorrhage;
Recession or bulging of the eyeball;
Crunch of bones when pressed;
Decreased visual acuity.

First aid for a fracture of the orbit of the eye

The first thing to do when the orbit is fractured is: place the patient on his back. In this case, you cannot bend or straighten the cervical spine. In addition, any head movements, even passive ones, should be avoided.

To relieve severe pain, you should use. They will not completely remove pain, but will significantly reduce the patient’s suffering. The victim should be taken to a trauma hospital as soon as possible to an eye injury department, if available.

It is important! An orbital fracture is often combined with a concussion. Any movement in this case can lead to damage to brain tissue, inflammation and swelling. These processes will significantly worsen the patient’s condition, so it is important to monitor the victim’s position.

Fracture treatment

There are two ways to treat this injury:

Conservative. It helps in the case of an isolated small fracture without displacement of the orbital bones. In this case, the eye is treated with antibiotic solutions and a special bandage is applied to it. The procedure is repeated daily for 2 weeks.
Operational. It is used if the bones of the orbit need to be returned to their previous position or damage to soft tissues needs to be repaired. In this case, surgical intervention is performed, the volume of which depends on the number of damaged structures. For example, this is how they can remove fragments of the orbit from cavities, sew together the muscles and tissues of the eyeball, clean the orbit from blood, pus, and much more.

Regardless of the treatment method, the patient must take painkillers and antibiotics orally.

Consequences of an orbital fracture

The consequences directly depend on the severity of the injury. Sometimes, in the place where a displaced fracture occurred, a bone defect. The displaced areas are simply removed, leaving part of the eye socket empty.

If the defect is large enough, tissue plastic surgery is performed. In other cases, the role of the wall is taken over by a dense scar.

The most severe consequences are the consequences of soft tissue injury. If the eye is severely damaged, it is simply removed, leaving the eye socket empty.

Sometimes eye injury leads to complete loss of vision or sudden deterioration of vision.

In addition, impaired mobility of the eyeballs and their displacement may remain with the victim for life.

Rehabilitation period

Recovery time depends on the nature of the injury and the complexity of the fracture.

An isolated small fracture may heal completely within 2 weeks.

The orbital area is well supplied with blood, so the tissues here are restored quickly.

For more significant fractures, even after surgery, rehabilitation may take a month or even six months.

In some cases, complete restoration of the structure and functioning of this area does not occur.

Medical procedures for rehabilitation

In order to speed up recovery, you must follow your doctor's recommendations. First of all: change the bandage on time, treat the eye, use sterile materials for dressings, limit head and eye movements, take vitamins and minerals.

If the eye muscles are damaged, the doctor may prescribe set of exercises for the eyes. The earlier treatment is started, the better the prognosis.

Injury to this area 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, there is also a rare (about 16.1% of all cases) isolated fracture of the orbit, which is usually the result of a direct blow towards the eyeball.

Moreover, more often the blow comes from the side of the lower or inner wall, that is, precisely those walls that limit the paranasal sinuses from the orbital cavity. This is where the name “blast” injury comes from.

Subcutaneous emphysema is an accumulation of air as a result of traumatic “exposure” and the entry of gas from the orbital cavity into the adjacent paranasal sinuses. This phenomenon is most often detected after a strong exhalation through the nose, after which the air trapped in the subcutaneous formations seems to “crunch” when pressed on the periorbital area.

Often the inferior rectus muscle is pinched, especially when the floor of the orbit is fractured, which is why upward movement of the eye is limited and causes the development of diplopia (double vision).

In addition, hemorrhage into the muscles or surrounding tissues is possible with limited mobility downwards.

Frequent patients in medical institutions are people with an injured facial area. Unfortunately, physical trauma is common, as is a fracture of the orbital bone.

Spilling out accumulated anger and fatigue, few people think about the possible consequences of a thoughtless outburst of their emotions. Of course, there can be many reasons for such injuries: car accidents, accidental collisions, falls, conflict situations, sports injuries, violence... Regardless of what the injury occurred, you should immediately contact a specialist for an objective assessment of your health.

Often, in the event of any physical shock, people make their own diagnosis and seek medical advice only in emergency cases, for example, with a concussion.

But, as you know, many diagnoses and terms have been studied today, and they can cause no less harm than those that are already known. You should always be attentive to your health and carefully examine your face after injury, since the consequences of a blow can lead to a fracture of the orbit.

Falling onto an object from a great height or from a height of human height;
A strong blow to the eye socket with a blunt or sharp object;
Impact on the victim with a firearm;

Structure of the eye socket

The eye socket does not consist of a single bone, but of many small bones and processes of large bones of the skull. The orbit is formed by the processes of the frontal, sphenoid, ethmoid, palatine and zygomatic bones, as well as the upper jaw. In addition, it includes a separate small bone - the lacrimal bone.

All bones are connected to each other by sutures. There are five seams in total. These are the thinnest places in the orbit where a fracture can occur.

Vessels and nerves pass through the openings of the orbit, which are directed to the eye and surrounding tissues. There are muscles and connective tissue around the eyeball.

It is worth remembering that when the eye is injured, soft tissues are damaged much more often than the orbit itself.

Symptoms

Symptoms of fractures can be divided into direct and indirect.

Direct signs of fractures:

The “step” symptom is a palpable unevenness (“ledge”) in the area of the edge of the orbit, disrupting its smoothness and continuity. In fresh cases, the “step” area is often accompanied by local pain.
Deformation of the periorbital (zygomatic, infraorbital, nasal) areas, involving the edge of the orbit or its entire wall and visible when examining the patient.
The presence of direct signs of a fracture (fracture line, displacement from fractures, deformation of contours) with radiation and other research methods (radiography, computed and magnetic resonance imaging, ultrasound) (Fig. 121).

Indirect signs of fractures:

Emphysema of the orbit and eyelids, associated with the entry of air into the tissue of the orbit and subcutaneous tissue of the eyelids from the paranasal sinuses (and primarily from the ethmoid sinuses) as a result of a fracture of the walls. Emphysema of the orbit is manifested by exophthalmos, emphysema of the eyelids by an increase in the volume of the eyelids and crepitus during their palpation examination. The radiograph reveals the cellular structure of tissues containing air (small areas of increased airiness).
Dislocation of the eyeball downwards and backwards (enophthalmos, especially early) due to an increase in the volume of the orbit as a result of the mixing of fragments in the direction from the orbit. This symptom in the first days after injury can be weakened by a temporary increase in the volume of the contents of the orbit due to traumatic swelling and hemorrhages. On the 5th-7th day after the injury, in the presence of a displaced fracture, this symptom becomes obvious. Drooping of the eyeball is sometimes visible on a radiograph as an expansion of the space between the shadow of the eyeball and the upper wall of the orbit (Fig. 122). Very rarely, when a bone fragment is displaced inside the orbit, a fracture of its walls is accompanied by exophthalmos. It is possible to shift the eyeball horizontally (right and left) towards the damaged wall of the orbit (Fig. 123). Dislocation of the eyeball in combination with limited mobility leads to diplopia.
Limitation of passive mobility of the eyeball, determined using the “traction test” After preliminary terminal anesthesia (Dicaine 0.25% epibulbar, 3 times), the researcher uses tweezers through the conjunctiva to grab the muscle at the site of attachment to the eyeball, the infringement of which is expected, and moves the eyeball in the direction opposite to the action of this muscle (stretching). Limitation of the mobility of the eyeball in this case indicates fixation (infringement) of the muscle under study or the tissues surrounding it.
Impaired skin sensitivity in the area of innervation of the infraorbital nerve (the inner half of the infraorbital region, the wing of the nose, the upper lip, and sometimes the upper teeth on the side of the fracture) due to its damage during a fracture of the lower wall of the orbit.
A decrease in visual acuity or complete loss can be observed when the fracture is localized at the apex of the orbit with damage to the optic nerve.
Long-lasting and non-intense exophthalmos may indicate liquor leakage into the orbital cavity.
Pulsating exophthalmos is associated with rupture of the internal carotid artery in the cavernous sinus due to damage to the upper wall of the orbit.
Indirect radiological signs of fractures of the orbital walls associated with changes in the paranasal sinuses.
Impaired lacrimal drainage is often a sign of a fracture of the inner wall of the orbit with damage to the nasolacrimal canal.

Symptoms of contusion of the soft tissues of the orbit (external muscles of the eye, tissue, optic nerve) are listed below:

Exophthalmos due to swelling and hemorrhage. Swelling of the soft tissues of the orbit may be accompanied by swelling of the eyelids and chemosis. Hemorrhages into the orbital cavity can be parietal or in the form of a retrobulbar hematoma. Parietal hemorrhages from peripheral small vessels, depending on the degree of severity, can, like traumatic edema, cause moderate exophthalmos, in which the eyeball is quite easily reduced posteriorly. Hemorrhage may spread under the conjunctiva and be accompanied by hemorrhage into the thickness of the eyelids. Early hemorrhages indicate damage to the soft tissues of the orbit and eyelids. Late hemorrhages that appear on the 2-3rd day may indicate fractures of the base of the skull. Retrobulbar hematoma is hemorrhage from the central (larger) vessels into the muscular funnel, which is a closed cavity formed by the external muscles of the eye and the funnel part of Tenon’s capsule (Fig. 124).
An increase in pressure in the muscular funnel causes significant (up to 10 mm) tense exophthalmos. The degree of exophthalmos is directly dependent on the degree of contusion of the soft tissues of the orbit. At the same time, the absence of exophthalmos is not always a sign of a favorable condition of the soft tissues of the orbit. A fracture of the walls of the orbit, increasing its volume, can hide (compensate for) exophthalmos, indicating severe contusion of the soft tissues of the orbit.
Reduced visual acuity as a result of damage or compression of the optic nerve by retrobulbar hematoma.
Limitation of the mobility of the eyeball as a result of severe contusion of the muscles, nerves, and tissue of the orbit, accompanied by circulatory disorders, innervation, hemorrhages, swelling of the muscles and tissue. Mild contusional changes can be reversible, which is manifested in an increase in the range of movements of the eyeball 5-7 days after the injury. As a result of severe contusion, after 1-2 months, cicatricial atrophic processes can develop in the external muscles of the eye, Tenon’s capsule, and tissue of the orbit, which are little susceptible to reverse development.

DIAGNOSTICS OF CONTUSIONAL INJURIES OF THE ORBIT

When starting to examine and treat victims with fractures of the walls of the orbit, it is necessary first of all to exclude damage to the skull, brain and other organs, since these complications can threaten the patient’s life.

The diagnosis of orbital damage is based on:

medical history;
data from radiation research methods;
examining the patient and identifying visible deformations of the edges and walls of the orbit, changes in organs and areas adjacent to the orbit;
determination of violations of the position and mobility of the eyeball;
disturbances of binocular vision, diplopia (Fig. 125).

To diagnose abnormalities in the position of the eyeball, measurements of its vertical displacements relative to the horizontal line passing through the pupil of the healthy eye and horizontal displacements relative to the vertical midline of the face are used.

They are usually made using two rulers at right angles to each other. One of them is located along the measurement axis, the second serves to measure the deviation of the eyeball from this axis.

Anteroposterior displacements are measured using a Hertel exophthalmometer. An express method for identifying these biases is as follows.

The patient, throwing his head back, transfers the plane of the face from vertical to horizontal, directing his gaze perpendicular to the plane of the face (to the ceiling) (Fig. 125).

The doctor, observing the protrusion of the eyeballs from the chin, can note even a slight difference in their position.

The study of the mobility of the eyeballs is carried out on the Förster perimeter by determining the field of view.

Diplopia is determined by the Haab double image method or the Lancaster grid coordimetry method. The presence of binocular vision is determined using a color test, as well as using Bagalini glasses or Maddox prisms.

The binocular vision zone can also be determined on the perimeter using red glass, marking the boundaries of areas of the visual field where there is no double vision. In case of profound disorder of binocular vision, when double vision persists in all directions, this method is not applicable.

In order to exclude pinching of the muscle in the fracture zone when the mobility of the eyeball is limited, a “traction test” is performed.

If examination of the position and mobility of the eyeball is difficult due to severe swelling and hematoma of the eyelids, a wait-and-see approach should be followed for several days.

During this period, rest, cold, and osmotic agents are prescribed. The patient is examined by an otorhinolaryngologist, and, if necessary, by other related specialists, and their recommendations are followed.

If the dynamics are positive, you can postpone the operation, but no more than 10-14 days after the injury. On day 14, a final decision should be made using CT scan data.

If there are direct signs of a fracture of the walls of the orbit, leading to impaired mobility and position of the eyeball, accompanied by functional disorders (decreased vision - diplopia), early surgical intervention is indicated.

The main signs of orbital bone fractures are acute pain and limitation of eye movement, double vision, restrictions in facial expressions and mouth movement, formation of air bubbles under the skin near the eyes, as well as in their mucous membrane, depression (enophthalmos) or protrusion (exophthalmos) of the eye, reduction facial skin sensitivity.

Secondary symptoms may include nosebleeds and swelling around the eyes. Often damage to the upper bone wall of the eye is accompanied by damage to the brain. When the lower wall of the orbit is fractured, infection can enter from the nasal cavity onto the mucous membrane of the eye, which increases the severity of the patient’s condition.

Depending on the location of the injury to the skull and its characteristics, various signs can be observed. Therefore, depending on the symptoms, treatment for facial fractures can vary significantly.

The following symptoms are observed in injuries to the lower jaw:

excessive salivation;
sudden pain syndrome;
swallowing dysfunction;
hematomas and swelling;
swelling of the skin;
altered bite;
change in skin color (redness or blueness);
jaw shift.

How to determine an orbital bone fracture? Doctors identify the following symptoms:

swelling, stiffness in the movement of the eyeballs and pain;
state of shock with elements of blurred vision;
decreased sensitivity of the lower orbital nerve, and therefore the back of the nose, cheeks, eyelids, upper teeth and gums;
split field of view;
ptosis (flattening of the eyelid);
in case of serious injuries - displacement of the eyeball;
bleeding and internal hemorrhage;
the presence of air in the subcutaneous area and visible bubbles in the tissues.

Pain in the orbital area;
The victim complains of blurred vision (this symptom is caused by a state of shock);
The patient has double vision of all nearby objects;
Some victims have severe swelling in the eyelid area;
When examining the patient, attention is drawn to a pronounced hematoma in the eyelid area;
The patient experiences a narrowing of the palpebral fissure as a result of edema and hematoma;
Restricted mobility of the eyeball;
The victim has exophthalmos or enophthalmos;
When the orbit of the eye is fractured, the patient experiences ptosis (drooping of the outer corner of the eye);
Some patients may experience subcutaneous emphysema (crepitus);

With massive injuries, small areas of fatty tissue, damaged external eye muscles and ophthalmoplegia can be observed in the wound.

Causes

The causes of an orbital fracture include many factors. The most common is damage that was received as a result of a fight, careless movement, playing sports and much more. Direct injury is caused either by a blunt and heavy object, or by a fist, fingers, elbows, or a blow from a puck or ball.

Despite the fact that the lower jaw is the strongest in the skull, the majority of injuries to the facial bones occur there (more than 60%). The reason for this is its mobility and placement on the internal skeleton.

Injuries to the upper jaw and nasal cavity occur much less frequently, although they are also recorded quite often. The arch of the cheekbones is even less susceptible to injury.

The most common patients in trauma departments are people who received bruises as a result of alcohol intoxication, who got involved in violent confrontations, or who were involved in an accident. The risk group also includes active people who are professionally involved in any sport.

From this it follows that the causes of fractures can be intentional attempts or accidental injuries.

The main causes of pathologies are:

injury to the head area with any object;
falling from a high point of support;
falling from a moving or stationary vehicle;
emergency situation on the road;
injury resulting from active motor functions;
anatomical pathology.

First of all, the visual organ and nerves serving the eye may be injured. Bone fragments can injure this delicate organ so much that it may no longer perform its functions, and irreversible processes may develop that will lead to loss of vision.

Also, improper treatment of such a fracture can lead to the development of inflammatory processes and disruption of the proper functioning of the nasal part of the head. Purulent processes are very dangerous for this part of the human body and can be fatal.

The main reasons for the formation of purulent processes:

Open fractures, when the integrity of the skin is broken.
Remaining bone fragments that were not surgically removed.
Presence of a foreign body.
Decreased immune response of the body, various disturbances in the functioning of the immune system.

In the emergency room of a hospital, a doctor will immediately examine the injuries to a patient with a head injury, assess their extent and the urgency of providing first aid. The only examination that can give a complete diagnostic picture of fractures is an x-ray examination.

A photograph of the skull will show the doctor the condition of the eye socket and other parts of the skull. Based on the X-ray examination data, the primary treatment strategy for the patient will be built.

Some anatomical information: in medicine, the orbit is the place where the organs of vision are located. It is a recessed bony cavity that connects to other parts of the skull.

Typically, an orbital fracture is caused by blunt trauma. For example, a blow received on the steering wheel or seat during an accident or a hit with a tennis ball.

Even just a punch to the eye with great force can lead to such consequences. In this case, the eye and orbital tissue are very often injured.

It is also worth remembering that fragments of the eye socket can damage the tissue of the eye.

When injured by a sharp object, the bone may be slightly damaged, and symptoms of damage to the eyeball will come to the fore.

Note! The most dangerous type of injury is a gunshot wound. It significantly damages soft tissue, crushes the bones of the orbit and other areas of the skull, and can affect the brain.

Regardless of the type of fracture, the following symptoms are observed:

Intense pain in the area of the affected eye socket;
Significant swelling of the surrounding tissues;
Severe subcutaneous hemorrhage;
Recession or bulging of the eyeball;
Crunching of bones when pressed;
Decreased visual acuity.

The consequences directly depend on the severity of the injury. Sometimes, in the place where the displaced fracture occurred, a bone defect forms. The displaced areas are simply removed, leaving part of the eye socket empty.

If the defect is large enough, tissue plastic surgery is performed. In other cases, the role of the wall is taken over by a dense scar.

The most severe consequences are the consequences of soft tissue injury. If the eye is severely damaged, it is simply removed, leaving the eye socket empty.

Sometimes an eye injury leads to a complete loss of the ability to see or a sharp deterioration in vision.

In addition, impaired mobility of the eyeballs and their displacement may remain with the victim for life.

According to the timing of the operation, early surgical intervention is distinguished, performed in the acute period of injury, within the first two weeks, that is, precisely in that period of time when there are the most optimal conditions for restoring the integrity and ensuring adequate physiological functioning of the affected organ.

The operation can also be delayed, performed after a two-week period, but before the fourth month after the injury. This is the so-called “gray period”.

And finally, late provision of medical care, requiring mandatory osteotomy.

The most effective treatment methods include surgery, which includes several methods for correcting the bone tissue of the orbit and zygomatic arch. They are all similar in that they are made through small incisions, which then heal, that is, they become completely invisible.

This operation can be performed from one of the walls of the orbit and may include providing expanded access to the opening of the fracture area and the subsequent possibility of using various types of prostheses.

Often, a fracture of the orbital bone involves the main parts of the orbit: the frontal, temporal, zygomatic, maxillary and bony parts of the nasal region. In case of any damage, it is necessary to conduct a professional examination, examining the injuries received.

Any type of skull fracture is always followed by an irreversible concussion. An orbital fracture results from a blow to the eyeball. The structure of the skull is a rather delicate system, entailing a lot of unpleasant consequences if you are careless and have an incorrect, risky lifestyle. This type of injury has its own name – “explosive”.

Damage to the lower zone of the orbit is often not isolated. Basically, there is a holistic injury to the internal, external and maxillary walls of the eye canals.

Classification

In order to subdivide fractures of the facial bones according to anatomical features and the degree of displacement of their parts, it is necessary to know the structure of the cranium.

Orbital fractures vary depending on the location of the injury—medial, inferior, superior, or internal orbital walls.

Isolated orbital wall fractures

An isolated fracture is one in which only the inner walls of the orbit are damaged. At the same time, its edges, like other parts of the facial skeleton, remain intact. Such damage is quite rare. The cause of an isolated fracture may be a blow to the orbital area with a small diameter object.

Most often, along with the inner surface, the outer edges of the orbit break. Such a fracture can no longer be called isolated.

According to the characteristics of the damage
- Firearms;
- Non-firearms.
By type of damage:
- Isolated fracture;
- Fracture combined with injury to the eyeball;
- Combined fracture (with damage to the bones of the brain and facial skull, as well as the paranasal sinuses located next to the fracture);
- Fracture with the presence of a foreign body in the orbit.

Non-gunshot wounds are divided into:

Orbital damage and soft tissue contusion;
Open fracture of the bone walls of the orbit;
Closed fracture of the bony walls of the orbit.

Wounds of the soft tissues of the orbit are divided into:

Torn;
Cut;
Chipped.

Currently, according to statistical data, the most common injury to the orbit is fracture of the bony walls of the orbit.

Fracture of the bone walls of the orbit is divided into:

Closed fracture of bone walls;
Open fracture of the bone walls (in this case the orbit communicates with the external environment).

Diagnostics

At the first stage of the examination, it is necessary to conduct a thorough examination of the patient’s injured organ of vision for the presence of swelling of the eyelids, the motor ability of the eyeball, the sensitivity of the skin around the eye, and measure intraocular pressure.

For a more accurate examination, if there is a suspicion of bone damage, but the x-ray did not show this, a computed tomography is performed. But this research method also has its drawbacks - irradiation of the lens, and also due to the presence of edema, it can only be carried out over time.

To diagnose eye injuries, magnetic resonance imaging (MRI) can be used as an auxiliary method. This method can reveal pinched muscles in the fracture zone and fluid accumulation in the orbit.

Recently, the method of ultrasound examination of orbital injuries has become more common. Using ultrasound, you can determine both damage to the orbit and identify the presence of injury to the eyeball, the condition of the optic nerve and eye muscles.

A significant proportion of victims show signs of proptosis and prose, as a result of traumatic hemorrhage in tissue and muscles and swelling in the facial part of the skull. Upon examination, foreign bodies of various sizes and structures can be identified.

Approximately 30% of all “explosive” orbital fractures are combined with the development of erosion of the cornea of the eye, the phenomena of traumatic hyphema (the presence of signs of hemorrhage in the anterior chamber), iritis (inflammation of the iris), rupture of the eyeball, signs of concussion of the retina, its detachment and, finally, hemorrhages.

The severity of the orbital fracture is high.

Computed tomography (CT) is preferred, and axial and coronal thin sections are desirable for a better understanding of the condition of the orbital walls.

To identify a fracture and the introduction of orbital contents into adjacent sinuses, it is necessary to examine the internal (medial) part of the fundus and the wall adjacent to the nasal bone.

Inspection of the bony apex allows one to identify the condition of the posterior edge of the bone, which is mandatory during surgery.

If the lower or inner (medial) wall is fractured, mucosal secretions may spread through the damaged areas into the paranasal sinuses with concomitant infection.

How to treat an orbital fracture? Let's look further.

Taking an anamnesis (mechanism and circumstances of injury);
Examination of the organ of vision and tear ducts;
X-ray of the orbits and paranasal sinuses;
Tomography of orbital damage;
Ultrasound diagnosis of orbital injuries;
Consultation of the victim with a dentist, otolaryngologist, or neurosurgeon.

Principles of therapy

The goal of treatment is aimed at preserving or restoring the structure of the orbit and its contents, that is, the eyeball (restoring the range of motion of both active and passive muscles, eliminating such unpleasant accompanying symptoms as diplopia or, for example, strabismus, which cause significant discomfort to the victim).

Often in this situation they resort to surgical intervention, which at the same time has an adverse effect on the contents of the orbit, manifested in the form of excessive pressure on the eyeball.

The danger also lies in the fact that the hemorrhage that occurs behind the eye several times increases the pressure exerted on the optic nerve, and mainly on its disc, which entails not only deterioration of vision, but also, in an unfavorable outcome, its complete loss.

Since trauma also involves a lot of other anatomical components of the skull, loading on these affected parts is also prohibited, in particular, pressure exerted on the respiratory tract.

A simple effort, even a slight one, for example, when blowing your nose, leads to an increase in pressure inside the cavity of the zygomatic arch, which aggravates the swelling and can provoke complete closure of the eye, or contribute to the development of subcutaneous emphysema.

Treatment

Diagnosis and surgical treatment of combined orbital injuries should be carried out with the participation of related specialists. The need for the participation of related specialists can be determined both in the preoperative period and, often, during the surgical procedure (intraoperative diagnostics).

If the upper wall of the orbit is fractured during surgery, you may need the help of a neurosurgeon. In these cases, an otorhinolaryngologist is necessary to apply an anastomosis between the frontal sinus and the nose.

For displaced fractures of the zygomatic and maxillary bones that require repositioning of the fragments, the operation is performed by a maxillofacial surgeon with the participation of an ophthalmologist. The ophthalmologist’s task is to release the orbital tissue from the fracture zone, and, if necessary, plastic surgery of the orbital walls.

In addition, the ophthalmologist monitors the adequacy of the treatment performed in relation to the eyeball and optic nerve. For fractures of the lower and inner walls of the orbit, the operation is performed by an ophthalmic surgeon with the participation of an otolaryngologist or at least in his presence.

The ophthalmic surgeon's tactics are determined by the condition of the eyeball. According to appropriate indications, it is necessary first of all to perform surgical intervention on the eyeball, and only then to engage in plastic surgery of the walls of the orbit.

The time between these operations is determined individually, depending on the nature and severity of the damage, the extent of surgery, the expected restoration of function and the surgeon's experience in performing operations on the orbit.

During the first two days after injury, it is necessary to apply cold to the damaged area. Vasoconstrictor nasal drops and antibiotic therapy are prescribed for one to two weeks.

Also, in the first days, the patient must be provided with rest, since fractures of the orbital walls can be accompanied by brain injuries. Corticosteroid drugs are sometimes prescribed to reduce inflammation.

For minor injuries, if the patient’s condition allows, surgical operations to reconstruct the bones can be performed within the first three days. In severe cases, with severe swelling, persistent double images and pronounced enophthalmos, surgery can be performed after 1-2 weeks.

Early surgery (within the first 10 days) is preferable to later surgery.

If the upper wall of the orbit is damaged, the patient must be examined by a neurosurgeon, possibly with further hospitalization in the neurosurgery department.

The examination must be carried out very carefully to determine all the damage and subsequently carry out reduction and fix all bone fragments.

To fix bone fragments, interosseous wire sutures are applied or microplates and screws are used. To restore the walls of the orbit, primarily the lower one, bone grafts are used, which are made from dissolved cartilage tissue and bones of the ribs, skull, tibia, or inorganic implants.

Structures made of titanium, silicone, Teflon, etc. are used as inorganic fragments.

Often during surgery, consultation with an otolaryngologist and an oral and maxillofacial surgeon is necessary.

Treatment of violations of the integrity of the frontal, temporal, jaw lobes and cheekbones is carried out depending on the obvious signs and condition of the patient. Based on the depth of injury, the patient may experience a concussion, traumatic shock, or other conditions.

People with a pathology of the skull structure can spend at least half a month in a hospital bed. During this time, they receive medical care with qualified methods of treating fractures.

For this, medical staff use orthopedic, medicinal and surgical means, including the reduction of bones and fixation of fragments of fractured bones of the facial skull.

When a patient is diagnosed with a concussion, doctors decide to treat them using gentle methods aimed at improving their health and preventing deterioration in their well-being. Such patients receive safe, non-traumatic therapeutic interventions. Sometimes your doctor may recommend removing your tonsils to allow air into your airways.

Treatment of a facial bone fracture proceeds in the following sequence:

breaking off fragments from the arches of the cheekbones;
jaw realignment;
fixation of the nasal septum in its proper place.

In some cases, with ruptures of the cranial skeleton, immobilization of hard tissue processes is indicated for the patient. If it is impossible to carry out simultaneous reduction and fixation of the main fragments in the desired position, the patient is treated using the intermaxillary traction method.

For comminuted nasal cartilage fractures, therapeutic methods of reducing the fragments with securing soft tissues with special tools like knitting needles are usually used.

In any case, whatever the nature of the injury, in injuries with a similar outcome, the victim requires urgent hospitalization to provide timely and high-quality medical care.

Surgical treatment

If more than two weeks have passed as a result of a violation of the cranial skeleton, and fragments of hard tissue are displaced, surgical intervention is necessary.

There are two ways to treat this injury:

Conservative. It helps in the case of an isolated small fracture without displacement of the orbital bones. In this case, the eye is treated with antibiotic solutions and a special bandage is applied to it. The procedure is repeated daily for 2 weeks.
Operational. It is used if the bones of the orbit need to be returned to their previous position or damage to soft tissues needs to be repaired. In this case, surgical intervention is performed, the volume of which depends on the number of damaged structures. For example, this is how they can remove fragments of the orbit from cavities, sew together the muscles and tissues of the eyeball, clean the orbit from blood, pus, and much more.

Regardless of the treatment method, the patient must take painkillers and antibiotics orally.

First aid consists of treating the wound with a disinfectant solution and applying an aseptic dressing.

Complications and consequences

The prognosis for both life and ability to work is quite favorable if rehabilitation was carried out within fourteen days from the moment of injury.

Damage to the eye nerves and muscles is possible. If damage to various structures of the eye is detected, then complete recovery occurs only within four months. In severe cases, recovery may not occur.

Damage to the outer and inner walls of the orbit can lead to a fracture of the optic nerve canal, which in turn can cause damage to the optic nerve itself, and, as a result, irreversible loss of vision.

To avoid loss of vision, urgent surgery is necessary to remove bone fragments that may be causing nerve damage and to prevent bleeding inside the optic canal.

If the inner wall is damaged, you should refrain from sneezing and sharp inhalation of air in the first few weeks; to do this, you need to prohibit physical activity and ensure complete rest for the patient, as well as carry out regular wet cleaning and ventilation of the room, observe the humidity level and temperature conditions of the room.

In different cases, depending on the severity of the damage, there may be consequences. To prevent complications, any eye injuries require immediate medical attention.

If the examination is carried out in a timely manner and the necessary treatment is prescribed, then the patient’s condition is generally restored without any problems. Sometimes, with severe injuries and cosmetic disorders, plastic surgery may be required in the future.

It is not recommended to delay a visit to the doctor for eye injuries, even if in your opinion there are no superficial changes.

Only a specialist can determine the extent of damage and prescribe the correct treatment, which will help avoid consequences altogether. Failure to follow the doctor's recommendations can lead to serious complications, namely irreversible loss of vision.

A patient with eye injuries must be under medical supervision for a month. After 20-30 days, it is necessary to examine the retina and white of the damaged eye to prevent possible retinal detachment, glaucoma and inflammation of the eye tissue.

When severe swelling of the tissues of the orbit has subsided, after 5-10 days the patient should be examined to identify the development of chronic double image or enophthalmos. These symptoms may indicate pinched eye muscles, which requires surgery.

If treatment is not carried out, then 15-20 days after the injury, tissue grows between the bone fragments and scars form, and the bones fuse. Bone fragments, when destroyed, form rough scars that are not able to perform the functions of the bone skeleton. The violations obtained in this case are irreversible.

Types of orbital fracture surgeries

Simple supraperiosteal orbitotomy and drainage of the retrobulbar space for retrobulbar hematoma. The operation is usually performed under local infiltration anesthesia with a 0.5-2% novocaine solution.

A percutaneous supraperiosteal orbitotomy is performed through an incision along the lower edge of the orbit. If, according to computed tomography, magnetic resonance imaging or ultrasound, a more precise localization of the hematoma is known, the incision is made according to its location: along the upper, outer or lower edges of the orbit.

Parallel to the edge of the orbit, a layer-by-layer incision of the skin and subcutaneous tissue is made with a scalpel.

The fibers of the orbicularis oculi muscle can not be cut, but moved apart, having previously stretched them with the branches of tweezers placed under the muscle. To avoid eyelid retraction in the postoperative period, the skin incision (2.5-4 cm) should be located no closer than 5 mm from the edge of the orbit.

To prevent the formation of a rough scar fused to the periosteum, it is advisable to shift the incision of each layer to the edge of the orbit by 1.5-2 mm. To ensure that the skin incision coincides with the folds of the face or existing scars, the projection of the upcoming incision should be marked before anesthesia.

Bleeding from a wound can be stopped by diathermocoagulation or a clamp followed by ligation of the vessel. Bleeding from small vessels usually stops on its own or after targeted massaging movements with a gauze ball.

The tarso-orbital fascia is incised directly at the edge of the orbit. The contents of the orbit are bluntly separated from the wall and lifted upward with a spatula.

If, after expanding the wound deeper and to the sides, no blood is obtained, then the space of the muscle funnel should be opened. To do this, in the lower outer quadrant, the tip of the “mosquito” is passed through the parabulbar tissue between the muscles of the eye towards the posterior pole of the eyeball to a depth of 1-1.5 cm. By spreading the jaws of the clamp, the infundibular part of the Tenon capsule is broken.

To avoid damage to the optic nerve, all surgeon actions must be as careful as possible. A sign of the effectiveness of the manipulation is the appearance in the wound of loose, bright yellow funnel fat or blood from a retrobulbar hematoma.

Even if no bleeding is obtained during the operation, the orbitotomy itself will reduce the intraorbital (more precisely, retrobulbar) pressure caused by swelling of the tissues or their saturation with blood, and will eliminate compression of the optic nerve.

As an alternative approach to retrobulbar hematoma, a transconjunctival approach, usually used in operations on the eye muscles, can be used. By bluntly pushing the tissues apart at a depth of 3 cm from the place of muscle attachment to the eyeball, the retrobulbar space is opened and drained.

The operation ends with drainage of the retrobulbar space for 1~2 days with a strip of rubber glove or perforated polyethylene tube. The wound is sutured layer by layer with synthetic monofilament (Perlon, 5/0-7/0).

The use of catgut should be avoided as it can sometimes delay wound healing. In the postoperative period, it is advisable to prescribe osmotic therapy and local use of steroids.

Rehabilitation period

Recovery time depends on the nature of the injury and the complexity of the fracture.

An isolated small fracture can heal completely within 2 weeks.

The orbital area is well supplied with blood, so the tissues here are restored quickly.

For more significant fractures, even after surgery, rehabilitation can take a month or even six months.

In some cases, complete restoration of the structure and functioning of this area does not occur.

Medical procedures for rehabilitation

In order to speed up recovery, you must follow your doctor's recommendations. First of all: change the bandage on time, treat the eye, use sterile materials for dressings, limit head and eye movements, take vitamins and minerals.

If the eye muscles are damaged, the doctor may prescribe a set of eye exercises. The earlier treatment is started, the better the prognosis.

Although the first description and photographic recording of traumatic enophthalmos resulting from blunt trauma to the orbit in a twelve-year-old boy dated back to 1889, the cause-and-effect relationship of enophthalmos with an orbital fracture was established by R. Pfeiffer only in 1943. The term “blow-out” for cracking the inferior wall of the orbit without involving the infraorbital margin was proposed by J. M. Converse and B. Smith in 1956.

A year later, B. Smith and W. F. Regan put forward a “hydraulic” theory of the occurrence of “explosive” fracture. Its essence boils down to the fact that the wounding agent, the magnitude of which exceeds the size of the entrance to the orbit, deforms and displaces the eyeball deep into the orbit, thereby compressing its contents and sharply increasing intraorbital pressure, which causes the weakest lower wall to be pushed into the maxillary sinus. Prolapsed soft tissues return to their original position more slowly than bone fragments, and therefore are pinched in the zone of a fracture, usually linear.

It is curious that, contrary to popular belief, a hit with a tennis ball does not lead to a fracture, although it can cause damage to the eyeball. Apparently, the deformation of the hollow ball during contact and the suction effect that occurs at the moment of rebound from the periorbital region dampens the rise in intraorbital pressure. For a fracture to occur, exposure to a wounding agent that is incapable of transient deformation, such as a fist, is required.

With extensive comminuted defects of the lower wall, the soft tissues are not so much pinched as they are displaced downwards under the influence of gravity and reactive edema. Not so many supporters of the “mechanical” hypothesis formulated by R. Le Fort (1901) consider the main mechanism of explosive cracking of the orbital floor to be wave-like deformations transmitted from the infraorbital margin.

Depending on the direction of the force vector, the bottom of the orbit (primarily its inner half) experiences either horizontal or rotatory deformation. The fracture area will be maximum if the wounding agent moves from bottom to top at an angle of 30º to the infraorbital margin. The kinetic energy required to destroy the orbital floor by wave-like deformation and through hydraulic shock is almost the same, but the location and extent of “hydraulic” and “mechanical” fractures differ significantly. Experimental studies in cadaver orbits have demonstrated that fractures caused by wave-like deformation are limited to the anterior half of the inner part of the orbital floor, do not extend to the medial wall, and are not accompanied by entrapment of soft tissues in the area of the bone defect.

The hydraulic mechanism causes much more extensive fractures, involving not only the entire lower but also the medial wall of the orbit, soft tissue prolapse and enophthalmos. According to some authors, both mechanisms play a role in the occurrence of a fracture, and it is fundamentally wrong to oppose them. The simultaneous initiation of both mechanisms of injury, their coexistence, complementarity with the dominance in each specific case of one option explains the variety of orbital fractures.

At one time, another mechanism for the occurrence of a fracture was considered - “pushing through” the lower wall of the orbit by the equator of the eyeball, which was sharply deformed at the time of injury. This hypothesis still finds its supporters today. However, experimental studies on cadaveric orbits, based on serious mathematical apparatus, have established that the direct wounding agent is still the soft tissue adjacent to the lower wall of the orbit, and not the eyeball itself.

An isolated burst fracture of the orbital floor requires less energy than an injury to the medial wall or an inferomedial fracture. This seemingly illogical, but long-known fact to clinicians, was explained in the work of H. Takizawa et al. (1988). Based on experiments and subsequent computer modeling, the authors clearly demonstrated that not only the thickness, but also the contour (profile) of the orbital walls plays a very important role. In particular, the arched roof of the orbit is much more resistant to deformation than the almost flat bottom, which is more easily deformed and broken. The medial wall is even thinner, but it is reinforced from behind like buttresses by the cells of the ethmoid bone. Therefore, more mechanical energy is required to fracture the medial wall than to fracture the orbital floor.

Anatomical formations such as the inferior orbital fissure, infraorbital groove and canal, as well as reflex contraction of the orbicularis oculi muscle and the presence of a large air cavity under the orbit, contribute to damage to the orbital floor. It is the underdevelopment of the maxillary sinus and the continuing growth of the orbit that explains the rarity of orbital floor fractures in children under 7–8 years of age. If fracture does occur, it requires surgical treatment less often than in adults.

Classification

According to the radiographic classification of G. F. Fueger, A. T. Milauskas and W. Britton (1966), “burst” fractures are divided into six main types, some of which contain subtypes:

Classic - low-energy fracture of the inner (weakest) half of the lower wall medial to the infraorbital canal.
Involving the infraorbital canal.
Inferomedial, that is, a fracture of the lower and medial walls.
Complete (total) fracture of the inferior wall of the orbit. The spread of fracture lateral to the infraorbital canal is usually caused by the impact of a wounding agent with a sufficiently large kinetic energy, which leads to cracking of the entire lower wall.
Atypical forms of burst fractures:

rectangular;
triangular;
star-shaped.

Linear fractures of the lower wall without displacement of fragments:

Y-shaped;
lateral linear

Symptoms

The only symptom specific to a fracture of the orbital floor that can be detected when examining the eyeball is pupil dilation of up to 5–8 mm, which lasts from several weeks to several months. The pupil does not react to light, but narrows when instilled with pilocarpine, which makes it possible to differentiate this pathology from contusional mydriasis.

Complaints of hyposthesia along the infraorbital nerve, presented by 70% of patients, are very typical. . And the combination of neurological disorders with vertical diplopia and enophthalmos makes it possible to almost accurately formulate a clinical diagnosis of a fracture of the orbital floor.

Periocular signs (a, b): periorbital ecchymosis, subconjunctival hemorrhage (hyposphagma), edema and subcutaneous emphysema of varying degrees.
Narrowing of the palpebral fissure of the damaged eye, clearly visible when comparing the position of the lower eyelid on both sides (c - narrowing of the left palpebral fissure).
Anesthesia of the area of innervation of the inferior orbital nerve affects the lower eyelid, cheek, dorsum of the nose, upper eyelid, upper teeth and gums, since a burst fracture often involves the walls of the infraorbital fissure.
Diplopia may be due to one of the following mechanisms:

Hemorrhage and swelling cause hardening of the orbital tissue between the inferior rectus, inferior oblique muscles and periosteum, which limits the mobility of the eyeball. Ocular motility usually improves once hemorrhage and swelling resolve.
Mechanical entrapment in the area of the fracture of the inferior rectus or inferior oblique muscle or adjacent connective and fatty tissue. Diplopia usually occurs when looking both up and down (double diplopia). In these cases, the traction test and differential eyeball reposition test are positive. Diplopia may subsequently decrease if it was caused mainly by pinching of connective tissue and fiber, but usually persists when the muscles are directly involved in the fracture.
Direct trauma to the extraocular muscles in combination with a negative traction test. The muscle fibers usually regenerate and normal function is restored after 2 months.

Enophthalmos occurs in severe fractures, although it usually appears several days after swelling begins to resolve. Without surgical intervention, enophthalmos can increase up to 6 months due to post-traumatic degeneration and tissue fibrosis. ( d - enophthalmos on the left, manifested by deepening of the fold upper eyelid).

D, f - limitation of supraduction (upward movements of the eyeball) on the side of the fracture

Eye injuries(hyphema, angle recession, retinal detachment) are usually uncharacteristic, but they should be excluded with careful examination at the slit lamp and with ophthalmoscopy.

Diagnostics

The diagnosis of an “explosive” fracture of the lower wall of the orbit is facilitated by very characteristic complaints, of which the most important is double vision during vertical eye movements, which occurs in 58% of patients.

The primary position of gaze, as well as changes in the severity of diplopia during movements of the eyeball, suggests an area of entrapment of the inferior rectus muscle.

In 1970, S. Lerman formulated very interesting principles regarding diplopia in “burst” fractures.

So, if diplopia increases when looking up and decreases when looking down, and in the primary position of gaze the eyeball in the damaged orbit is slightly deviated downward, then the inferior rectus muscle is pinched in the preequatorial zone.
If limited mobility and double vision are equally pronounced when looking up and down, and in the primary position of gaze the eye occupies a central position, then the muscle is pinched in the area of the equator of the eyeball.
Finally, if diplopia increases when looking down and weakens when looking up, and in the primary gaze position the eyeball is slightly tilted upward, then the inferior rectus muscle is pinched behind the equator of the eyeball

Paresis of the inferior rectus muscle, displacement of the inferior muscle complex to the fracture zone, and an unnatural angle of attachment of the dislocated inferior rectus muscle to the sclera are considered as a possible cause of upward deviation of the eyeball.

A detailed assessment of the mechanism of injury helps in making a diagnosis. In this case, attention should be paid to two factors that largely determine the clinical picture of a fracture: the size of the wounding agent and the energy component of the injury. If the area of a blunt hard object is smaller than the size of the entrance to the orbit, the patient may develop a subconjunctival scleral rupture. If the dimensions of the wounding projectile are larger than the dimensions of the orbital entrance, then two options are possible:

when exposed to an agent with a relatively low speed and, accordingly, low kinetic energy, a low-energy “explosive” fracture of the lower wall occurs; with a pronounced impact, a medium-energy combined fracture of the infraorbital margin and orbital floor occurs.
Finally, a large wounding agent with high kinetic energy causes a fracture not only of the edge and floor of the orbit, but also of other facial bones, up to the formation of high-energy panfacial fractures. Most often, such situations arise as a result of road accidents.

Thus, analysis of the circumstances of the injury is of great practical importance, because it allows us to predict the nature of the injury and suspect those changes that during the initial examination may be masked by edema and hematoma of the periocular tissues.

Objective research begins with an external examination. A probable fracture of the orbital floor is indicated by symptoms such as severe swelling and hematoma of the eyelids, hyposphagma, and chemosis of the bulbar conjunctiva.

It is generally accepted that if a patient has such symptoms, a reliable assessment of the position of the eyeball in the orbit (in three planes) and the range of its movements becomes possible only 2–3 weeks after the injury, since reactive edema and hematoma of the soft tissues of the orbit can hide enophthalmos up to 3 mm.

Axial dystopia(eno- or exophthalmos) is determined in relation to a healthy eye using a Hertel-Krahn exophthalmometer. The basis is selected so that the stops of the exophthalmometer are pressed tightly against the anterior surface of the lateral edges of the orbit. The doctor uses his left eye to evaluate the alignment of the patient's right eye and vice versa. When assessing the subject's right eye, the examiner's left eye is open, and the patient must look at the examiner's right eye closed. Using his left eye, the researcher brings together parallel lines in the mirror and uses a scale printed on it to evaluate the height of the cornea.

Exophthalmos in case of damage to the lower wall of the orbit, it is possible only in the acute period of injury and is caused by edema and/or hematoma of the orbital tissues. A typical symptom of a burst fracture is retraction of the eyeball.

Enophthalmos indicates an increase in the volume of the orbit, which is typical for a “burst” fracture with
significant displacement of fragments (classical, inferomedial, total).

Axial dystopia of 1-2 mm is considered mild, moderate - 3-4 mm, enophthalmos over 5 mm is pronounced.

K. Yab et al (1997), based on an analysis of CT scans of patients with orbital fractures, established that until the increase in orbital volume exceeds 2 ml, enophthalmos remains at the level of 1 mm. Then the degree of retraction of the eyeball increases in proportion to the increase in the volume of the orbit, but with an isolated fracture of the lower wall it never exceeds 4 mm.

Vertical dystopia (hypophthalmos) is assessed relative to a horizontal line passing through the center of the pupil of the healthy eye. As a rule, drooping of the eyeball indicates an extensive fracture of the lower wall of the orbit. The most pronounced variant of hypophthalmos are casuistic cases of dislocation of the eyeball into the maxillary sinus.

Lateral dystopia (in the frontal plane) measured by comparing the distance from the middle of the bridge of the nose to the nasal limbus. The difference between the healthy and injured side indicates a concomitant fracture of the medial orbital wall.

The next stage of the study is the analysis of oculomotor disorders. First, the position of the eyeballs in the primary direction of gaze is assessed, then their excursions in the horizontal and vertical meridians are assessed. Next, eye mobility is checked in each of the six main directions of gaze - right, left, up-out, up-in, down-out, down-in.

Total restriction of mobility usually indicates edema or hematoma of the orbit. The fact of decreased supraduction or infraduction on the damaged side in comparison with the mobility of the fellow eye has diagnostic value. It should be remembered that obvious limitations in ocular motility are rare.

To identify less obvious oculomotor disorders, a test with “provoked” diplopia is performed, based on an assessment of the relative position in space of the images belonging to the fixed and deviated (affected) eye.

Diplopia is caused by placing a red glass over one eye. This allows you to simultaneously determine which of the double images belongs to the right and which to the left eye.

The doctor and patient are at a distance of 1.5–2 m and face each other. The doctor holds a flashlight in his hands, which he moves to the right, left, up, down and in between positions, while asking the victim whether he sees one or two images of a light bulb. If the patient sees two images, then he is asked to report in what position they are relative to each other, what is the distance between them and when it increases or decreases.

When assessing the results of the study, the following rules are used:

the muscle of the eye whose image moves further from the middle horizontal or vertical line is affected; this image is called imaginary;
the virtual image is always projected in the direction of action of the paralyzed muscle, therefore diplopia of the same name occurs when the abductor muscles are affected, and diplopia of the same name occurs when the adductor muscles are affected;
the distance between the double images increases as the gaze moves towards the action of the affected muscle.

Differential diagnosis between the main causes of motor disorders (paresis of a branch of the oculomotor nerve or pinched muscle in the fracture zone) is carried out using traction test , which is performed as follows

The patient is asked to look at his hand, which is extended in the direction of the planned displacement of the eyeball, that is, upward. After epibulbar anesthesia, the conjunctiva at the limbus in the 6 o'clock meridian is fixed with corneal tweezers (a) and the eyeball moves in the direction opposite to the vector of traction of the inferior rectus muscle, the infringement of which is suspected (i.e., upward) (b). At the same time, it is important not to press the eyeball into the orbit, which can create the illusion of normal eye mobility if the muscle is pinched.

Positive traction test (c) is a difficult passive displacement of the eyeball upward while maintaining its normal mobility downward. In this case, clinically, eye mobility is limited both up and down. A positive traction test indicates impingement of the inferior rectus or inferior rectus and inferior oblique muscles at the fracture site. In some cases, only the lower portion of the anterior suspensory system is infringed, but its close connection with the muscles also leads to diplopia and requires surgical treatment.
Negative traction test (d) (uncomplicated passive upward displacement of the eyeball) occurs in 18% of cases and indicates paralysis of the levator oculi or muscle damage (contusional edema, hematoma, separation from the sclera).
In this case, the so-called generation test (muscle force generation test) is carried out. After epibulbar anesthesia, the conjunctiva at the limbus in the 6 o'clock meridian is fixed with corneal forceps and the eyeball is held in the primary direction of gaze. The patient is asked to look in the direction of action of the inferior rectus muscle being tested, i.e. down. With preserved innervation, the doctor will feel a muscle pull tending to lower the eyeball (positive test). A negative test result cannot be interpreted as unambiguously, since it may be due to either oculomotor nerve palsy or muscle damage. In most cases, the cause of a negative test is muscle dysfunction, which usually resolves within 1 to 2 weeks. The protracted nature of oculomotor disorders indicates their neurogenic nature.

A contraindication to performing tests is the presence of pain, blepharospasm, orbital hematoma or tissue edema in the patient, when there is a high probability of obtaining false positive results.

Despite the fact that a “burst” fracture dampens the sharply increased intraorbital pressure, in 30-40% of cases such injuries are combined with various eye injuries, often (20-30%) severe.

According to L. Tong et al. (2001), 40% of them are contusional ruptures of the sclera. In 38% of cases, a fracture of the lower wall of the orbit is accompanied by injuries outside the bones of the face, primarily the skull and brain. In general, with a “burst” fracture, the likelihood of injury to the eye
apple is 2.5 times higher than with zygomatic-orbital.

Therefore, it is imperative to ensure the integrity of the eyeball, which is an indispensable condition for reconstruction of the lower wall of the orbit. Unfortunately, injuries to the eye and periorbital region are often overlooked during the admission of patients with midface fractures.

Upon admission of the victim, first of all, it is necessary to assess visual acuity and pupillary reactions.
Low visual acuity in the emergency department can be due to a variety of reasons - lack of correction means, blood in a tear, pain, intoxication, fear, which does not allow the victim to concentrate. In general, careful visual examination at the admission stage
often impossible and probably not that important. But amaurosis clearly indicates serious damage to the visual analyzer.

In the absence (real or apparent) of object vision, the perception of the intensity of normal white color by the healthy and affected eye is assessed. To assess the condition of the optic nerve, a red discrimination test is performed. Coloring the test object (it can be
the nail phalanx of the index finger illuminated by a flashlight or the red cap from a bottle of mydriatic) in orange or brownish shades is a bad prognostic sign.

If the patient is unconscious, then the only integral indicator of the functioning of the visual analyzer is the state of the pupils, in particular their shape and size. Corectopia (deformation and displacement of the pupil) is characteristic of a penetrating injury to the eyeball or contusive rupture of the sclera.

When assessing the pupil, it should be remembered that its diameter is not in close correlation with visual acuity, since it is a function of the optic nerve (n. II), and the size of the pupil is determined by the interaction of the sympathetic fibers of the ophthalmic branch of the trigeminal nerve (n. VI) and parasympathetic fibers located in the lower branch of the oculomotor nerve (n. III).

As a result, the blind eye may have a normal pupil diameter and, conversely, maximum mydriasis does not interfere with high visual acuity.

Next, pupillary reactions to bright light are analyzed. An afferent pupillary defect, or Marcus-Gunn pupil (weakened direct pupillary response to light while the concomitant one is preserved), is a clear confirmation of optic nerve injury. The essence of the symptom lies in the paradoxical reaction of the pupil when the light flux quickly moves from the healthy eye to the patient, whose pupil, when illuminated, not only does not narrow, but expands due to the loss of a direct reaction due to a violation of the afferent part of the arc of the pupillary reflex.

The next step is to study the central visual field using the Amsler grid and roughly determine the boundaries of the visual field.

Then, using a flashlight, the anterior segment is inspected. The examination ends with ophthalmoscopy of the fundus under conditions of drug-induced mydriasis. The pharmacological effect on the pupil, as well as a detailed description of its initial state, must be recorded in the medical history. Unless absolutely necessary, you should not dilate the pupil of the contralateral healthy eye.

CT signs of a fracture of the lower wall:

Extensive bone defect with displacement of a fragment (indicated by an arrow) into the sinus (a)
P rollup into the maxillary sinus of the orbital fat strangulated in the “fracture-trap”fiber (arrow) (b)
Rounding of the normally flattened belly of the inferior rectus muscle(indicated by an arrow). The symptom does not have any particular diagnostic value in case of an obvious fracture (c), but is very informative in case of minor injuries.bottom wall (d, d)
Massive hemorrhage in the maxillary sinus, relievingdiagnosis of a fracture with minimal displacement of fragments.

Indirect signs of a fracture:

Presentation of the muscle to the seemingly intact floor of the orbit. The combination of this symptom with a characteristic clinical picture indicates infringement of the sheath of the oculomotor muscle and the surrounding connective tissue bridges in the area of a linear fracture of the “trap” type.
Symptom of the “missing inferior rectus muscle”, when during a “trap” type fracture the muscle is pinched in the area of the bone defect in such a way that it is not visualized on coronal CT grams either in the orbit or in the maxillary sinus
The rounding of the normally flattened belly of the inferior rectus muscle, clearly visible on the coronal CT scan, indicates the loss of its bone and connective tissue support. In an experiment on cadaver orbits, it was established that with a fracture area of up to 1 cm, rounding of the belly of the inferior rectus muscle occurs only when the periosteum is ruptured (which is fraught with late enophthalmos and requires early surgical intervention). With a fracture area of 4 cm, the abdomen is rounded without trauma to the periosteum, but when it ruptures, the symptom is more pronounced.
Presence of free fluid in the paranasal sinus

In case of severe general condition of the patient and the impossibility of performing coronal CT, transantral (through the Caldwell-Luc approach to the maxillary sinus) endoscopy of the lower wall of the orbit, performed in the ward under local anesthesia and having sufficient information content, helps.

Treatment

Initially conservative and includes antibiotics if the fracture involves the maxillary sinus. The patient should be informed that nose blowing is not advisable. The following is aimed at preventing permanent vertical diplopia and/or cosmetically unacceptable anophthalmos.

There are three factors that determine the risk of these complications:

fracture size,
herniation of orbital contents into the maxillary sinus
muscle pinching. Although there may be some confusion of signs.

Most fractures fall into one of the following categories:

Small cracks without the formation of a hernia do not require treatment, since the risk of complications is insignificant.
Fractures affecting less than half of the orbital floor, with small or absent hernias, and positive dynamics of diplopia also do not require treatment until anophthalmos of more than 2 mm appears.
Fractures extending to half or more of the orbital floor, with entrapment of the orbital contents and persistent diplopia in the erect position should be operated on within 2 weeks. If surgery is delayed, results will be less effective due to the development of fibrotic changes in the orbit.

Indications for surgery

Indications for surgery
a - total fracture,
b - significant increase in volume,
c - defect n. wall, equal to 0.5 its S in the coronal projection,
g - defect n. wall, equal to 0.5 its S in the sagittal projection,
d - three-dimensional reconstruction.
e - infringement n. straight line in the zone of a linear “fracture-trap”.

Burst fractures that do not cause functional or cosmetic harm to the patient cannot be treated surgically. Other cases require surgical assistance.

Conservative and delayed surgical treatment of orbital fractures is a thing of the past. The goal of treatment for a fracture of the inferior orbital wall is to restore the original shape and volume of the orbit, reposition its contents and restore the mobility of the eyeball. The key to success is adequate exposure of the fracture zone, clear visualization of its posterior edge and restoration of the defect over its entire area. Intervention should be early, immediate and comprehensive.

Indications for plastic surgery of the lower wall of the orbit during first three days from the moment of injury are:

early hypo- and enophthalmos, indicating a total fracture (destruction) of the orbital floor
"trap" type fracture of the lower wall in children
oculocardial reflex that does not tend to spontaneous regression

In other cases of fresh combined injuries of the orbit and midface, restoration of the integrity of the orbit should be carried out on days 3–9 - upon passing or in the absence of a threat
for life, as well as the risk of loss or serious impairment of vision.

More than two-thirds of American plastic surgeons perform such an intervention in the first 14 days, and half of British surgeons operate on a fracture of the lower wall of the orbit 6–10 days after the injury

The indication for surgery is each of the following criteria individually or a combination of them:

diplopia in functionally important directions of gaze, for example, downward (within 30º of the primary direction of gaze) or upright, persisting for 2 weeks after injury with a radiologically confirmed fracture and a positive traction test
enophthalmos over 2 mm; a defect in the orbital floor exceeding half of its area, fraught with the development of late hypo- and enophthalmos
significant prolapse of the orbital contents and enophthalmos over 3 mm, occurring with a radiologically confirmed increase in the volume of the orbit by 20% or more

Enucleation with implantation of an orbital liner, performed against the background of a concomitant extensive defect in the lower wall of the orbit, must necessarily be completed with osteoplasty. Otherwise, the patient will develop anophthalmic eno- and hypophthalmos.

According to the timing of implementation, the intervention is considered early , if performed in the “acute” period of injury, that is, in the first 14 days. It is these periods that are considered optimal for reconstructing the damaged orbit and restoring the mobility of the eyeball, although the chances of success do not decrease for a month after the injury.
Deferred An operation is considered to be performed 3 weeks to 4 months after the injury, in the so-called “gray” period, when fused fragments can still be mobilized without the help of osteotomy, and prolapsed soft tissues can be separated from the edges of the fracture.
Finally, late An intervention is considered to be carried out 4 or more months after the injury and requires mandatory osteotomy. During these periods, it is difficult to achieve not only good aesthetic but also functional results due to the inevitable postoperative scarring of the soft tissues covering the fracture area

Treatment of “burst” fractures of the lower wall of the orbit should be early, immediate and comprehensive. The implant used during the operation must satisfy a number of requirements, which include:

ease of modeling and subsequent implantation;
ability to serve as a support for orbital structures;
stability of the given position due to rapid integration with surrounding tissues;
resistance to bacterial contamination;
formation of clear images on CT and MR sections.

To the greatest extent, these requirements are met by modern non-biological porous materials, which include porous polyethylene, coral hydroxyapatite and porous poly-tetrafluoroethylene developed in Russia, which is not inferior in its chemical and physical-mechanical properties to the best foreign analogues.

The final assessment of the results of the operation according to such criteria as the mobility of the eyeball and its position in the orbit, the presence or absence of diplopia, is performed no earlier than 6 months after the intervention. It is not advisable to perform a CT scan after surgery with obvious positive dynamics in order to save the patient from additional radiation exposure.

An integral indicator of long-term success is the correct position of the eyeball in the orbit and the absence of diplopia.

Antibiotic therapy

The question of the need for antibiotic therapy for “explosive” fractures of the lower wall of the orbit deserves special consideration. It turned out that there is no description in the literature of standardized antibiotic regimens for this category of patients.

Given the lack of consensus on this matter, it is proposed to use general surgical standards for prescribing antibiotics depending on the type of wound:

Type I - clean wound; the risk of bacterial infection does not exceed 1.5%.The effectiveness and, accordingly, the need for prophylactic antibiotic therapy have not been proven;
Type II - a conditionally clean wound in contact with the upper respiratory tract without massive bacterial contamination. Risk of infectiouscomplications are 7.7%, prophylactic antibiotic therapy is indicated;
Type III - a contaminated wound that communicates with the digestive tract. The risk of complications reaches 15.2%, preventiveantibiotic therapy;
Type IV - infected wound (old injury, previous infection, presence of purulent discharge, non-viable tissue, foreigntel). The risk of wound infection is 40%; antibiotic therapy is indicated, which serves not only a preventive, but also a therapeutic purpose.

The presence of a graft or foreign body in the wound (a condition after osteoplasty of the orbital floor) significantly increases the risk of infection and is also an indication for prophylactic antibiotic therapy.

What class of wounds does a “burst” fracture belong to? The paranasal sinuses are considered sterile. Therefore, a burst fracture connecting to an intact sinus can be considered a clean wound (type I); if the fracture developed against the background of sinusitis, then the wound is infected (type IV).

If the fracture connects to the nasopharynx (considered non-sterile), then it should be classified as type II - the wound is conditionally clean. Thus, a “burst” fracture can be classified as any of the four types of surgical wounds (except the third); often requires antibacterial treatment from the moment of injury and necessarily after surgery using an implant.

Ideally, antibiotic therapy should be started within the first three hours after injury, which is often unrealistic. A very effective prevention of purulent complications is intraoperative antibiotic therapy, for example, intravenous administration of 1.5 g of cefuroxime (Zinacef), started already during the induction anesthesia. If the intervention lasts more than four hours, then the drug is re-infused.

The choice of antibiotic, timing and route of administration are extremely important. The absence of anamnestic references to sinusitis, as well as contact with the oropharynx, allows us to limit ourselves to the intravenous administration of a first-generation cephalosporin (cefazolin). In other cases, third-generation cephalosporins are indicated, and if there is a possibility of saliva getting into the fracture zone (for example, zygomatic-orbital), aminoglycosides, amoxicillin or clindamycin are indicated.

During the intervention, 2 g of amoxicillin or 600 mg of clindamycin is administered. In the first two days of the postoperative period, 1 g of amoxicillin or (if allergic to penicillin) 600 mg of clindamycin is administered intravenously every 8 hours, then three times intravenous infusion for 5 days
600 and 300 mg respectively.

There is no doubt about the advisability of including glucocorticoids in the treatment regimen for orbital fractures, since they significantly accelerate the regression of swelling of the soft tissues of the orbit and associated diplopia, without slowing down the rate of osteogenesis.

Enophthalmos is visualized much faster, and indications for surgery become obvious. It is recommended to administer 250 mg methylprednisolone (20 mg dexamethasone)before the intervention and subsequent three-time intravenous infusionof the drug in the same (for dexamethasone - halved) dose every 6-8 hours.

Trauma in the eye area, in addition to fractures of the walls of the orbit, is usually associated with additional damage to the muscles of the eye, optic nerve, and infraorbital nerve, which is responsible for sensitivity in the cheeks, upper lip and front teeth.

Most often, fractures of the lower and inner walls of the orbit occur. In more rare cases, fractures occur in the outer wall, which is thicker than the inner one, and in the roof of the orbit, above which the brain is located.

It is also possible for the eyeball to shift to an unnatural place for it, for the eyeball to sink, or for limited eye movement due to fractures. Sometimes the above injuries are accompanied by a fracture of the upper jaw, as well as obstruction of the lacrimal ducts due to a complex fracture.

In most cases, the presence of fractures in the orbit does not require correction. However, sometimes in cases of injury, depending on the results of the examination of the eye and orbit, surgery is required, the degree of urgency of which is determined by the surgeon.

Surgery is usually necessary in cases where the eyeball has sunken in, or when a muscle is caught in a fissure, or in cases of bleeding that puts pressure on the optic nerve.

Injury to this area 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, there is also a rare (about 16.1% of all cases) isolated fracture of the orbit, which is usually the result of a direct blow towards the eyeball.

Subcutaneous emphysema is an accumulation of air as a result of traumatic “exposure” and the entry of gas from the orbital cavity into the adjacent paranasal sinuses. This phenomenon is most often detected after a strong exhalation through the nose, after which the air trapped in the subcutaneous formations seems to “crunch” when pressed on the periorbital area.

Often the inferior rectus muscle is pinched, especially when the floor of the orbit is fractured, which is why upward movement of the eye is limited and causes the development of diplopia (double vision).

In addition, hemorrhage into the muscles or surrounding tissues is possible with limited mobility downwards.

Causes and mechanism of eye orbital fracture

Typically, an orbital fracture is caused by blunt trauma. For example, a blow received on the steering wheel or seat during an accident or a hit with a tennis ball. Even just a punch to the eye with great force can lead to such consequences. In this case, the eye and orbital tissue are very often injured. It is also worth remembering that fragments of the eye socket can damage the tissue of the eye.

When injured by a sharp object, the bone may be slightly damaged, and symptoms of damage to the eyeball will come to the fore.

Note! The most dangerous type of injury is a gunshot wound. It significantly damages soft tissue, crushes the bones of the orbit and other areas of the skull, and can affect the brain.

Falling onto an object from a great height or from a height of human height;
A strong blow to the eye socket with a blunt or sharp object;
Impact on the victim with a firearm;

Classification

Orbital fractures are classified according to their anatomical component.

It is important for specialists not only to detect the location of the fracture, but also to diagnose the entire area of damage, to find out how strong the blow was and as a result of what it was received.

Orbital fractures vary depending on the location of the injury—medial, inferior, superior, or internal orbital walls.

Isolated orbital wall fractures

Most often, along with the inner surface, the outer edges of the orbit break. Such a fracture can no longer be called isolated.

According to the characteristics of the damage
- Firearms;
- Non-firearms.
By type of damage:
- Isolated fracture;
- Fracture combined with injury to the eyeball;
- Combined fracture (with damage to the bones of the brain and facial skull, as well as the paranasal sinuses located next to the fracture);
- Fracture with the presence of a foreign body in the orbit.

Non-gunshot wounds are divided into:

Orbital damage and soft tissue contusion;
Open fracture of the bone walls of the orbit;
Closed fracture of the bony walls of the orbit.

Wounds of the soft tissues of the orbit are divided into:

Torn;
Cut;
Chipped.

Currently, according to statistical data, the most common injury to the orbit is fracture of the bony walls of the orbit.

Fracture of the bone walls of the orbit is divided into:

Closed fracture of bone walls;
Open fracture of the bone walls (in this case the orbit communicates with the external environment).

The eyeball is located in the recess of the skull. It is called an orbit, which has walls, a top and a base. When an injury occurs, the bone tissue is damaged, leading to an eye fracture. Depending on the damage to the skin, fractures can be:

closed - located inside;
open - damage the skin.

According to severity, injuries are divided into:

fracture with displacement (in this case it is impossible to do without the help of a surgeon);
non-displaced injuries;
cracks without fracture.

According to the timing of the operation, early surgical intervention is distinguished, performed in the acute period of injury, within the first two weeks, that is, precisely in that period of time when there are the most optimal conditions for restoring the integrity and ensuring adequate physiological functioning of the affected organ.

The operation can also be delayed, performed after a two-week period, but before the fourth month after the injury. This is the so-called “gray period”.

And finally, late provision of medical care, requiring mandatory osteotomy.

The most effective treatment methods include surgery, which includes several methods for correcting the bone tissue of the orbit and zygomatic arch. They are all similar in that they are made through small incisions, which then heal, that is, they become completely invisible.

Signs of an orbital fracture

Regardless of the type of fracture, the following symptoms are observed:

Intense pain in the area of the affected eye socket;
Significant swelling of the surrounding tissues;
Severe subcutaneous hemorrhage;
Recession or bulging of the eyeball;
Crunching of bones when pressed;
Decreased visual acuity.

Symptoms

Symptoms of fractures can be divided into direct and indirect.

Direct signs of fractures:

The “step” symptom is a palpable unevenness (“ledge”) in the area of the edge of the orbit, disrupting its smoothness and continuity. In fresh cases, the “step” area is often accompanied by local pain.
Deformation of the periorbital (zygomatic, infraorbital, nasal) areas, involving the edge of the orbit or its entire wall and visible when examining the patient.
The presence of direct signs of a fracture (fracture line, displacement from fractures, deformation of contours) with radiation and other research methods (radiography, computed and magnetic resonance imaging, ultrasound) (Fig. 121).

Indirect signs of fractures:

Emphysema of the orbit and eyelids, associated with the entry of air into the tissue of the orbit and subcutaneous tissue of the eyelids from the paranasal sinuses (and primarily from the ethmoid sinuses) as a result of a fracture of the walls. Emphysema of the orbit is manifested by exophthalmos, emphysema of the eyelids by an increase in the volume of the eyelids and crepitus during their palpation examination. The radiograph reveals the cellular structure of tissues containing air (small areas of increased airiness).
Dislocation of the eyeball downwards and backwards (enophthalmos, especially early) due to an increase in the volume of the orbit as a result of the mixing of fragments in the direction from the orbit. This symptom in the first days after injury can be weakened by a temporary increase in the volume of the contents of the orbit due to traumatic swelling and hemorrhages. On the 5th-7th day after the injury, in the presence of a displaced fracture, this symptom becomes obvious. Drooping of the eyeball is sometimes visible on a radiograph as an expansion of the space between the shadow of the eyeball and the upper wall of the orbit (Fig. 122). Very rarely, when a bone fragment is displaced inside the orbit, a fracture of its walls is accompanied by exophthalmos. It is possible to shift the eyeball horizontally (right and left) towards the damaged wall of the orbit (Fig. 123). Dislocation of the eyeball in combination with limited mobility leads to diplopia.
Limitation of passive mobility of the eyeball, determined using the “traction test” After preliminary terminal anesthesia (Dicaine 0.25% epibulbar, 3 times), the researcher uses tweezers through the conjunctiva to grab the muscle at the site of attachment to the eyeball, the infringement of which is expected, and moves the eyeball in the direction opposite to the action of this muscle (stretching). Limitation of the mobility of the eyeball in this case indicates fixation (infringement) of the muscle under study or the tissues surrounding it.
Impaired skin sensitivity in the area of innervation of the infraorbital nerve (the inner half of the infraorbital region, the wing of the nose, the upper lip, and sometimes the upper teeth on the side of the fracture) due to its damage during a fracture of the lower wall of the orbit.
A decrease in visual acuity or complete loss can be observed when the fracture is localized at the apex of the orbit with damage to the optic nerve.
Long-lasting and non-intense exophthalmos may indicate liquor leakage into the orbital cavity.
Pulsating exophthalmos is associated with rupture of the internal carotid artery in the cavernous sinus due to damage to the upper wall of the orbit.
Indirect radiological signs of fractures of the orbital walls associated with changes in the paranasal sinuses.
Impaired lacrimal drainage is often a sign of a fracture of the inner wall of the orbit with damage to the nasolacrimal canal.

Symptoms of contusion of the soft tissues of the orbit (external muscles of the eye, tissue, optic nerve) are listed below:

Exophthalmos due to swelling and hemorrhage. Swelling of the soft tissues of the orbit may be accompanied by swelling of the eyelids and chemosis. Hemorrhages into the orbital cavity can be parietal or in the form of a retrobulbar hematoma. Parietal hemorrhages from peripheral small vessels, depending on the degree of severity, can, like traumatic edema, cause moderate exophthalmos, in which the eyeball is quite easily reduced posteriorly. Hemorrhage may spread under the conjunctiva and be accompanied by hemorrhage into the thickness of the eyelids. Early hemorrhages indicate damage to the soft tissues of the orbit and eyelids. Late hemorrhages that appear on the 2-3rd day may indicate fractures of the base of the skull. Retrobulbar hematoma is hemorrhage from the central (larger) vessels into the muscular funnel, which is a closed cavity formed by the external muscles of the eye and the funnel part of Tenon’s capsule (Fig. 124).
An increase in pressure in the muscular funnel causes significant (up to 10 mm) tense exophthalmos. The degree of exophthalmos is directly dependent on the degree of contusion of the soft tissues of the orbit. At the same time, the absence of exophthalmos is not always a sign of a favorable condition of the soft tissues of the orbit. A fracture of the walls of the orbit, increasing its volume, can hide (compensate for) exophthalmos, indicating severe contusion of the soft tissues of the orbit.
Reduced visual acuity as a result of damage or compression of the optic nerve by retrobulbar hematoma.
Limitation of the mobility of the eyeball as a result of severe contusion of the muscles, nerves, and tissue of the orbit, accompanied by circulatory disorders, innervation, hemorrhages, swelling of the muscles and tissue. Mild contusional changes can be reversible, which is manifested in an increase in the range of movements of the eyeball 5-7 days after the injury. As a result of severe contusion, after 1-2 months, cicatricial atrophic processes can develop in the external muscles of the eye, Tenon’s capsule, and tissue of the orbit, which are little susceptible to reverse development.

DIAGNOSTICS OF CONTUSIONAL INJURIES OF THE ORBIT

When starting to examine and treat victims with fractures of the walls of the orbit, it is necessary first of all to exclude damage to the skull, brain and other organs, since these complications can threaten the patient’s life.

The diagnosis of orbital damage is based on:

medical history;
data from radiation research methods;
examining the patient and identifying visible deformations of the edges and walls of the orbit, changes in organs and areas adjacent to the orbit;
determination of violations of the position and mobility of the eyeball;
disturbances of binocular vision, diplopia (Fig. 125).

They are usually made using two rulers at right angles to each other. One of them is located along the measurement axis, the second serves to measure the deviation of the eyeball from this axis.

Anteroposterior displacements are measured using a Hertel exophthalmometer. An express method for identifying these biases is as follows.

The patient, throwing his head back, transfers the plane of the face from vertical to horizontal, directing his gaze perpendicular to the plane of the face (to the ceiling) (Fig. 125).

The doctor, observing the protrusion of the eyeballs from the chin, can note even a slight difference in their position.

The study of the mobility of the eyeballs is carried out on the Förster perimeter by determining the field of view.

Diplopia is determined by the Haab double image method or the Lancaster grid coordimetry method. The presence of binocular vision is determined using a color test, as well as using Bagalini glasses or Maddox prisms.

The binocular vision zone can also be determined on the perimeter using red glass, marking the boundaries of areas of the visual field where there is no double vision. In case of profound disorder of binocular vision, when double vision persists in all directions, this method is not applicable.

In order to exclude pinching of the muscle in the fracture zone when the mobility of the eyeball is limited, a “traction test” is performed.

If examination of the position and mobility of the eyeball is difficult due to severe swelling and hematoma of the eyelids, a wait-and-see approach should be followed for several days. During this period, rest, cold, and osmotic agents are prescribed.

The patient is examined by an otorhinolaryngologist, and, if necessary, by other related specialists, and their recommendations are followed. If within 5-7 days the range of movements of the eyeball has not expanded, if signs of displacement of the eyeball have appeared (intensified), a positive “traction test” is noted and diplopia remains, especially when looking directly or close to this position (about 5° from the point of fixation ), in this case (if there are radiological signs of a fracture), surgical intervention is necessary.

If the dynamics are positive, you can postpone the operation, but no more than 10-14 days after the injury. On day 14, a final decision should be made using CT scan data.

If there are direct signs of a fracture of the walls of the orbit, leading to impaired mobility and position of the eyeball, accompanied by functional disorders (decreased vision - diplopia), early surgical intervention is indicated.

By their nature, the upper arch of the orbit has a strong bone structure, therefore, when damaged, a fracture of the lower wall of the orbit most often occurs.

How to determine an orbital bone fracture? Doctors identify the following symptoms:

swelling, stiffness in the movement of the eyeballs and pain;
state of shock with elements of blurred vision;
decreased sensitivity of the lower orbital nerve, and therefore the back of the nose, cheeks, eyelids, upper teeth and gums;
split field of view;
ptosis (flattening of the eyelid);
in case of serious injuries - displacement of the eyeball;
bleeding and internal hemorrhage;
the presence of air in the subcutaneous area and visible bubbles in the tissues.

Pain in the orbital area;
The victim complains of blurred vision (this symptom is caused by a state of shock);
The patient has double vision of all nearby objects;
Some victims have severe swelling in the eyelid area;
When examining the patient, attention is drawn to a pronounced hematoma in the eyelid area;
The patient experiences a narrowing of the palpebral fissure as a result of edema and hematoma;
Restricted mobility of the eyeball;
The victim has exophthalmos or enophthalmos;
When the orbit of the eye is fractured, the patient experiences ptosis (drooping of the outer corner of the eye);
Some patients may experience subcutaneous emphysema (crepitus);

With massive injuries, small areas of fatty tissue, damaged external eye muscles and ophthalmoplegia can be observed in the wound.

A doctor will help you treat your injury. The main thing is to find the problem behind the various symptoms.

The main symptoms of a fracture of the lower orbit of the eye:

Swelling of the area around the eye.
Weak mobility of the eyeball.
Diplopia is the splitting of objects.
Enophthalmos is a displacement of the eyeball inside the orbit, or vice versa (exophthalmos).
Crunching in the lower part of the eye socket.
Severe pain in the eye area.
Presence of hematomas.

Diagnostics

At the first stage of the examination, it is necessary to conduct a thorough examination of the patient’s injured organ of vision for the presence of swelling of the eyelids, the motor ability of the eyeball, the sensitivity of the skin around the eye, and measure intraocular pressure.

To diagnose eye injuries, magnetic resonance imaging (MRI) can be used as an auxiliary method. This method can reveal pinched muscles in the fracture zone and fluid accumulation in the orbit.

Recently, the method of ultrasound examination of orbital injuries has become more common. Using ultrasound, you can determine both damage to the orbit and identify the presence of injury to the eyeball, the condition of the optic nerve and eye muscles.

Upon admission to the trauma department, the patient is sent for radiography. The first step is to examine the patient for pronounced fracture phenomena; if the lower wall of the orbit is broken, then the patient has a hematoma of the eyelid, subconjunctival hemorrhage (the entire area of the white of the eye is filled with blood), and a tumor of the eye shell.

The examination begins directly with a complete examination of the patient’s head and facial part, checking the reaction to external stimuli and conducting a study of the nerve endings of the skull.

In the ophthalmology department, the patient is examined for suspicion of severe injuries: rupture of the white of the eye, pinching of the optic nerve, high pressure in the orbital cavity.

To identify eye motility disorders, a test with artificial splitting (diplopia) is used. The ophthalmologist and the patient sit at a distance of two meters from each other, and a translucent red glass is applied to the injured eye.

The doctor picks up the switched-on flashlight and moves it in different positions, after which the patient is asked how many images of the light bulb he has seen. If there were two or more images, then the patient is asked to report in what position, vertical or horizontal, and at what distance from each other they were.

The next stage is a differential diagnosis to identify the victim’s difficulty rotating the eyeball. For this, a “traction test” is used: the patient looks at his arm extended in the area of suspected displacement.

After local anesthesia of the affected area, the eyelids of the injured orbit are fixed with a special object, while the eyeball is shifted in the opposite direction from the supposedly pinched muscle.

If the traction test is positive, the nerve of the inferior orbital arch is pinched in the area of the fracture. It is difficult for the patient to move the eye up and down. In rare cases, diplopia develops and surgery is required.

Negative result of the “traction test”: the patient has a slight displacement of the eyeball to the upper region, while he can freely move it towards the floor. The eye socket is fixed in a similar way as in the previous test, the patient is asked to look with the injured eye at the floor area, the specialist must feel a convulsive contraction of the nerve endings and identify the specifics of the damage.

Typically, paralysis is associated with severe contusion of the orbital muscles and goes away within two weeks; if the motor function of the eye has not been restored, the optic nerve is re-diagnosed.

After all examination procedures and diagnosis, the patient is transferred for treatment to the ENT department.

When you receive a fracture of the orbit and are admitted to the hospital, the doctor conducts an examination and urgently prescribes x-rays, CT and MRI. The results of the study allow us to accurately determine the degree of damage to the injury and prescribe appropriate treatment.

The most informative in case of a fracture of the left or right orbit is considered to be computed tomography or magnetic resonance, which can determine the slightest changes in the structure of bone and muscle tissue with 98% accuracy.

Taking an anamnesis (mechanism and circumstances of injury);
Examination of the organ of vision and tear ducts;
X-ray of the orbits and paranasal sinuses;
Tomography of orbital damage;
Ultrasound diagnosis of orbital injuries;
Consultation of the victim with a dentist, otolaryngologist, or neurosurgeon.

First you need to see a traumatologist and ophthalmologist. Doctors will examine the injury, study the patient's symptoms, and make a diagnosis. To determine the severity of the injury, the patient will be sent for the following procedures:

X-ray will allow you to examine the injury in more detail. This procedure will help determine the severity and location of the broken bone.
Magnetic resonance imaging will help determine the general condition of the orbit. After all of the above procedures are completed, the patient will be prescribed treatment and will be referred to specialized doctors who will begin treatment of the patient. A complex operation may also be prescribed, but this is only if, in addition to the orbit, other areas of the face are damaged.

The severity of the orbital fracture is high.

Computed tomography (CT) is preferred, and axial and coronal thin sections are desirable for a better understanding of the condition of the orbital walls.

To identify a fracture and the introduction of orbital contents into adjacent sinuses, it is necessary to examine the internal (medial) part of the fundus and the wall adjacent to the nasal bone.

Inspection of the bony apex allows one to identify the condition of the posterior edge of the bone, which is mandatory during surgery.

The main manifestations depend on the force of the applied blow to the facial part of the skull and associated injuries: for example, with a fracture of predominantly the upper wall, the percentage of development of a concussion is high. If the lower or inner (medial) wall is fractured, mucosal secretions may spread through the damaged areas into the paranasal sinuses with concomitant infection.

Treatment

If the upper wall of the orbit is fractured during surgery, you may need the help of a neurosurgeon. In these cases, an otorhinolaryngologist is necessary to apply an anastomosis between the frontal sinus and the nose.

The ophthalmic surgeon's tactics are determined by the condition of the eyeball. According to appropriate indications, it is necessary first of all to perform surgical intervention on the eyeball, and only then to engage in plastic surgery of the walls of the orbit.

During the first two days after injury, it is necessary to apply cold to the damaged area. Vasoconstrictor nasal drops and antibiotic therapy are prescribed for one to two weeks.

Also, in the first days, the patient must be provided with rest, since fractures of the orbital walls can be accompanied by brain injuries. Corticosteroid drugs are sometimes prescribed to reduce inflammation.

For minor injuries, if the patient’s condition allows, surgical operations to reconstruct the bones can be performed within the first three days. In severe cases, with severe swelling, persistent double images and pronounced enophthalmos, surgery can be performed after 1-2 weeks.

Early surgery (within the first 10 days) is preferable to later surgery.

If the upper wall of the orbit is damaged, the patient must be examined by a neurosurgeon, possibly with further hospitalization in the neurosurgery department.

The examination must be carried out very carefully to determine all the damage and subsequently carry out reduction and fix all bone fragments.

Structures made of titanium, silicone, Teflon, etc. are used as inorganic fragments.

Often during surgery, consultation with an otolaryngologist and an oral and maxillofacial surgeon is necessary.

First, the patient is prescribed a course of antibiotics, and the victim should be warned about the danger of blowing his nose. Next, the victim undergoes classes in visual gymnastics and restoration of rotational motor skills of the apple. Prophylactic treatment is also prescribed to prevent the development of diplopia and pupil deformation.

Conventional fractures of the lower wall of the orbital orbit are not operated on; in most cases, the patient does not suffer from neurological disorders or pronounced deformation of the facial bone. In more severe cases, surgical intervention is required. The operation should take place at an early stage after accurate diagnosis. Indications for surgery:

severe visual impairment and double vision;
displacement of the eyeball by more than 2 millimeters;
fracture of a large area of the lower wall of the orbit;
severe optic nerve dysfunction;
permanently dilated lens of the eye;
non-perception of the delivery of light pulses to the iris.

In the postoperative period, the patient is prescribed intravenous injections, and muscle injections with bone-plant substances are also prescribed.

Based on instrumental diagnostic methods, the doctor makes a decision on treatment, which can be carried out conservatively or surgically. Emergency surgery is performed only in cases where the eyeball sinks inward, the patient has severe bleeding or damage to the optic nerve.

In case of minor damage to the eyeball or in cases of a linear fracture, treatment can be carried out conservatively, which includes applying a tight bandage to the affected eye, taking painkillers and anti-inflammatory drugs. In the vast majority of cases, conservative treatment lasts 2 weeks.

Sometimes doctors delay surgery, citing excessive pressure on the eyeball, but in such cases there will always be a risk of damage to the optic nerve, which will lead to blindness.

Despite advances in modern ophthalmology, it is impossible to completely restore vision after an orbital fracture. Very often, after an injury, patients lose their vision, so in order to minimize all sorts of risks and complications after an eye injury, you need to seek help from a doctor as soon as possible, or better yet, be more careful about your health and prevent such injuries.

The goal of treating such fractures is to restore the previous state of the orbital bone (as far as possible). Medical measures are also taken to regulate the position of the eye and restore its motor functions. If the fracture is not complicated, then the doctor may prescribe a conservative method of treating such a fracture.

Such treatment, in most cases, is rarely prescribed. Surgery is used to treat orbital fractures. All this is done in the first hours to reduce pressure on the eye and prevent hemorrhage in the near-ocular area. If pressure on the optic nerve increases, the patient experiences a partial progressive loss of vision.

There are two ways to treat this injury:

Conservative. It helps in the case of an isolated small fracture without displacement of the orbital bones. In this case, the eye is treated with antibiotic solutions and a special bandage is applied to it. The procedure is repeated daily for 2 weeks.
Operational. It is used if the bones of the orbit need to be returned to their previous position or damage to soft tissues needs to be repaired. In this case, surgical intervention is performed, the volume of which depends on the number of damaged structures. For example, this is how they can remove fragments of the orbit from cavities, sew together the muscles and tissues of the eyeball, clean the orbit from blood, pus, and much more.

Regardless of the treatment method, the patient must take painkillers and antibiotics orally.

First aid consists of treating the wound with a disinfectant solution and applying an aseptic dressing.

The goal of surgery for significantly displaced midface fractures involving the orbit is to prevent the development of enophthalmos, as well as dystopia of the orbit and canthal ligaments.

Reconstruction of complex three-dimensional spatial anatomy of the orbit;

Releasing the contents of the orbit that are trapped in the fracture;

Reduction of hernial protrusion of orbital contents;

- reposition of the eyeball.

Stabilization and reconstruction of the orbital ring (medial, lateral, superior and inferior edges of the orbit);

Reconstruction of defects in the fundus and, if necessary, other orbital walls to restore the size of the orbital cavity.

Restoration of orbital soft tissue injuries, including the position of the medial and lateral canthal ligaments.

Bone autografts - split bones of the cranial vault, ribs, iliac crest, tibial tuberosity.

Bone or cartilage homografts

Inorganic allografts (titanium structures, silicone, Teflon, etc.).

It is advisable to fix any material that is used for bottom reconstruction to avoid its displacement or extrusion.

If contact of the graft with the maxillary sinus or ethmoidal labyrinth is possible, autologous bones or titanium structures should be used to reconstruct the orbital walls, since in these cases there is a minimal risk of developing inflammatory complications.

The most common complications of inadequately treated orbital floor fractures are diplopia, enophthalmos, and limited mobility of the eyeball in the vertical plane (Fig. 16-15). Fractures of the medial wall of the orbit often accompany fractures of the orbital floor (Fig. 16-19) and are sometimes an unrecognized cause of residual postoperative enophthalmos.

When reconstructing the orbital floor to eliminate diplopia and enophthalmos, maxillofacial surgeons in our country quite often use transantral access. After repositioning the eyeball, the orbital floor is reconstructed with a titanium F-shaped plate or titanium mesh inserted into the orbital cavity at an angle sufficient to eliminate enophthalmos.

The plates are fixed in the region of the lower orbital margin and the posterior wall of the maxillary sinus.

Early surgery (within the first 10 days after injury) is preferable to late surgery. Only due to vital or local, from the orbit and eyeball, contraindications, the operation can be postponed.

S.A.Eolchiyan, A.A.Potapov, F.A.Van Damme, V.P.Ippolitov, M.G.Kataev

Principles of therapy

Simple supraperiosteal orbitotomy and drainage of the retrobulbar space for retrobulbar hematoma. The operation is usually performed under local infiltration anesthesia with a 0.5-2% novocaine solution.

Parallel to the edge of the orbit, a layer-by-layer incision of the skin and subcutaneous tissue is made with a scalpel.

To prevent the formation of a rough scar fused to the periosteum, it is advisable to shift the incision of each layer to the edge of the orbit by 1.5-2 mm. To ensure that the skin incision coincides with the folds of the face or existing scars, the projection of the upcoming incision should be marked before anesthesia.

Bleeding from a wound can be stopped by diathermocoagulation or a clamp followed by ligation of the vessel. Bleeding from small vessels usually stops on its own or after targeted massaging movements with a gauze ball.

The tarso-orbital fascia is incised directly at the edge of the orbit. The contents of the orbit are bluntly separated from the wall and lifted upward with a spatula.

As an alternative approach to retrobulbar hematoma, a transconjunctival approach, usually used in operations on the eye muscles, can be used. By bluntly pushing the tissues apart at a depth of 3 cm from the place of muscle attachment to the eyeball, the retrobulbar space is opened and drained.

The use of catgut should be avoided as it can sometimes delay wound healing. In the postoperative period, it is advisable to prescribe osmotic therapy and local use of steroids.

The cost does not include the cost of the implant, which depends on the type of injury and the extent of damage. The final price is determined by an ophthalmologist during a face-to-face consultation. The estimated price of the implant is $350.

The patient can be discharged home a few hours after surgery. However, in some cases hospitalization may be necessary. The decision on the need and duration of hospitalization will be made by the operating surgeon at the end of the operation.

Cost of one day of hospitalization - $ 780

First, the patient must be given first aid. It is necessary to treat the injury site and then apply an antiseptic bandage.

After this, you will soon need to call for medical help. If the patient suffered a minor injury - a linear fracture - he can be treated conservatively.

The patient should not put heavy strain on the airways. This method may also be prescribed if surgery may cause complications due to excessive pressure on the eye socket.

If, on the contrary, the fracture is of high severity and is accompanied by deterioration or loss of vision, you need to resort to surgical intervention. During eye orbital fracture surgery, the doctor will remove dead tissue and rebuild the bones.

Types of operations are divided into 3 types:

early surgery - performed within 2 weeks after the fracture, is the most effective;
“gray period” surgery – from 2 weeks to 4 months after injury;
late surgery (osteotomy) - 4 months or more.

Includes taking medications:

Painkillers. For example, "Analgina".
Anti-inflammatory. You can also combine the first two properties and buy nonsteroidal anti-inflammatory drugs (NSAIDs), which relieve pain and reduce inflammation. For example, Nurofen, Ibuprofen, Ketorol, Nise and many others. Most of them can be purchased with a prescription, but there are also over-the-counter ones that also work quite well.
Antibiotics. Dispensed strictly according to a doctor's prescription! Perhaps the doctor will prescribe medications that help restore bone tissue. For example, "Mummy".
Vitamin-mineral complexes or drugs that strengthen the immune system (immunomodulators). It is also very important that the patient follows all the doctor’s recommendations for a speedy recovery. He also provided himself with rest, ate healthy foods (vegetables, fruits) and limited eye strain.

The full rehabilitation complex lasts from 2 weeks to 2 months. The first days of rehabilitation should be under the supervision of a doctor. The bone itself is restored up to 3 months, healing is divided into 3 stages:

1-10 days after the fracture - the body recovers from the injury;
10-45 days - primary bone callus is formed;
up to 3 months - complete formation of callus.

Often in this situation they resort to surgical intervention, which at the same time has an adverse effect on the contents of the orbit, manifested in the form of excessive pressure on the eyeball.

The danger also lies in the fact that the hemorrhage that occurs behind the eye several times increases the pressure exerted on the optic nerve, and mainly on its disc, which entails not only deterioration of vision, but also, in an unfavorable outcome, its complete loss.

Since trauma also involves a lot of other anatomical components of the skull, loading on these affected parts is also prohibited, in particular, pressure exerted on the respiratory tract. A simple effort, even a slight one, for example, when blowing your nose, leads to an increase in pressure inside the cavity of the zygomatic arch, which aggravates the swelling and can provoke complete closure of the eye, or contribute to the development of subcutaneous emphysema.

First aid for a fracture of the orbit of the eye

If the orbital socket is fractured, it is best to immediately call an ambulance. If the victim’s condition is serious, then before the arrival of doctors it is necessary to provide first emergency aid:

A common occurrence with such injuries is nosebleeds, which are caused by damage to blood vessels during the impact. It is contraindicated to throw your head back. To stop bleeding, you need to place cotton pads in the nostrils.
To reduce swelling, you can apply cold ice under the eye.
To wash wounds, use any disinfectant solution, but not peroxide.

The ambulance will take the victim to the trauma department, where all emergency measures will be taken and the necessary diagnostics performed.

Consequences

The prognosis for both life and ability to work is quite favorable if rehabilitation was carried out within fourteen days from the moment of injury.

To avoid loss of vision, urgent surgery is necessary to remove bone fragments that may be causing nerve damage and to prevent bleeding inside the optic canal.

If the inner wall is damaged, you should refrain from sneezing and sharp inhalation of air in the first few weeks; to do this, you need to prohibit physical activity and ensure complete rest for the patient, as well as carry out regular wet cleaning and ventilation of the room, observe the humidity level and temperature conditions of the room.

In different cases, depending on the severity of the damage, there may be consequences. To prevent complications, any eye injuries require immediate medical attention.

It is not recommended to delay a visit to the doctor for eye injuries, even if in your opinion there are no superficial changes.

Only a specialist can determine the extent of damage and prescribe the correct treatment, which will help avoid consequences altogether. Failure to follow the doctor's recommendations can lead to serious complications, namely irreversible loss of vision.

A patient with eye injuries must be under medical supervision for a month. After 20-30 days, it is necessary to examine the retina and white of the damaged eye to prevent possible retinal detachment, glaucoma and inflammation of the eye tissue.

If the defect is large enough, tissue plastic surgery is performed. In other cases, the role of the wall is taken over by a dense scar.

The most severe consequences are the consequences of soft tissue injury. If the eye is severely damaged, it is simply removed, leaving the eye socket empty.

Sometimes an eye injury leads to a complete loss of the ability to see or a sharp deterioration in vision.

In addition, impaired mobility of the eyeballs and their displacement may remain with the victim for life.

A fracture of the orbital socket can lead to the following complications:

Facial deformation.
Deterioration of vision.
Strabismus, diplopia.
Poor mobility of the eyeball.

Timely consultation with a doctor will reduce the risk of these complications. If you do not see a doctor for a certain time, the patient's condition will worsen.

In the absence of treatment, 2 weeks after the fracture, fibrous adhesions begin to form, and the bone walls of the eye orbit begin to collapse. Scar tissue begins to form, causing facial deformation.

After 3 months, the deformity is considered formed.

If treatment is not started on time, after a hematoma has formed, fibrin strands are deposited over time, and eventually fibrous adhesions are formed. Which you will then have to struggle with for a long time and painfully.

megan92 2 weeks ago

Tell me, how does anyone deal with joint pain? My knees hurt terribly ((I take painkillers, but I understand that I’m fighting the effect, not the cause... They don’t help at all!

Daria 2 weeks ago

I struggled with my painful joints for several years until I read this article by some Chinese doctor. And I forgot about “incurable” joints a long time ago. That's how things are

megan92 13 days ago

Daria 12 days ago

megan92, that’s what I wrote in my first comment) Well, I’ll duplicate it, it’s not difficult for me, catch it - link to professor's article.

Sonya 10 days ago

Isn't this a scam? Why do they sell on the Internet?

Yulek26 10 days ago

Sonya, what country do you live in?.. They sell it on the Internet because stores and pharmacies charge a brutal markup. In addition, payment is only after receipt, that is, they first looked, checked and only then paid. And now everything is sold on the Internet - from clothes to TVs, furniture and cars

Editor's response 10 days ago

Sonya, hello. This drug for the treatment of joints is indeed not sold through the pharmacy chain in order to avoid inflated prices. Currently you can only order from Official website. Be healthy!

Sonya 10 days ago

I apologize, I didn’t notice the information about cash on delivery at first. Then, it's OK! Everything is fine - for sure, if payment is made upon receipt. Thanks a lot!!))

Margo 8 days ago

Has anyone tried traditional methods of treating joints? Grandma doesn’t trust pills, the poor thing has been suffering from pain for many years...

Andrey A week ago

No matter what folk remedies I tried, nothing helped, it only got worse...

A fracture of the lower wall of the orbit of the eyes is one of the well-known types of injuries. The eye socket itself is a depression in the skull in which the eyeball is located. According to statistical information, men in the age group from 20 to 40 years are more susceptible to orbital fractures.

In most situations, a fracture of the orbital bone of the eye occurs as a result of trauma, impact, falling from a height, road accidents, use of firearms, home and work injuries. The fracture itself appears as a result of a sudden increase in pressure in the area of the eye orbit. Orbital fractures are usually accompanied by injuries to the cheekbones, nose, frontal bone, etc.

Causes

You can get a fracture of the orbit of the eye due to:

Kinds

closed - located inside;
open - damage the skin.

According to severity, injuries are divided into:

fracture with displacement (in this case it is impossible to do without the help of a surgeon);
non-displaced injuries;
cracks without fracture.

Symptoms

A doctor will help you treat your injury. The main thing is to find the problem behind the various symptoms.

The main symptoms of a fracture of the lower orbit of the eye:

Swelling of the area around the eye.
Weak mobility of the eyeball.
Diplopia is the splitting of objects.
Enophthalmos is a displacement of the eyeball inside the orbit, or vice versa (exophthalmos).
Crunching in the lower part of the eye socket.
Severe pain in the eye area.
Presence of hematomas.

Diagnostics

X-ray - will allow you to examine the injury in more detail. This procedure will help determine the severity and location of the broken bone.
Magnetic resonance imaging will determine the general condition of the orbit. After all of the above procedures are completed, the patient will be prescribed treatment and will be referred to specialized doctors who will begin treatment of the patient. A complex operation may also be prescribed, but this is only if, in addition to the orbit, other areas of the face are damaged.

X-ray

X-ray of the eye orbits is one of the main methods for studying the eyeball and internal tissues. It helps to obtain an image using an x-ray machine. This method reveals:

tuberculosis and various diseases of the orbit;
osteoma;
congenital anomaly.

This type of diagnosis is the best due to the fact that:

you can identify various defects and recognize early stage diseases;
suitable for any age;
you can get a good photo to save on your computer;
it's cheap.

To prescribe treatment, consult your doctor. He will make the correct diagnosis. There are other diagnostic methods:

Method 1. First, the doctor examines the condition of the injury, after which he palpates. When making a diagnosis, he must talk about the symptoms. It is very important.

Method 2. Orbital x-rays must be performed continuously. Using this method, you will see the condition of the bone tissue.

Surgery

First, the patient must be given first aid. It is necessary to treat the injury site and then apply an antiseptic bandage. After this, you will soon need to call for medical help. If the patient suffered a minor injury - a linear fracture - he can be treated conservatively. The patient should not put heavy strain on the airways. This method may also be prescribed if surgery may cause complications due to excessive pressure on the eye socket. If, on the contrary, the fracture is of high severity and is accompanied by deterioration or loss of vision, you need to resort to surgical intervention. During eye orbital fracture surgery, the doctor will remove dead tissue and rebuild the bones. Types of operations are divided into 3 types:

early surgery - performed within 2 weeks after the fracture, is the most effective;
"gray period" surgery - from 2 weeks to 4 months after injury;
late surgery (osteotomy) - 4 months or more.

Rehabilitation

If the wall of the orbit of the eye is fractured, special attention must be paid to the rehabilitation period. The better it is, the faster healing will occur. Recovery lasts from a couple of weeks to a month and a half. During the first two days, the patient is under the supervision of specialists in the hospital. For a quick recovery during the rehabilitation period and for preventive measures, various drugs are used. During treatment, rehabilitation is required, the patient is prescribed medications (painkillers and anti-inflammatory drugs, a complex of vitamins and antibiotics) and physiotherapy.

Medication therapy

Includes taking medications:

Painkillers. For example, "Analgina".
Anti-inflammatory. You can also combine the first two properties and buy nonsteroidal anti-inflammatory drugs (NSAIDs), which relieve pain and reduce inflammation. For example, Nurofen, Ibuprofen, Ketorol, Nise and many others. Most of them can be purchased with a prescription, but there are also over-the-counter ones that also work quite well.
Antibiotics. Dispensed strictly according to a doctor's prescription! Perhaps the doctor will prescribe medications that help restore bone tissue. For example, "Mummy".
Vitamin-mineral complexes or drugs that strengthen the immune system (immunomodulators). It is also very important that the patient follows all the doctor’s recommendations for a speedy recovery. He also provided himself with rest, ate healthy foods (vegetables, fruits) and limited eye strain.

1-10 days after the fracture - the body recovers from the injury;
10-45 days - primary bone callus is formed;
up to 3 months - complete formation of callus.

Consequences

The negative consequences of any injury, especially when it comes to this, can lead to a disastrous outcome. The likelihood of severe consequences after an injury to the orbit of the orbit will directly depend on the nature of the injury, the promptness of emergency care, and the involvement of the optic nerve, blood vessels and muscles of the eyeball in the process. Among the most common consequences of a fracture of the orbit of the eye (photo of injury above) are:

Complications

A fracture of the orbital socket can lead to the following complications:

Facial deformation.
Deterioration of vision.
Strabismus, diplopia.
Poor mobility of the eyeball.

Timely consultation with a doctor will reduce the risk of these complications. If you do not see a doctor for a certain time, the patient's condition will worsen. In the absence of treatment, 2 weeks after the fracture, fibrous adhesions begin to form, and the bone walls of the eye orbit begin to collapse. Scar tissue begins to form, causing facial deformation. After 3 months, the deformity is considered formed.

If treatment is not started on time, after a hematoma has formed, fibrin strands are deposited over time, and eventually fibrous adhesions are formed. Which you will then have to struggle with for a long time and painfully.

Be sure to remember these tips:

Don't throw your head back.
To stop blood loss, place a tampon in your nostrils.
Apply something cold to reduce swelling.
Wash the wounds with a disinfectant solution (Chlorhexidine). Peroxide is useless in this case.