Medial Orbital Fractures
Naso-orbital-ethmoidal (NOE) fractures (Fig 6-4) usually result from the face striking a solid surface. These fractures commonly involve the frontal process of the maxilla, the lacrimal bone, and the ethmoid bones along the medial wall of the orbit. Patients characteristically have a depressed bridge of the nose and traumatic telecanthus. These fractures may be divided into 3 categories:
Type I involve a central fragment of bone attached to canthal tendon.
Type II are comminuted fractures of the central fragment.
Type III involve a comminuted tendon attachment or an avulsed tendon.
Complications associated with NOE fractures include cerebral and ocular damage, severe epistaxis due to avulsion of the anterior ethmoidal artery, orbital hematoma, cerebrospinal fluid rhinorrhea, damage to the lacrimal drainage system, lateral displacement of the medial canthus, and associated fractures of the medial orbital wall and floor. Treatment is dependent on the type of fracture; it generally includes fracture reduction and microplate fixation. Transnasal wiring of the medial canthus is used less frequently, because microplates often allow precise bony reduction.
Indirect (blowout) fractures of the medial wall are frequently extensions of blowout fractures of the orbital floor. Isolated blowout fractures of the medial orbital wall may also occur. Surgical intervention is indicated in cases involving muscle and associated tissue entrapment, persistent restrictive diplopia, and aesthetically unacceptable enophthalmos. Some surgeons choose to intervene on the basis of fracture size and believe the risk of enophthalmos is greatest when both the floor and the medial wall are fractured. However, determining the size of the fracture from imaging studies can be difficult. If surgery is required, the medial orbital wall can be approached by continuing the exploration of the floor superiorly along the medial wall via a lower eyelid or transconjunctival approach. An alternative approach is a medial orbitotomy through a retrocaruncular approach or, less commonly, a frontoethmoidal skin incision. See Chapter 7 in this volume for discussion of orbital surgery approaches.
Figure 6-4 Naso-orbital-ethmoidal fractures result in traumatic telecanthus with rounding of the medial canthus. Types I–III are described according to the severity of the injury.
(Illustration by Christine Gralapp.)
Vicinanzo MG, McGwin G Jr, Allamneni C, Long JA. Interreader variability of computed tomography for orbital floor fracture. JAMA Ophthalmol. 2015;133(12):1393–1397.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.