broken faces

Monday, March 5, 2012

Baseball is supposed to be a non-contact sport but when a ball is travelling close to 100 miles per hour, it’s sometimes tough to get out of the way. This is especially true, when the ball ricochets off the bat and there’s no time to blink. When A.J. Burnett of the Pirates tried to bunt the ball, it caromed up into his face and he was left with an orbital fracture that needed surgery to fix. Fortunately, it was the bone that got hurt and not the eye that it protected.

The eye socket is made up of seven different bones that provide protection to the eye itself and the other structures within the orbit. Surrounding the globe, muscles attach to bone so that the eye can swivel. In the back of the orbit, the optic nerve is the cable that collects information from the retina and runs directly to the brain delivering the sense of sight. Bad things can happen when the orbit gets hit and it’s important to sort out a sight threatening emergency from other injuries that can be assessed and treated at a more leisurely pace.

When the ball hit his eye, Mr. Burnett likely sustained a blowout fracture of the inferior orbital rim. The round globe of the eye is compressible and since it sits in an orbit that is shaped like a cone, anything that drives the globe back ward can cause the orbital bones to break, crack or fracture (all the words mean the same thing). The thinnest bone of the orbit forms the inferior orbital rim. It is part of the maxilla or cheek bone and helps support the eye from below and it is the most often bone to fail. While this is a painful injury, there are more important things to worry about.

The first order of business is to make certain that the eye works. Even though the eyelids may swell shut, they can be pried open to check vision. Can the patient see normally? If not, can they count fingers or see light? Or is there total blackness? Major vision loss is a true emergency and has to be sorted out relatively quickly. Injury assessment follows how light flows through the eye to get to the brain. The injury can be due to damage to the front of the eye, like a hyphema or collection of blood in the space between the cornea and the iris. There may be bleeding in the globe or the globe can be ruptured. Blood prevents light from travelling from the outside world and landing on the retina that lines the inner surface of the globe. A retina injury can prevent light from being received and damage to the optic nerve can prevent signals moving from the eye to the brain for interpretation.

If the vision is alright, then it’s time to check out the rest of the eye. Does the eye move normally? And does it move together with the other eye? If not, the patient may complain of double vision. Are there scratches on the cornea or superficial covering of the eye? Did the injury cause the pressure within the eye to increase (this is called glaucoma}. Broken bones hurt and palpating or touching them can help determine the location of the injury. There is a trick to help sort out inferior orbital rim injury. Numbness of the cheek or the upper teeth may indicate a fracture, since the inferior orbital nerve runs in a small groove beneath the eye and it turns off when irritated.

In a blowout fracture, the inferior orbital rim breaks and some of the fat that supports the eye and perhaps a bit of one of the muscles of the orbit get trapped in fractured spot. When the patient looks upward, the good eye moves but the injured eye cannot and the patient complains of double vision. If there is suspicion of a fracture, plain x-rays may be taken, but facial bone CT scan may better be able to show the anatomy and any other associated injury.

As long as the eye itself works, the decision to operate can be delayed. The ENT or plastic surgeon won’t be in a rush, often waiting for the swelling to decrease so that they can better plan their approach to injury repair. Meanwhile, routine icing and elevating the head of the bed will help decrease the swelling. The big instruction reminds the patient not to blow their nose. Since the inferior orbital rim is also the roof of the maxillary sinus, there can be an air leak into the orbit that blowing a nose can make worse and force air where it doesn’t belong.

Mr. Burnett’s return to work will take a little longer than usual. Aside from the month it will take to recover from surgery, he will need to spend more time getting back in shape as an elite athlete. Running, jumping and dodging 100 mph fastballs are not recommended activities immediately after the operation. In that regard, fractures are like baseball games. A baseball game takes nine innings to finish, no matter what the clock says. Fractures can also just take their own sweet time.

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