Orbital fracture

Background

• Types
  • Blow-out Fracture
    • Fracture of inferior or medial orbital walls w/o fx of orbital ridge
    • Adipose tissue, inf rectus or inf oblique can entrap within maxillary or ethmoid sinus
    • 33% are assoc w/ ocular trauma
  • Non Blow-out Fracture
    • Lateral, inf, and sup orbital ridge fx typically occurs w/ other facial fractures
• Naso-orbito-ethmoid fx
  • Associated w/ force applied to nasal bridge
  • Often accompanied by injury to lacrimal duct, dural tears, and traumatic brain injury

Diagnosis

• Findings suggestive of orbital fx:
  • Enophthalmos (globe herniation)
  • Orbital rim step-off
  • Crepitus
  • Infraorbital anesthesia (orbital floor fx)
  • Diplopia on upward gaze
    • Entrapment of inf rectus or inf oblique or orbital fat
    • Injury to oculomotor nerve
• Findings suggestive of naso-orbito-ethmoid fx
  • Pain w/ eye movement
  • Traumatic telecanthus
  • Epiphora (tears spilling over lower lid)
  • CSF leak
• Findings suggestive of ocular involvement:
  • Retrobulbar hematoma or malignant orbital emphysema
    • Exophthalmos, decreasing visual acuity, increased ocular pressure
  • Orbital fissure syndrome
    • Fx of orbit involving the sup. orbital fissure
      • May result in injury to oculomotor and ophthalmic divisions of CN V
      • Paralysis of extraocular motions, ptosis, periorbital anesthesia

Imaging

• Obtain orbital CT as initial study in pts w/ sig clinical findings
  • Evidence of fracture on exam
  • Decreased extraocular mobility
  • Decreased visual acuity
  • Severe pain
  • Unable to perform adequate exam
• Otherwise can obtain Waters' view first
  • Shows cloudy maxillary sinus representing blood, fluid or tissue

DDX

1. Orbital Hematoma
   1. Proptosis, diffuse pain
2. Globe Rupture
   1. Tear-shaped pupil
   2. Extrusion of intraocular content
3. Orbital zygomatic fracture
   1. Most common
4. Nasoethmoid fracture
   1. Damage to medial canthal ligament
   2. Damage to lacrimal duct
   3. Medial rectus entrapment
5. Orbial Floor fracture
   1. Entrapment of inferior rectus
   2. Enophthalmos
   3. Damage to infraorbital nerve
6. Retinal Detachment
   1. Hyphema
   2. Optic Nerve Sheath Hematoma

Management

1. Isolated orbital fx
   1. Cephalexin 250-500mg PO QID x10d
   2. Decongestants
   3. Instructions to avoid nose blowing
2. Ocular injury
   1. Emergent ophtho consultation
3. Malignant emphysema and/or retrobulbar hemmorhage
   1. Lateral canthotomy
4. Extraocular Muscle Dysfunction
   1. May result in oculocardiac reflex -> vagal symptoms
   2. Consider release of entrapped muscle
5. Decreased extraocular movement not due to entrapment
   1. Consider corticosteroids
   2. Surgical indications include >2mm enopthalmos and/or persistent diploplia

Disposition

1. Isolated orbital fx
   1. Dischrage w/ f/u in 3-10d
   2. Refer to ophtho for outpt full dilated exam to rule-out unidentified retinal tears
2. Naso-orbito-ethmoid fx
   1. Admit

See Also

• Orbital Hematoma
• Globe Rupture

Source

• Tintinalli
• UpToDate