Orbital fracture: Difference between revisions

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==Background==
==Background==
*Types
*Thin inferior wall frequently injured, requires less energy
**Blow-out Fracture
*Medial wall consists of thin lamina papyracea, requires intermediate energy
***Fracture of inferior or medial orbital walls w/o fx of orbital ridge
*Lateral blow out fractures require higher force
***Adipose tissue, inf rectus or inf oblique can entrap within maxillary or ethmoid sinus
===Types===
***33% are assoc w/ ocular trauma
*Blow-out Fracture
**Non Blow-out Fracture
**Fracture of inferior or medial orbital walls with out fracture of orbital ridge
***Lateral, inf, and sup orbital ridge fx typically occurs w/ other facial fractures
**Adipose tissue, inferior rectus or inferior oblique can entrap within maxillary or ethmoid sinus
*Naso-orbito-ethmoid fx
**33% are associated with ocular trauma
**Associated w/ force applied to nasal bridge
*Non Blow-out Fracture
**Lateral, inferior, and superior orbital ridge fracture typically occurs with other facial fractures
*Naso-orbito-ethmoid fracture
**Associated with force applied to nasal bridge
**Often accompanied by injury to lacrimal duct, dural tears, and traumatic brain injury
**Often accompanied by injury to lacrimal duct, dural tears, and traumatic brain injury


==Diagnosis==
==Clinical Features==
*Findings suggestive of orbital fx:
[[File:Infrectus.png|thumbnail|Inferior rectus highlighted in blue. Entrapment of muscle causes upward gaze diplopia.]]
**Enophthalmos (globe herniation)
[[File:PMC3375999 eplasty12ic09 fig1.png|thumb|Orbital fracture with right eye entrapment.]]
**Orbital rim step-off
===Orbital fracture===
**Crepitus
*Enophthalmos (globe herniation)
**Infraorbital anesthesia (orbital floor fx)
*Orbital rim step-off
**Diplopia on upward gaze
*Crepitus
***Entrapment of inf rectus or inf oblique or orbital fat
*Infraorbital anesthesia (damage to infraorbital nerve from orbital floor fracture)
***Injury to oculomotor nerve
*[[Diplopia]] on upward gaze
*Findings suggestive of naso-orbito-ethmoid fx
**Entrapment of inf rectus or inf oblique or orbital fat
**Pain w/ eye movement
**Injury to oculomotor nerve
**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==
===Naso-orbito-ethmoid fracture===
*Obtain orbital CT as initial study in pts w/ sig clinical findings
*Pain with 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
*[[Globe rupture]]
**Extrusion of intraocular contents, severe conjunctival hemorrhage, a tear-shaped pupil
*Orbital fissure syndrome
**Fracture 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
 
==Differential Diagnosis==
{{Maxillofacial trauma DDX}}
 
==Evaluation==
[[File:Orbitalblowout.png|thumbnail|Left orbital floor fracture on cT]]
*Obtain orbital CT as initial study if significant clinical findings
**Evidence of fracture on exam
**Evidence of fracture on exam
**Decreased extraocular mobility
**Decreased extraocular mobility
**Decreased visual acuity
**Decreased visual acuity or diplopia
**Severe pain
**Severe pain
**Unable to perform adequate exam
**Unable to perform adequate exam
*Look for teardrop sign on coronal view of CT
*Otherwise can obtain Waters' view first  
*Otherwise can obtain Waters' view first  
**Shows cloudy maxillary sinus representing blood, fluid or tissue
**Shows cloudy maxillary sinus representing blood, fluid or tissue
 
*Check for associated infraorbital nerve injury
==DDX==
#[[Orbital Hematoma]]
##Proptosis, diffuse pain
#[[Globe Rupture]]
##Tear-shaped pupil
##Extrusion of intraocular content
#Orbital zygomatic fracture
##Most common
#Nasoethmoid fracture
##Damage to medial canthal ligament
##Damage to lacrimal duct
##Medial rectus entrapment
#Orbial Floor fracture
##Entrapment of inferior rectus
##Enophthalmos
##Damage to infraorbital nerve
#Retinal Detachment
##Hyphema
##Optic Nerve Sheath Hematoma


==Management==
==Management==
#Isolated orbital fx
*Fractures of medial and inferior walls may be considered open fractures into sinus mucosa
##Cephalexin 250-500mg PO QID x10d
**Cephalexin x5-7 days
##Decongestants
**OR amoxicillin-clavulanate x5-7 days
##Instructions to avoid nose blowing
**No difference between 5-7 days vs. 10-14 days of treatment<ref>Reiss B et al. Antibiotic Prophylaxis in Orbital Fractures. Open Ophthalmol J. 2017; 11: 11–16.</ref>
#Ocular injury
*Isolated orbital fracture
##Emergent ophtho consultation
**[[Cephalexin]] 250-500mg PO QID x10d
#Malignant emphysema and/or retrobulbar hemorrhage
**Decongestants
##[[Canthotomy]]
**Instructions to avoid nose blowing
#Extraocular Muscle Dysfunction
*Ocular injury
##May result in oculocardiac reflex -> vagal symptoms
**Emergent ophtho consultation
##Consider release of entrapped muscle
*Malignant emphysema and/or retrobulbar hemorrhage
#Decreased extraocular movement not due to entrapment
**[[Canthotomy]]
##Consider corticosteroids
*Extraocular Muscle Dysfunction
##Surgical indications include >2mm enopthalmos and/or persistent diploplia
**May result in oculocardiac reflex → vagal symptoms
**Consider release of entrapped muscle
*Decreased extraocular movement not due to entrapment
**Consider corticosteroids
**Surgical indications include >2mm enopthalmos and/or persistent diploplia


==Disposition==
==Disposition==
#Isolated orbital fx
===Isolated orbital fracture===
##Dischrage w/ f/u in 3-10d
*Discharge with follow up in 3-10d
##Refer to ophtho for outpt full dilated exam to rule-out unidentified retinal tears
*Refer to ophtho for outpatient full dilated exam to rule-out unidentified retinal tears
#Naso-orbito-ethmoid fx
 
##Admit
===Naso-orbito-ethmoid fracture===
*Admit


==See Also==
==See Also==
Line 90: Line 90:
*[[Globe Rupture]]
*[[Globe Rupture]]


==Source==
==References==
*Tintinalli
<references/>
*UpToDate
 


[[Category:Ophtho]]
[[Category:Ophthalmology]]
[[Category:Trauma]]
[[Category:Trauma]]

Revision as of 02:27, 16 August 2019

Background

  • Thin inferior wall frequently injured, requires less energy
  • Medial wall consists of thin lamina papyracea, requires intermediate energy
  • Lateral blow out fractures require higher force

Types

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

Clinical Features

Inferior rectus highlighted in blue. Entrapment of muscle causes upward gaze diplopia.
Orbital fracture with right eye entrapment.

Orbital fracture

  • Enophthalmos (globe herniation)
  • Orbital rim step-off
  • Crepitus
  • Infraorbital anesthesia (damage to infraorbital nerve from orbital floor fracture)
  • Diplopia on upward gaze
    • Entrapment of inf rectus or inf oblique or orbital fat
    • Injury to oculomotor nerve

Naso-orbito-ethmoid fracture

  • Pain with 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
  • Globe rupture
    • Extrusion of intraocular contents, severe conjunctival hemorrhage, a tear-shaped pupil
  • Orbital fissure syndrome
    • Fracture 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

Differential Diagnosis

Maxillofacial Trauma

Evaluation

Left orbital floor fracture on cT
  • Obtain orbital CT as initial study if significant clinical findings
    • Evidence of fracture on exam
    • Decreased extraocular mobility
    • Decreased visual acuity or diplopia
    • Severe pain
    • Unable to perform adequate exam
  • Look for teardrop sign on coronal view of CT
  • Otherwise can obtain Waters' view first
    • Shows cloudy maxillary sinus representing blood, fluid or tissue
  • Check for associated infraorbital nerve injury

Management

  • Fractures of medial and inferior walls may be considered open fractures into sinus mucosa
    • Cephalexin x5-7 days
    • OR amoxicillin-clavulanate x5-7 days
    • No difference between 5-7 days vs. 10-14 days of treatment[1]
  • Isolated orbital fracture
    • Cephalexin 250-500mg PO QID x10d
    • Decongestants
    • Instructions to avoid nose blowing
  • Ocular injury
    • Emergent ophtho consultation
  • Malignant emphysema and/or retrobulbar hemorrhage
  • Extraocular Muscle Dysfunction
    • May result in oculocardiac reflex → vagal symptoms
    • Consider release of entrapped muscle
  • Decreased extraocular movement not due to entrapment
    • Consider corticosteroids
    • Surgical indications include >2mm enopthalmos and/or persistent diploplia

Disposition

Isolated orbital fracture

  • Discharge with follow up in 3-10d
  • Refer to ophtho for outpatient full dilated exam to rule-out unidentified retinal tears

Naso-orbito-ethmoid fracture

  • Admit

See Also

References

  1. ↑ Reiss B et al. Antibiotic Prophylaxis in Orbital Fractures. Open Ophthalmol J. 2017; 11: 11–16.
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