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

Inferior rectus highlighted in blue. Entrapment of muscle causes upward gaze diplopia.

• 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

Left orbital floor fracture on cT

• Obtain orbital CT as initial study in pts w/ sig 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

Differential Diagnosis

Maxillofacial Trauma

• Ears
  • Auricular hematoma
• Nose
  • Nasal fracture
  • Nasal septal hematoma
• Oral
  • Dental trauma
  • Lip laceration
  • Tongue laceration
• Other face
  • Le Fort fractures
  • Mandible fracture
• Zygomatic arch fracture
• Zygomaticomaxillary (tripod) fracture
• Related
  • Head trauma (main)
    • Skull fracture
    • Skull fracture (peds)
    • Basilar skull fracture
  • Orbital trauma
    • Eyelid laceration
  • Scalp laceration

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 hemorrhage
   1. 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