Orbital fracture

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Background

  • Types
    • Blow-out Fracture
      • Fracture of inferior or medial orbital walls with out fracture of orbital ridge
      • Adipose tissue, inf rectus or inf oblique can entrap within maxillary or ethmoid sinus
      • 33% are associated with ocular trauma
    • Non Blow-out Fracture
      • Lateral, inf, and sup 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.
  • Findings suggestive of orbital fracture:
    • Enophthalmos (globe herniation)
    • Orbital rim step-off
    • Crepitus
    • Infraorbital anesthesia (orbital floor fracture)
    • Diplopia on upward gaze
      • Entrapment of inf rectus or inf oblique or orbital fat
      • Injury to oculomotor nerve
  • Findings suggestive of 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
    • 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

Orbital trauma

Acute

Subacute/Delayed

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

Management

  • 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