Orbital fracture: Difference between revisions
 
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==Initial Assessment==
==Background==
*Eye
*Thin inferior wall frequently injured, requires less energy
#Acuity, extraocular movements
*Medial wall consists of thin lamina papyracea, requires intermediate energy
#Blurry, double, or decreased vision?
*Lateral blow out fractures require higher force
#Pain with EOM?
===Types===
*Pupil
*Blow-out Fracture
# Reactivity, size, shape
**Fracture of inferior or medial orbital walls with out fracture of orbital ridge
*Globe
**Adipose tissue, inferior rectus or inferior oblique can entrap within maxillary or ethmoid sinus
# Proptosis or enophthalmos?
**33% are associated with ocular trauma
# Increased intercanthal distance?
*Non Blow-out Fracture
# Extrusion of intraocular contents?
**Lateral, inferior, and superior orbital ridge fracture typically occurs with other facial fractures
*Orbit
*Naso-orbito-ethmoid fracture
# Crepitus from fracture into sinuses?
**Associated with force applied to nasal bridge
**Often accompanied by injury to lacrimal duct, dural tears, and traumatic brain injury


==DDX==
==Clinical Features==
*[[Orbital Hematoma]]
[[File:Infrectus.png|thumbnail|Inferior rectus highlighted in blue. Entrapment of muscle causes upward gaze diplopia.]]
**Proptosis, diffuse pain
[[File:PMC3375999 eplasty12ic09 fig1.png|thumb|Orbital fracture with right eye entrapment.]]
*[[Ruptured Globe]]
===Orbital fracture===
**Tear-shaped pupil
*Enophthalmos (globe herniation)
**Extrusion of intraocular content
*Orbital rim step-off
*Orbital zygomatic fracture
*Crepitus
**Most common
*Infraorbital anesthesia (damage to infraorbital nerve from orbital floor fracture)
*Nasoethmoid fracture
*[[Diplopia]] on upward gaze
**Inspect for:
**Entrapment of inf rectus or inf oblique or orbital fat
***Damage to medial canthal ligament
**Injury to oculomotor nerve
***Damage to lacrimal duct
 
***Medial rectus entrapment
===Naso-orbito-ethmoid fracture===
*Orbial Floor fracture
*Pain with eye movement
**Inspect for:
*Traumatic telecanthus
#Entrapment of inferior rectus
*Epiphora (tears spilling over lower lid)
#Enophthalmos
*CSF leak
#Damage to infraorbital nerve
 
*Retinal Detachment
===Findings suggestive of ocular involvement===
*Hyphema
*[[Retrobulbar hematoma]] or malignant orbital emphysema
*Optic Nerve Shealth Hematoma
**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}}


==Treatment==
==Evaluation==
*Orbital CT indicated for:
[[File:Orbitalblowout.png|thumbnail|Left orbital floor fracture on CT]]
#Evidence of fracture on exam
[[File:PMC4786376 cureus-0008-000000000487-i01.png|thumb|Head CT image with maxillary sinus opacification on coronal (left) and sagittal (right) non-contrast head CT images. Example of a typical fracture involving the right orbital floor (green arrow) and medial maxillary sinus wall (red arrow), which is associated with resultant hemorrhage and an air-fluid level in the right maxillary sinus (blue star).]]
#Decreased extraocular mobility
*Obtain orbital CT as initial study if significant clinical findings
#Decreased visual acuity
**Evidence of fracture on exam
#Severe pain
**Decreased extraocular mobility
#Unable to perform adequate exam
**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


===Orbital fracture into sinus===
==Management==
*Azithromycin or augmentin
*Fractures of medial and inferior walls may be considered open fractures into sinus mucosa
**Cephalexin x5-7 days
===Extraocular muscle entrapment===
**OR amoxicillin-clavulanate x5-7 days
*May result in oculocardiac reflex -> vagal symptoms
**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>
*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
**[[Canthotomy]]
*Extraocular Muscle Dysfunction
**May result in oculocardiac reflex → vagal symptoms
**Consider release of entrapped muscle
**Consider release of entrapped muscle
*Decreased extraocular movement not due to entrapment
*Decreased extraocular movement not due to entrapment
**Consider corticosteroids
**Consider corticosteroids
**Surgical indications include >2mm enopthalmos and/or persistent diploplia


===Orbital blowout fx===
==Disposition==
*Water's view is 83% sensitive at detecting these. If present needs CT to eval soft tissue structures (retrobulbar hemmorhage). Surgical indications include greater tha 2mm enopthalmos and/or persistent diploplia.
===Isolated orbital fracture===
*Discharge with follow up in 3-10d
*Refer to ophtho for outpatient full dilated exam to rule-out unidentified retinal tears


10-20% have ocular injury. binocular diploplia from direct muscle injury resolves in 82%, but diploplia from entrapment requires surgical repair.Malignant emphysema and/or retrobulbar hemmorhage are emergencies requiring a lateral canthotomy.
===Naso-orbito-ethmoid fracture===
*Admit


==See Also==
==See Also==
Trauma: Maxilofacial
*[[Orbital Hematoma]]
*[[Globe Rupture]]
 
==References==
<references/>
 


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

Latest revision as of 12:35, 25 September 2021

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
Head CT image with maxillary sinus opacification on coronal (left) and sagittal (right) non-contrast head CT images. Example of a typical fracture involving the right orbital floor (green arrow) and medial maxillary sinus wall (red arrow), which is associated with resultant hemorrhage and an air-fluid level in the right maxillary sinus (blue star).
  • 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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