Orbital fracture: Difference between revisions
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**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 | ||
== | ==Clinical Features== | ||
[[File:Infrectus.png|thumbnail|Inferior rectus highlighted in blue. Entrapment of muscle causes upward gaze diplopia.]] | [[File:Infrectus.png|thumbnail|Inferior rectus highlighted in blue. Entrapment of muscle causes upward gaze diplopia.]] | ||
*Findings suggestive of orbital fx: | *Findings suggestive of orbital fx: | ||
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***Entrapment of inf rectus or inf oblique or orbital fat | ***Entrapment of inf rectus or inf oblique or orbital fat | ||
***Injury to oculomotor nerve | ***Injury to oculomotor nerve | ||
*Findings suggestive of naso-orbito-ethmoid | *Findings suggestive of naso-orbito-ethmoid fracture | ||
**Pain w/ eye movement | **Pain w/ eye movement | ||
**Traumatic telecanthus | **Traumatic telecanthus | ||
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**CSF leak | **CSF leak | ||
*Findings suggestive of ocular involvement: | *Findings suggestive of ocular involvement: | ||
**Retrobulbar hematoma or malignant orbital emphysema | **[[Retrobulbar hematoma]] or malignant orbital emphysema | ||
***Exophthalmos, decreasing visual acuity, increased ocular pressure | ***Exophthalmos, decreasing visual acuity, increased ocular pressure | ||
**Orbital fissure syndrome | **Orbital fissure syndrome | ||
*** | ***Fracture of orbit involving the sup. orbital fissure | ||
****May result in injury to oculomotor and ophthalmic divisions of CN V | ****May result in injury to oculomotor and ophthalmic divisions of CN V | ||
****Paralysis of extraocular motions, ptosis, periorbital anesthesia | ****Paralysis of extraocular motions, ptosis, periorbital anesthesia | ||
== | ==Differential Diagnosis== | ||
{{Maxillofacial trauma DDX}} | |||
==Diagnosis== | |||
[[File:Orbitalblowout.png|thumbnail|Left orbital floor fracture on cT]] | [[File:Orbitalblowout.png|thumbnail|Left orbital floor fracture on cT]] | ||
*Obtain orbital CT as initial study in pts w/ sig clinical findings | *Obtain orbital CT as initial study in pts w/ sig clinical findings | ||
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*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 | ||
==Management== | ==Management== | ||
*Isolated orbital | *Isolated orbital fracture | ||
**[[Cephalexin]] 250-500mg PO QID x10d | **[[Cephalexin]] 250-500mg PO QID x10d | ||
**Decongestants | **Decongestants | ||
Revision as of 14:53, 8 November 2015
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
- Blow-out Fracture
- Naso-orbito-ethmoid fx
- Associated w/ force applied to nasal bridge
- Often accompanied by injury to lacrimal duct, dural tears, and traumatic brain injury
Clinical Features
- 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 fracture
- 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
- 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
- Fracture of orbit involving the sup. orbital fissure
- Retrobulbar hematoma or malignant orbital emphysema
Differential Diagnosis
Maxillofacial Trauma
- Ears
- Nose
- Oral
- Other face
- Zygomatic arch fracture
- Zygomaticomaxillary (tripod) fracture
- Related
Diagnosis
- 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
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
- Dischrage with follow up in 3-10d
- Refer to ophtho for outpt full dilated exam to rule-out unidentified retinal tears
- Naso-orbito-ethmoid fracture
- Admit
See Also
References
- Tintinalli
- UpToDate