Orbital fracture
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
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
- Fracture of orbit involving the sup. orbital fissure
Differential Diagnosis
Maxillofacial Trauma
- Ears
- Nose
- Oral
- Other face
- Zygomatic arch fracture
- Zygomaticomaxillary (tripod) fracture
- Related
Evaluation
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
- ↑ Reiss B et al. Antibiotic Prophylaxis in Orbital Fractures. Open Ophthalmol J. 2017; 11: 11–16.