Orbital fracture

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  • 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

  • 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


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
  • Check for associated infraorbital nerve injury


  • 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


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