Orbital fracture

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

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
- Ruptured globe
  - 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

Acute

Subacute/Delayed

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

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
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