Author:
ShariSchabowski
AshleaWinfield-Dial
Description
- Defined as an orbital floor fracture that results from sudden blunt trauma to the globe:
- Typically caused by the force of a projectile > half the size of the fist
- Force transmitted through the noncompressible structures of the glove to the weakest structural point, the orbital floor, causing it to “blow out”
- Orbital floor serves as roof to air-filled maxillary and ethmoid sinuses:
- Communication between the spaces results in orbital emphysema
- Orbit contains fat, which holds the globe in place:
- Orbital floor fracture may result in herniation of the fat on the inferior orbital surface into the maxillary or ethmoid sinuses
- Leads to enophthalmos owing to orbital volume loss and sinus congestion; fluid collection may occur secondary to edema and bleeding
- Infraorbital nerve runs through the bony canal 3 mm below the orbital floor:
- Injury may result in hypoesthesia of the ipsilateral cheek and upper lip
- To distinguish facial hypoesthesia related to local swelling from nerve injury: Test for sensation on the ipsilateral gingiva, which is within the infraorbital nerve distribution
- Inferior rectus and the inferior oblique muscle run along the orbital floor:
- Restriction of these extraocular muscles may occur because of entrapment within the fracture, contusion, or cranial nerve dysfunction
- Typically manifests as diplopia on upward gaze
- Inability to elevate the affected eye normally on exam
- Medial rectus located above the ethmoid sinus:
- Less commonly entrapped
- Diplopia on ipsilateral lateral gaze
Etiology
Caused by a projectile that strikes the globe. The force is transmitted through the noncompressible structures of the globe to the weakest structural point, the orbital floor resulting in a blow-out fracture
Pediatric Considerations |
- Orbital roof fractures with associated CNS injuries more common in children
- Orbital floor fractures: Unlikely before 7 yr of age:
- Orbital floor is not as weak a point in the orbit due to lack of pneumatization of the paranasal sinuses
- Unfortunately fractures can occur in children and may result in unrecognized entrapment of the rectus muscle labeled the “white-eyed” fracture:
- Findings are subtle and there may be little associated soft tissue injury
- These children may present with marked nausea, vomiting, bradycardia, headache, and irritability suggestive of a head injury that commonly distracts from the true diagnosis
|
Signs and Symptoms
- Periorbital tenderness, swelling, and ecchymosis
- Impaired ocular mobility or diplopia:
- Restricted upward gaze owing to inferior rectus entrapment
- Restricted ipsilateral lateral gaze with medial rectus entrapment
- Infraorbital hypoesthesia:
- Caused by compression/contusion of infraorbital nerve
- May extend to upper lip
- Enophthalmos:
- Globe set back owing to orbital fat displaced through fracture
- Periorbital emphysema:
- From the ethmoid or maxillary sinus
- Epistaxis
- Normal visual acuity:
- If not, consider more extensive injuries
- No orbital rim step off
Associated Severe Injuries
- Ocular injuries:
- Ruptured globe:
- Incidence up to 30% of blow-out fractures
- Ophthalmologic emergency
- Retrobulbar hemorrhage
- Emphysematous optic nerve compression
- Cervical spine or intracranial injuries
- Commonly associated injuries:
- Subconjunctival hemorrhage
- Corneal abrasion/laceration
- Hyphema
- Traumatic mydriasis
- Traumatic iridocyclitis (uveitis)
- Less common:
- Iridodialysis
- Retinal detachment
- Vitreous hemorrhage
- Optic nerve injury
- Associated fractures:
- Nasal bones
- Zygomatic arch fracture
- Le Fort fracture
- Late complications:
- Sinusitis
- Orbital infection
- Permanent restriction of extraocular movement
- Enophthalmos
History
Struck in the eye with a projectile. Paintball, hand ball, racquetball, baseball, rock, or possibly fist. Larger-sized projectiles will likely be blocked by the orbital rim. Seen frequently after MVCs which are the most common cause of maxillofacial trauma
Physical Exam
- Thorough ophthalmologic exam:
- Palpate bony structures of the orbit for evidence of step off
- Careful attention not to place pressure on the globe until ruptured globe excluded:
- Desmarres lid retractors may be necessary to evaluate the eye with swollen lid
- Document pupillary response
- Visual acuity (should not be affected):
- Hand held visual acuity Rosenbaum card is most useful with injuries
- Test extraocular movements for disconjugate gaze or diplopia
- Test sensation in inferior orbital nerve distribution
- Examine lid and adnexa:
- Orbital emphysema may be present
- Slit-lamp and funduscopic exam to identify associated injuries
- Full physical exam to identify associated injuries and neurologic impairment
Diagnostic Tests & Interpretation
Lab
- Preoperative lab studies if indicated
- Pregnancy testing prior to radiography
Imaging
- If CT unavailable or contraindicated, plain radiographs will provide important information:
- Facial films
- Orbits
- Waters view and exaggerated Waters view:
- Classic “teardrop sign” illustrates herniated mass of orbital contents in the ipsilateral maxillary sinus
- Opacification of or air-fluid level in the ipsilateral maxillary sinus (less specific)
- Orbital floor bony fracture
- Lucency in orbits consistent with orbital emphysema
- CT-preferred modality:
- Defines involved anatomy
- Obtain axial and coronal 1.5-mm cuts:
- Reconstruction of coronals not preferred but acceptable if positioning impossible
Diagnostic Procedures/Surgery
Forced duction test:
- Distinguishes nerve dysfunction from entrapment
- Topical anesthesia applied to the conjunctiva on the opposite side, and the globe is pulled away from the expected point of entrapment; if the globe is not mobile, the test is positive - defining physical entrapment
Pediatric Considerations |
- Orbital CT: Study of choice:
- Essential to identify entrapment early as long-term outcome will likely be affected if left undiagnosed:
- Early surgical intervention for entrapment may significantly improve outcome
|
Differential Diagnosis
- Cranial nerve palsy
- Orbital cellulitis
- Periorbital cellulitis
- Periorbital contusion/ecchymosis
- Retrobulbar hemorrhage
- Ruptured globe
Prehospital
- Metal protective eye shield if possible globe injury
- Place in supine position
Initial Stabilization/Therapy
Initial approach and immediate concerns:
- Assess for associated intracranial or cervical spine injuries
- Rule out ruptured globe
- Test visual acuity:
- Decreased visual acuity suggestive of associated with more extensive injuries
ED Treatment/Procedures
- After globe rupture is excluded, apply cool compresses for at least 20 min out of every hour during the first 24-72 hr to decrease swelling, minimize or reverse herniation, and avoid surgical intervention
- Avoid Valsalva maneuvers, vigorous activity that may raise heart rate, and nose blowing to prevent compressive orbital emphysema
- Prophylactic antibiotics to prevent infection
- Nasal decongestants if no contraindication
- Analgesics as needed
- Tetanus prophylaxis
Medication
- Antibiotics are routinely recommended to prevent sinusitis and orbital cellulitis. Data supporting improved outcomes is limited:
- Systemic corticosteroids have been advocated to speed up the resorption of edema in order to more accurately assess any muscle entrapment and orbital damage, but data is limited to show any benefit outside of intraoperative use:
- Prednisone (60-80 mg/d): Within 48 hr of the injury and continued for 5 d
- Nasal decongestants may be beneficial if not contraindicated:
Disposition
Admission Criteria
- Rarely indicated
- 85% resolve without surgical intervention
- Consultation with facial trauma service in ED and consideration for admission if:
- 50% of floor fractured
- Diplopia or entrapment is identified
- Particularly in children
- Enophthalmos >2 mm or more
Discharge Criteria
In most cases, observe for 10-14 d until swelling resolves, then follow up with facial trauma surgeon to determine need for surgical intervention
Follow-up Recommendations
Symptoms should improve over time:
- If patient develops increased swelling, tenderness, redness, vision changes, or pain around the eye, they should return to ED for re-evaluation
- AlinasabB, RyottM, StjärneP. Still no reliable consensus in management of blow-out fracture . Injury. 2012;45:197-202.
- CruzAA, EichenbergerGC. Epidemiology and management of orbital fractures . Curr Opin Ophthalmol. 2004;15(5):416-421.
- GosauM, SchöneichM, DraenertFG, et al. Retrospective analysis of orbital floor fractures— complications, outcomes and review of the literature . Clin Oral Investig. 2011;15(3):305-313.
- HigashinoT, HirabayashiS, EguchiT, et al. Straightforward factors for predicting the prognosis of blow-out fractures . J Craniofac Surg. 2011;22(4):1210-1214.
- YewCC, ShaariR, RahmanSA, et al. White-eyed blow out fracture: Diagnostic pitfalls and review of literature . Injury. 2015;46(9):1856-1859.
See Also (Topic, Algorithm, Electronic Media Element)