Orbital Trauma
ORBITAL FRACTURES
ORBITAL FLOOR FRACTURE
Orbital floor fractures are the most common type of orbital fracture. This is the result of a blow to the eye itself or to the bony rim. Many fractures only result in swelling and ecchymosis of the orbital tissues. Those with entrapped tissue and persistent diplopia, or with a large fracture and enophthalmos, will require repair.
Epidemiology and Etiology
• Age: Most common in second to fourth decades
• Gender: More common in males
• Etiology: Direct force to the inferior orbital rim with buckling and fracture of the floor is one mechanism. The second mechanism consists of forces that raise the intraorbital pressure and then “blow out” the thin orbital floor.
History
• Trauma, such as fist, fingers, elbow, and hit with a ball
• The patient will often have double vision after the injury.
• Less commonly, the patient may note orbital swelling after the trauma from orbital emphysema after blowing the nose.
Examination
• Orbital swelling and ecchymosis are variable. Some fractures have very little swelling and ecchymosis.
• Infraorbital hypesthesia and restricted motility with diplopia are the most specific signs.
• As the orbital swelling decreases, large fractures will develop enophthalmos.
• Variable degrees of crepitance may be present as an indication of the fracture.
Imaging
• Computed tomography (CT) scanning shows a fracture of the orbital floor often with blood in the sinuses.
• A fracture that is very small is more likely to have entrapment of the orbital tissue than a very large fracture.
• The inferior rectus is almost never in the fracture itself, but tissues around the muscle are entrapped. The exception is the white-eyed blowout fracture (WEBOF),
where the muscle may be in the fracture (see Special Considerations below).
where the muscle may be in the fracture (see Special Considerations below).
• Magnetic resonance imaging (MRI) does not image bone well and should not be used initially after trauma.
Special Considerations
• Children and teenagers may sustain an orbital floor fracture with no ecchymosis but with severe entrapment of the inferior rectus muscle and associated pain, nausea, and vomiting.
• This is called a WEBOF (Fig. 15-1). These patients are very uncomfortable and difficult to examine.
• The entrapment needs to be released within 24 to 48 hours, because the muscle is severely entrapped and will become ischemic if not released. This requires emergent surgery.
 FIGURE 15-1. White-eyed blowout fracture. A and B. A 9-year-old boy with a history of being hit with an elbow 1 day prior. He has pain, worse with eye movement; double vision; and has nausea and some vomiting. The photograph shows his lack of ecchymosis and swelling as well as severe restriction of upgaze. |
Treatment
• Open repair is required for patients with functional diplopia that does not improve as the swelling resolves.
• Fractures involving more than 50% of the floor may result in significant enophthalmos and also should be considered for repair.
• Fractures should be repaired within 2 weeks of trauma with the exception of a WEBOF, which is an emergency.
• Most fractures that are repaired will require an implant of some type.
Prognosis
• Good if repaired within 2 weeks
• Some patients will have direct muscle or nerve injury and either will not improve or may take months to improve.
 FIGURE 15-1. (continued) C. Computed tomography (CT) scan shows a small trap-door floor fracture with tissue entrapment. This fracture needs to be repaired promptly because the entrapped muscle may become ischemic. Orbital floor fracture. |
 FIGURE 15-1. (continued) Orbital wall fracture. D. This 72-year-old woman fell and hit her eye on her bedpost. She has full motility but significant swelling, ecchymosis, and infraorbital hypesthesia. E. CT scan shows a large orbital floor fracture. The patient is at risk for development of enophthalmos from the large fracture. |
MEDIAL WALL FRACTURE
Medial wall fractures can be isolated fractures of the medial wall only or they can be a part of larger fractures involving the nose and sinuses. Isolated fractures are treated much like orbital floor fractures (Fig. 15-2). Larger fractures usually involve a multidisciplinary approach to the repair of the fractures.
Epidemiology and Etiology
• Age: Most common in second through fourth decades
• Gender: More common in males
• Etiology: Direct fractures occur from striking a solid object. Indirect (blowout) fractures occur in association with and by similar mechanisms as orbital floor fractures.
History
• Trauma history is variable.
• Symptoms include diplopia and cosmetic deformities depending on the extent of the nasal fractures.
Examination
• Medial rectus entrapment with diplopia and eventual enophthalmos are the two ocular manifestations that may occur.
• Direct fractures often have significant damage to the nasal bridge and medial orbit. The nasal bridge may be depressed with telecanthus.
• Other findings that can occur include epistaxis, orbital hematoma, cerebral spinal fluid rhinorrhea, and damage to the lacrimal drainage system.
Imaging
• CT scanning will show the extent of the fracture and assist with potential planning of the repair.
• MRI does not image bone well and should not be used initially after trauma.
Special Considerations
• Medial wall fractures with entrapment of the medial rectus need to be repaired sooner than floor fractures (within 1 week) if possible.
Treatment
• If isolated, medial wall fractures often do not need repair.
• Medial rectus entrapment with diplopia is one indication for repair.
• If the fracture is large, enophthalmos can develop and require surgery to build up the orbit. Implants are sometimes placed.
• Larger fractures involving the nasal bridge and medial orbit require repair and plating, usually in conjunction with an otolaryngology specialist.
Prognosis
• Good. Larger fractures may require multiple surgeries and revisions.
 FIGURE 15-2. Medial wall fracture. A to C. A 55-year-old man struck in the face with an unknown object presented with horizontal diplopia. Motility is restricted in the right eye in both adduction and abduction. |
 FIGURE 15-2. (continued) D and E. Computed tomography scans show a medial wall orbital fracture with the medial rectus muscle pulled into the fracture. |
 FIGURE 15-2. (continued) |
ORBITAL ROOF FRACTURE
Orbital roof fractures (Fig. 15-3) are rare fractures that need to be recognized because of the potential for life-threatening neurologic sequelae. There may just be a small fracture with no neurologic problems, or there may be significant intracranial air and bleeding. Treatment is in conjunction with neurosurgery.
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