Orbital Fracture in Emergency Medicine 

Updated: Sep 27, 2016
Author: Thomas Widell, MD; Chief Editor: Trevor John Mills, MD, MPH 

Overview

Background

Approximately 20% of patients with severe facial trauma injuries also have an ophthalmic injury. In such patients in the ED , eye injuries should be quickly ruled out, including retrobulbar hemorrhage and penetrating globe injury.[1, 2]

Blow-out fractures occur when a blow to the eye increases pressure in the orbit, causing the weak floor or medial wall (lamina papyracea) to "blow out" into the maxillary sinus or ethmoid bone.[3, 4, 5, 6, 7, 8, 9] This results in a fracture, though it often prevents globe rupture and loss of the eye.[6] Periorbital fat and extraocular muscles can become entrapped in the fracture, leading to problems of ocular movement.[6] When the medial wall (lamina papyracea) is fractured, the medial rectus becomes entrapped, leading to lateral gaze dysfunction.

In maxillary fracture, the orbit floor blows out, and the inferior rectus entrapment leads to problems in upward gaze.[3, 4, 5, 6, 7, 8, 9] The eye can be injured during compression before the ethmoid bone or the maxillary sinus fractures. About one third of blow-out fractures have an associated eye injury.[6] Superior orbital rim fracture is a frontal bone fracture that is associated with high-impact injuries to the brain, face, and cervical spine.[10] Tripod fractures and zygomaticomaxillary complex fractures occur from high-impact injury to the cheek's malar eminence (zygoma). Often, these fractures are associated with eye and inferior orbital nerve injuries.

The orbit is composed of 7 facial bones: frontal, zygoma, maxilla, lacrimal, ethmoid, sphenoid and palatine. The superior orbital ridge and upper medial orbital ridge are part of the frontal bone. The lateral orbital rim is part of the zygoma. The inferior and lower medial rims are part of the maxilla, and the floor of the orbit is made of the upper border of the maxillary sinus.

The medial rim separating the orbit from nares is the lacrimal bone. The medial wall and part of the posterior wall of the orbit are formed by the ethmoid bone. The remainder of the posterior of the orbit is formed by the 2 wings of the sphenoid bone, the continuation of the lacrimal bone from the medial wall, and the orbital process of the palatine bone.

The optic nerve exits the optic foramen in the lesser wing of the sphenoid bone. The globe of the eye sits within the orbit surrounded by periorbital fat and the extraocular muscles that control its movement. The inferior orbital nerve courses through the maxilla in the orbital floor. The weakest portion of the orbit is the thin orbital floor (maxilla) and the lamina papyracea (ethmoid bone) medially and inferiorly.

A study by Coon et al, identified 4 indications for surgical intervention in pediatric patients with orbital fractures[11] :

  • Rectus muscle entrapment
  • Early enophthalmos
  • Central-gaze diplopia or extraocular movement restriction after the resolution of swelling
  • Loss of orbital support likely to produce secondary changes in globe position and/or binocular stereo vision

See the image below.

 

 

Left orbital floor fracture. This patient presente Left orbital floor fracture. This patient presented with little motility disturbance; however, because of the large defect in the orbital floor, late enophthalmos was predicted. Surgical repair was undertaken. Note the pneumo-orbitum.

Epidemiology

The principal morbidity associated with orbital fractures is eye injury. Associated injuries include corneal abrasion, lens dislocation, iris disruption, choroid tear, scleral tear, ciliary body tear or bruise, retinal detachment and tear, hyphema, ocular muscle entrapment, and globe rupture.[6] Males are at higher risk of eye injuries because of their increased incidence of trauma. In women, ask if the injury was from a partner or if they feel threatened by anyone, as the incidence of domestic violence and sexual assault is highly associated with this type of injury. For all eye injuries, age distribution has 2 peaks: 10-40 years and older than 70 years.[12, 11]

 

For more information, see Medscape's Trauma Resource Center.

 

 

Patient Education

Instruct patients to use ice to reduce edema.

Instruct patients to return if visual problems develop.

If injury occurred at work or in a sporting accident, instruct patients to wear safety glasses or goggles.

For patient education resources, see the Breaks, Fractures, and Dislocations Center, as well as Facial Fracture.

Patients should be informed of the high risk of posttraumatic stress disorder and should be referred to a psychiatrist should symptoms occur.[13]

 

Presentation

History

Because orbital fractures are the result of trauma, primary survey and attention to ABCs take priority. Focus questions on patency of airway, control of cervical spine, breathing difficulties, and symptoms of shock or neurologic impairment, such as loss of consciousness.

Once life-threatening issues have been addressed, obtain a thorough (AMPLE) history:

  • Allergies

  • Medications

  • Past medical history

  • Last meal

  • Events leading to injury

Determine the answers to questions about the patient's injury:

  • Does patient have epistaxis or clear fluid running from nares or ears?

  • Did patient lose consciousness? If so, for how long?

  • Has patient had any visual problems, such as double or blurred vision?

  • Has patient had any hearing problems, such as decreased acuity or tinnitus?

  • Does patient have malocclusion and is the patient able to bite down without pain?

  • Does patient have areas of numbness or tingling on the face?

  • In women, ask if the injury was from a partner or if they feel threatened by anyone.

  • In children, ask questions to determine if child abuse is an issue.

Answer questions specific to the eye:

  • Does patient have diplopia, especially on lateral and upward gaze, indicating possible entrapment or lens dislocation?

  • Does patient have pain with eye motion indicating possible entrapment or periorbital edema?

  • Does patient have photophobia (iritis)?

  • Has patient experienced flashes of light (retinal detachment)?

  • Does patient have blurred vision (hyphema, retinal detachment, vitreous hemorrhage)?

Physical

Perform a complete exam of the face. Asterisks (*) designate portions of the exam that are involved specifically with orbital fracture or associated eye injuries.[6, 10, 14]

Inspect the face for asymmetry while looking down from the head of the bed. From this position, it is easiest to see enophthalmos (sunken eye) or proptosis (protruding eye).*

Examine lids for lacerations. If present, consider the possibility of globe penetration.*

Palpate bony structures of the supraorbital ridge and frontal bone for step-off fractures.*

Examine ocular movements, especially in upward and lateral gaze, and test for diplopia.*

Check visual acuity.*

Check cornea, using fluorescein if needed, for abrasion (uptake of dye) or lacerations (streaming of fluid in dye).*

Check pupils for roundness and reactivity, both direct and consensual.*

Examine anterior chamber for presence of blood (flaring on slit-lamp exam) or hyphema (blood layering in inferior aspect of anterior chamber).*

Examine limbus for signs of laceration (teardrop sign) or deformity.*

Perform a funduscopic exam to check for blood in the posterior chamber, and examine retina for signs of detachment.*

Inspect nares for telecanthus (widening of the nasal bridge), then palpate for tenderness and crepitus.

Inspect nasal septum for clear rhinorrhea, indicating cerebrospinal fluid (CSF) leak, and for septal hematoma.

Check facial stability by grasping the teeth and hard palate and gently pushing horizontally then vertically, feeling for movement or instability of midface.

Test teeth for stability and inspect for bleeding at the gum line, a sign of fracture through the alveolar bone.

Check teeth for malocclusion and step-off.

Palpate mandible along its symphysis, body, angle, and coronoid process (anterior to ear canal) to check for tenderness, swelling, and step-off.

Evaluate supraorbital, infraorbital*, inferior alveolar, and mental nerve distributions for anesthesia.

Palpate zygoma along its arch, as well as its articulations with the frontal bone, temporal bone, and maxillae.

Perform a slit-lamp examination of the eye to exclude eye injury.*

Complications

Complications include the following:

  • Corneal abrasion

  • Lens dislocation

  • Iris disruption

  • Choroid tear

  • Scleral tear

  • Ciliary body tear or bruise

  • Retinal detachment and tear

  • Hyphema

  • Ocular muscle entrapment

  • Globe rupture

 

DDx

Differential Diagnoses

 

Workup

Imaging Studies

Radiographs

CT is replacing plain films in the evaluation of orbital trauma because of higher sensitivity and better definition of the injuries. When CT is not available or there is low suspicion without ocular symptoms plain films can be used.

Obtain routine facial views, including Waters, Caldwell, and lateral projections.

Waters view best displays inferior orbital rims, nasoethmoidal bones, and maxillary sinuses. If the patient is upright when the film is taken, an air-fluid level can often be seen in the maxillary sinus, which may indicate fracture of the maxillary sinus (orbital floor).

If the patient is immobilized on a backboard when the film is taken, blood layers form in the posterior of the sinus, making it appear clouded. Another sign of orbital blow-out fracture is the teardrop sign, an opacification in the upper maxillary sinus, which represents periorbital fat and possibly an entrapped extraocular muscle in the maxillary sinus.

Caldwell projection provides the best view of the lateral orbital rim and ethmoid bone.

Lateral views are the least helpful, but if the patient is lying supine on the backboard, he or she may show air-fluid levels in the posterior of the maxillary sinus.

Cervical spine radiographs may be indicated in patients with severe facial injuries or with a consistent mechanism and/or neck pain.

Computed tomography

Depending on the institution and severity of the incident, CT scanning is generally considered the test of choice to diagnose facial/orbital fractures. Benefits include increased sensitivity, improved ability to plan for operative repair when needed, and utility in diagnosing associated injuries.[2, 12]

Orbital blow-out fractures may require CT scanning to evaluate the floor and medial wall of the orbit. CT scanning may not be needed in the emergent setting if the patient has no ocular injury or entrapment. However, in patients with a decrease in visual acuity, this test is helpful in diagnosing direct optic nerve involvement in the fracture and the presence of retro-ocular edema or hematoma, which can stretch the optic nerve.

In severe injuries in the orbit area, facial CT scanning may identify associated orbital rim, nasoethmoidal, and zygomaticomaxillary fractures.

Consider CT scanning of the brain to exclude concomitant intracranial injuries.

 

Treatment

Prehospital Care

Airway, breathing, and circulation are the first priorities. Hold the airway open by jaw thrust or airway adjuncts, including endotracheal intubation. Because of the concern with intracranial placement of endotracheal tubes, severe facial injury is considered a relative contraindication to using the nasotracheal route of intubation.

Place patient on a backboard with a collar if cervical spine injury is a possibility.

Treat hypoventilation with intubation and bag ventilation.

Control actively bleeding wounds by applying direct pressure with a bandage.

If globe is open, cover it with a protective shield.

Emergency Department Care

Airway, breathing, and circulation are the first priorities. Reassess airway frequently. Intubation performed early on, before swelling occurs, makes airway control much easier than waiting until a problem arises from obstruction.

Do not focus on the obvious deformity, thereby neglecting to perform a complete primary survey. Rapidly diagnose other life threats and undertake appropriate resuscitation.

Diagnosis of orbital fracture in the ED is part of the secondary survey. Diagnose other injuries to the eye as well by performing a complete slit-lamp examination of the eye and tests for visual acuity.

In one study, treatment of ocular emergencies in trauma centers and treatment in traditional community hospital emergency departments were compared. The records of 1027 patients with ocular emergencies between July 2007 and November 2010 were reviewed. The incidence of patients requiring ophthalmic intervention was 77.2 per 100,000 in the community hospitals and 208.9 per 100,000 in the trauma centers. Orbital fractures were found in 86% of all orbital contusion cases in trauma centers; and in 66.7% of patients with fall injuries and open globe diagnoses, the result was legal blindness.[15]

Consultations

Depending on the institution, orbital fractures are cared for by an eye, ear, nose, throat (EENT) surgeon, oromaxillofacial surgeon, ophthalmologist, or plastic surgeon.

Patients with serious eye injuries and decreased visual acuity should have an ophthalmology consultation. Monitor minor injuries, such as corneal abrasions, on an outpatient basis.[6]

Provide care for the patient with multiple injuries in conjunction with a surgeon with experience in trauma care.

The incidence of posttraumatic stress disorder is high in patients with facial injuries, and a consultation with a psychiatrist should be considered.[13, 7, 9]

Medical Care

Blow-out fractures without associated serious eye injury do not require admission. Admit patients with serious eye injury to the ophthalmology service for further care, unless other significant injuries mandate admission to the trauma service.[6]  I

If appropriate specialists are not available in the receiving institution, arrange transfer to a higher level hospital. Because the incidence of posttraumatic stress disorder is high, referral to a psychiatrist should be considered if symptoms occur.[13]

Patients with simple blow-out fractures without eye injury can be discharged home, even if the patient has signs of entrapment, because most resolve as swelling goes down. Instruct the patient to return if he or she notes a change in visual acuity, increasing pain, or flashing lights.

Follow-up exam in 2 weeks allows for swelling to resolve. If entrapment is confirmed at that time, open reduction of fracture with a bone graft may be needed.

 

Medication

Medication Summary

When airway control is needed, facilitate intubation using drugs for rapid sequence induction. A cricothyrotomy kit should be at the bedside in case problems arise.

Medication for pain control is appropriate, including NSAIDs, narcotics, and local anesthetics.

Complete exam of the eye may require dilation of the pupil using mydriatic solutions.

Administer tetanus toxoid for open wounds if patient is not current on vaccinations.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Class Summary

These agents are used most commonly for relief of mild to moderately severe pain. Effects of NSAIDs in the treatment of pain tend to be patient specific, yet ibuprofen is usually DOC for the initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Ibuprofen (Ibuprin, Advil, Motrin)

Usually DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.

Ketoprofen (Oruvail, Orudis, Actron)

Used for relief of mild to moderately severe pain and inflammation. Administer small dosages initially to patients with small bodies, older persons, and those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe.

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.

Flurbiprofen (Ansaid, Ocufen)

Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis.

Analgesics

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)

DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs or those with upper GI disease or taking oral anticoagulants.

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for treatment of mild to moderately severe pain.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Morphine sulfate (Duramorph, Astramorph, MS Contin)

DOC for narcotic analgesia due to its reliable and predictable effects, safety, and ease of reversibility with naloxone. Administered IV, may be dosed in a number of ways and commonly is titrated until desired effect obtained.

Tetanus toxoid

Class Summary

This agent is used for tetanus immunization. Booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

Tetanus toxoid adsorbed or fluid

Used to induce active immunity against tetanus in selected patients. Tetanus and diphtheria toxoids are immunizing DOC for most adults and children >7 y. Necessary to administer booster doses to maintain tetanus immunity throughout life.

Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product.

In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is midthigh lateral.

Immunoglobulins

Class Summary

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.

Tetanus immune globulin (TIG)

Used for passive immunization of any person with a wound that may be contaminated with tetanus spores.