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Fracture, Orbital

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Fracture, Orbital
Jennifer J. Mitchell
Kelly T. Mitchell
Basics
Description
  • Types of orbital fractures:
    • Orbital rim: Caused by direct blow to bony orbit
    • Orbital wall: Caused by blunt trauma to globe
      • Blowout fracture: Most common; fracture fragment is directed away from the bony orbit.
      • Blow-in fracture: Trauma typically directed against frontal bone or maxilla; fracture fragment(s) is displaced toward the orbital space.
  • Orbital anatomy:
    • Bony orbit is a conical structure.
      • Base faces anterolaterally.
      • Apex originates posteromedially.
      • Seven bones
    • Anterior rim comprised of maxilla, zygoma, frontal bones
    • Orbital roof:
      • Frontal bone, orbital process
      • Sphenoid bone, lesser wing
      • Forms floor of frontal sinus
    • Medial wall:
      • Ethmoid bone
      • Lamina papyracea
      • Thinnest portion of the orbit
      • Sphenoid bone
      • Maxillary bone
      • Lacrimal bone
      • Forms walls of ethmoid sinus, sphenoid sinus, and nasal cavity
    • Orbital floor:
      • Zygomatic bone
      • Maxillary bone
      • Palatine bone
      • Forms roof of maxillary sinus
      • Most commonly fractured area of orbit
    • Lateral wall:
      • Sphenoid bone
      • Zygomatic bone
      • Frontal bone
      • Unique aspects: Not bordered by a sinus; thickest of the orbital walls
Epidemiology
  • ∼1/3 of orbital blowout fractures are sustained during sport. Other causes include motor vehicle accidents, assaults, and falls.
  • Eye injury is the second leading cause of visual impairment after cataract.
  • 40% of monocular blindness is due to eye trauma.
  • 57% of eye injuries were sustained by individuals under 30 yrs of age.
  • Males sustain around 80% of eye injuries.
  • 13% of serious eye injuries are related to sports and recreation.
  • Estimated 1,400 of every 100,000 U.S. citizens will sustain an eye injury in their lives (1).
Incidence
  • Trauma to the eye represents ∼3% of all ED visits in the U.S. (2).
  • The eye represents 0.3% of the body's total surface area.
  • Whole-person impairment or disability from loss of vision:
    • One eye, 24%
    • Both eyes, 85%
Prevalence
  • Around 2.5 million new eye injuries occur annually.
  • Eye trauma is the cause of 40,000–60,000 new cases of blindness each year.
  • Annually, ∼11,000 eye injuries sustained by children are caused by toys or home playground equipment (1).
Risk Factors
  • Most common causes of orbital fracture:
    • Sporting events
    • Falls
    • Assaults
  • Sports most commonly associated with orbital fracture (3):
    • U.S.:
      • Baseball
      • Football
      • Basketball
      • Racquetball
    • United Kingdom and Australia:
      • Soccer
      • Rugby
      • Cricket
General Prevention
Use of eye protection for any sport where an object or another participant may impact the globe.
Etiology
Blowout fractures:
  • Occur within bony orbit
  • Usually along:
    • Medial wall and/or
    • Orbital floor
  • Orbital rims are intact.
  • 2 proposed theories:
    • Hydraulic theory (3):
      • Blunt object of larger than diameter of the orbital entrance strikes the eye.
      • Compresses globe, resulting in sudden increase in intraorbital hydraulic pressure
      • Globe does not rupture.
      • Increased intraocular pressure dissipates via soft tissues to weakest portions of orbit: Posteromedial orbital floor, lamina papyracea of ethmoid bone, or medial orbital wall.
    • Buckling theory (4):
      • Fractures occur as a result of direct trauma to the inferior orbital rim.
      • Causes buckling of the orbital floor
      • Thinnest area fractures
Commonly Associated Conditions
  • Ocular injury is associated with blowout fracture 14–40% of the time (5).
  • Potential associated injuries:
    • Mild ocular injuries:
      • Subconjunctival hemorrhage
      • Conjunctival laceration
      • Corneal abrasion
    • Vision threatening injuries:
      • Corneal laceration
      • Globe rupture
      • Hyphema
      • Traumatic iridocyclitis
      • Acute glaucoma
      • Lens subluxation/dislocation
      • Posttraumatic cataract

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      • Vitreous hemorrhage
      • Retinal detachment/tear
      • Commotio retinae, traumatic retinal swelling
      • Foreign body: Intraocular or intraorbital
      • Optic nerve injury
      • Orbital emphysema with ocular vascular compromise
      • Retrobulbar hemorrhage
    • Injuries to ocular adnexa:
      • Eyelid contusion ± ecchymosis
      • Eyelid laceration ± margin involvement
      • Canthal injury, laceration or avulsion
      • Traumatic ptosis
    • Intracranial injuries:
      • Pneumocephalus
      • Cerebral injury
      • Cerebrospinal fluid leak
    • Delayed complications:
      • Enophthalmos
      • Hypoglobus
Diagnosis
History
  • Timing
  • Mechanism:
    • Penetrating trauma:
      • Energy/velocity
      • Type of material
      • Size of object
    • Nonpenetrating trauma
  • Location
  • Protective eyewear in use
  • Visual symptoms:
    • Change in vision
    • Diplopia
    • Discharge
    • Flashing lights
    • Floaters
    • Pain
    • Photophobia
  • Prior ocular history:
    • Contact lens use
    • Previous visual impairment/visual correction
    • Prior trauma
    • Surgical history
  • Tetanus status
  • AMPLE history:
    • Allergies
    • Medications
    • Past medical history
    • Last meal
    • Events/environment related to injury (2)[C]
Physical Exam
  • Signs and symptoms include (4)[B]:
    • Decreased vision
    • Diplopia
    • Enophthalmos
    • Exophthalmos
    • Hypoesthesia in V2 distribution:
      • Infraorbital
      • Cheek
      • Lateral nose
      • Upper lip
    • Intraorbital emphysema
    • Nosebleed
    • Periorbital ecchymosis
    • Step-off abnormality of bony structures
  • Physical examination includes the following (2)[C]:
    • Neurologic survey first
    • If neurologically intact, then initial visual acuity (VA) to evaluate for emergent visual changes
    • Perform exam in systematic manner.
    • Avoid placing pressure on globe; risk of vitreous herniation if globe is ruptured
    • If no emergency visual changes, more detailed VA determination
    • Visual acuity before manipulation of eye
    • Near vision (near-reading card or other readily available reading material)
    • Far vision (Snelling chart)
    • Patient should use his or her corrective lenses (not contacts).
    • Use pinhole occluder if not available
    • Patient unable to see well enough to read
    • Display number of fingers
    • Detection of hand motion
    • Light perception or lack of
    • Examine head, scalp, face, periorbital tissues
    • Lacerations: Location, depth, length
    • Lid edema
    • Foreign body
    • Sensory deficit
    • Bony tenderness to palpation around orbital rim
    • Orbital rim fracture
    • Step-offs: Blowout fracture
    • Exophthalmos
    • Enophthalmos
    • Deformity of external eye structures:
      • Conjunctiva:
        • Blood (subconjunctival hemorrhage)
        • Chemosis (swelling)
        • Foreign bodies
        • Exposed tissue
      • Cornea:
        • Fluorescein stain/cobalt blue light
        • Irregularities (abrasion, laceration, ulceration)
        • Foreign bodies
    • Extraocular motility: Generally decreased motility may be due to edema.
    • Impaired upward gaze: Orbital floor fracture
    • Impaired downward gaze: Inferior rectus or oblique muscle entrapment
    • Internal structures: Iris/pupil:
      • Size, shape, symmetry
      • Reaction to light
    • Swinging flashlight test: Afferent pupillary defect is present if the pupil of the affected eye dilates when exposed to the light source.

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    • Intraocular pressure: Use tonopen; do not use Schiotz tonometer or manual pressure.
    • Funduscopic exam:
      • Red reflex presence or absence
      • Decreased intensity can imply vitreous hemorrhage or large retinal detachment
      • Central retinal artery pulsations
    • Slit-lamp exam:
      • If available: Anterior chamber, cornea, iris, lens
      • If not available, use penlight to look for:
        • Hyphema
        • Obvious laceration
        • Shrunken-appearing globe
Diagnostic Tests & Interpretation
Imaging
  • Plain-film radiographs:
    • Rarely used for diagnosis in orbital trauma
    • High false-negative rate: 50%
    • Nondiagnostic rate 30% (3)[B]
  • If ordered:
    • Waters' view best displays inferior orbital rims, nasoethmoid bones, maxillary sinuses.
    • Teardrop sign represents orbital contents herniated into maxillary sinuses.
    • Air–fluid levels/opacifications of sinuses that may indicate fracture
    • Orbital emphysema: Medial wall blowout fracture
  • CT scan:
    • Reference standard imaging modality
    • Thin-sliced helical CT with coronal reconstructions:
      • Improved image quality
      • Reduced radiation to lens
    • If helical CT scan not available (5)[B]:
      • CT scan with slices of 3 mm or less
      • Axial plane and
      • Coronal plane
      • Only way to assess orbital floor and roof
      • Sagittal reconstruction helpful
    • Sensitivity 79–96%
    • Vegetable or other organic foreign bodies may not be visualized. Increased risk of endophthalmitis
    • May help distinguish between orbital edema and entrapment of extraocular muscles
    • Findings may predict future enophthalmos or diplopia: May play a role in prompting surgery
  • US:
    • Useful when:
      • CT scan impractical
      • Unable to retract eyelids
    • May see periorbital emphysema with orbital fracture
    • Contraindicated if high suspicion of rupture
  • MRI:
    • Limited usefulness in acute stages of ocular trauma
    • Do not perform if metallic intraocular foreign body may be present.
    • Helpful if suspicion of optic nerve injury
    • May identify organic foreign body
Treatment
Not emergent unless:
  • Visual impairment
  • Globe injury
  • Immediate referral to ophthalmology for open globe injury, facial fracture, symptomatic orbital emphysema, orbital compartment syndrome, retrobulbar hemorrhage, and optic neuropathy and to rule out other ophthalmologic injuries
Pre-Hospital
  • Airway, breathing, and circulation (ABCs) first priorities
  • Cervical spine immobilization and neurologic evaluation
  • Control active bleeding with direct pressure.
  • No direct pressure to orbit if open globe is possible or suspected.
  • Cover with a protective shield, and refer to ophthalmologist immediately.
Medication
  • The use of prophylactic antibiotics is controversial.
  • Prudent when fracture communicates with sinus.
  • Nose blowing increases the risk of orbital cellulitis.
Additional Treatment
General Measures
  • Cold packs for at least 48 hr (4)[B]
  • Nasal decongestants
  • Elevate head of bed.
  • Avoid nose blowing.
  • Avoid Valsalva maneuvers such as coughing.
  • Sneeze with mouth open.
  • Tetanus booster if not current
  • Pain control to include acetaminophen, NSAIDs, narcotics, and local anesthetics
  • Avoid aspirin.

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Surgery/Other Procedures
  • Surgical goal (4)[B]:
    • Reconstruct the defect area of the fractured wall
    • Does not attempt to achieve bone healing
  • Strong surgical indications:
    • Diplopia, not improving
    • Enophthalmos >2 mm
    • Fracture >50% of floor
    • Increase in orbital volume >1 cm3
    • Lack of ocular motility
    • Significant hypoglobus
  • Lesser degrees of trauma indications controversial
  • Timing of surgery is controversial.
    • Rarely urgent:
      • Oculocardiac reflex present
      • Ocular motility lesions in children
      • Muscle entrapment in trapdoor fracture
      • Penetrating craniocerebral injuries
      • Concern for optic nerve compression
    • Appropriate timing important for achieving good results:
      • Delay allows for:
        • Orbital swelling resolution
        • Assisting in ensuring accurate diagnosis
        • Strengthens indications for surgery
  • No consensus on best material for repair
Ongoing Care
Return to play:
  • Based on significance of ocular injury and associated findings
  • Fracture only:
    • Noncontact sport: 2 wks
    • Contact sport: 4–6 wks
  • Surgery for fracture:
    • Return will vary.
    • Depends on specific repair required
  • Return to activities with proper eye protection
Patient Education
Return sooner than planned follow-up for:
  • Intense eye pain
  • Change in vision
  • Proptosis
  • Tense globe
References
1. May DR, Kuhn FP, Morris RE, et al. The epidemiology of serious eye injuries from the United States Eye Injury Registry. Graefes Arch Clin Exp Ophthalmol. 2000;238:153–157.
2. Bord SP, Linden J. Trauma to the globe and orbit. Emerg Med Clin North Am. 2008;26:97–123, vi–vii.
3. Petrigliano FA, Williams RJ. Orbital fractures in sport: a review. Sports Med. 2003;33:317–322.
4. Jatla KK, Enzenauer RW. Orbital fractures: a review of current literature. Curr Surg. 2004;61:25–29.
5. Go JL, Vu VN, Lee KJ, et al. Orbital trauma. Neuroimaging Clin N Am. 2002;12:311–324.
Additional Reading
Kontio R, Lindqvist C. Management of orbital fractures. Oral Maxillofac Surg Clin North Am. 2009;21:209–220, vi.
Codes
ICD9
  • 801.00 801.50 Open fracture of base of skull without mention of intracranial injury, with state of consciousness unspecified
  • 802.6 Closed fracture of orbital floor (blow-out)
  • 802.7 Open fracture of orbital floor (blow-out)
  • 802.8 Closed fracture of other facial bones
Clinical Pearls
  • Significant changes in visual acuity or vision loss: Possible optic nerve compromise:
    • Ophthalmic emergency
    • Immediate ophthalmology consultation
  • Significant other exam abnormality: Immediate ophthalmology consultation
  • All other abnormalities: Ophthalmology consultation within 48 hr
  • To diagnose orbital fracture, helical CT scan with coronal reconstructions or CT scan with 3-mm or smaller slices in both axial and coronal planes to assess orbit floor and roof is essential.
  • Most orbital fractures will resolve without significant visual sequelae or need for surgical intervention.
  • Pitfalls: Failure to diagnose orbital fracture and/or associated intracranial or cervical spine injuries


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