Orbital fractures are traumatic injuries usually caused by assault, sports, or accidents.
A careful assessment of the orbit injury may include examination of the facial bones, eyelids, and surrounding soft tissue; inspection of the globe; and visual acuity.
A definitive diagnosis is confirmed by computed tomography scan of the orbit.
Urgent surgery is indicated in paediatric patients with signs of soft tissue (muscle) entrapment; namely upgaze limitation and the oculovagal response (presence of vagal stimulation by pressure to intraorbital structures, which results in bradycardia, hypotension, and nausea and/or vomiting). Surgery is delayed in most adult cases to allow oedema and haemorrhage to resolve. In small, non-blow-out fractures, conservative treatment may be considered.
The use of goggles or safety glasses in contact sports is recommended to prevent orbital fractures and associated injuries.
The orbit is one of a pair of bony cavities each housing the globe and associated structures. The orbit is formed by 7 bones: zygomatic, sphenoid, maxillary, frontal, lacrimal, palatine, and ethmoid.
Fractures of the orbit may be seen in different scenarios of direct and indirect trauma to the globe, orbital, facial, or cranial bones. The most common presentation of orbital fractures is associated with zygomatic complex fractures (i.e., involving the cheek bone and thus the lateral orbital wall). The most common intraorbital fracture is the medial wall 'blow-out' fracture.
History and exam
Key diagnostic factors
- diplopia on upward gaze
- derangement of globe position
- intercanthal distance increased
- oculovagal symptoms (bradycardia, hypotension, nausea/vomiting)
Other diagnostic factors
- visual disturbance
- peri-orbital ecchymosis
- peri-orbital oedema
- nerve sensory loss
- subconjunctival haemorrhage
- step defect infra-orbital rim
- loss of colour vision
- impaired pupillary light reflex
- decreased visual acuity
- young adults and children
- male sex
1st investigations to order
- x-ray of the face
- CT scan of the orbit
Investigations to consider
- MRI of the orbit
- forced duction test
- orthoptic test
- ultrasonographic orbital scanning
urgent eye morbidity
no urgent eye morbidity
Alistair R.M. Cobb, MBBS, BDS, FRCS (OMFS), FDSRCS (Eng), MFSEM (UK)
Consultant Oral and Maxillofacial Surgeon
South West Cleft Service
United Hospitals Bristol NHS Trust
ARMC is an author of a number of references cited in this topic.
Mr Alistair Cobb would like to gratefully acknowledge Mr Timothy Lloyd, a previous contributor to this topic.
TL declares that he has no competing interests.
Andrew Parfitt, MBBS, FFAEM
Associate Medical Director
Consultant Emergency Medicine
Guy's and St Thomas' NHS Foundation Trust
Clinical Lead and Consultant
Accident Emergency Medicine
St Thomas' Hospital
AP declares that he has no competing interests.
Mark I. Neuman, MD
Assistant Professor of Pediatrics
Children's Hospital Boston
Harvard Medical School
MIN declares that he has no competing interests.
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