Orbital Fractures

A significant number of patients with trauma to the face are found to have fractures, including orbital fractures.  The term orbital “blow-out” fracture makes it seem very dramatic but one should know when this type of injury requires immediate intervention.

 

A blow-out fracture happens when an object of small diameter hits the globe without causing an orbital ridge fracture – the force transmitted causes a fracture of the inferior or medial orbital walls. Lateral, inferior, and superior orbital ridge fractures typically occur with other facial fractures.  Adipose tissue, inferior rectus muscle, or inferior oblique can herniated through the fracture and become entrapped within the maxillary or ethmoid sinus. Findings such as fluid in the maxillary sinus, herniated fat or muscle, and delayed enophthalmos occur with orbital floor fractures.

 

On exam, patients can have enophthalmos which occurs with herniation of globe contents before significant edema.  The entire orbital rim should be palpated to detect step-offs or crepitus.  Infraorbital anesthesia often occurs with an orbital floor fracture.  If there is entrapment of the inferior rectus, inferior oblique, or orbital fat, or injury of the muscles or oculomotor nerve, patients will have diplopia on upward gaze.  Naso-orbito-ethmoid fractures cause pain on eye movement, traumatic telecanthus, epiphora (tears spilling over the lower lid) and CSF leak.

 

An isolated orbital fracture requires treatment with oral augmentin to treat sinus pathogens, decongestants, and instructions to avoid nose blowing until repair.  There is controversy over operative repair timing and indications.  Repair may be delayed 1-2 weeks in adults, however children require a shorter time for follow up and repair.  Naso-orbito-ethmoid fractures require admission for consultation with facial surgery and neurosurgery.  Emergent ophtho consultation is required for an associated ocular injury.  Retrobulbar hematoma or malignant orbital emphysema may cause ocular compartment syndrome.  This results in an acute ischemic optic neuropathy.  Exam findings include exophthalmos, decreased visual acuity, and increased intraocular pressure.  To reduce ocular pressure and ischemia, you can perform an emergent lateral canthotomy.

 

To perform a lateral canthotomy, the patient’s head and lids should be stabilized.  Anesthetize the lateral canthus by injection 1-2% lidocaine with epinephrine.  Before incision, crush the lateral canthus with a small hemostat for 1-2 minutes.  This is to minimize bleeding.  Incis the canthus – begin the incision at the lateral canthus and extend it toward the orbital rim.  Find the superior and inferior crus of the lateral canthal tendon and release them from the orbital rim.  The inferior crus truly needs to be released initially – that may be done first with a subsequent reassessment of intraocular pressure.  If IOP is not reduced, then the superior crus may be released. 

 

 

References:

Up to date – Orbital fractures

Tintinalli – Ch 256 Trauma to the face, Ch 236 Eye emergencies

Clinical procedures in emergency medicine – Lateral canthotomy

 

Thanks to Dr Jacqui Khorasanee for this post.