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Orbital fractures

Orbital fractures
Literature review current through: Sep 2023.
This topic last updated: Feb 28, 2022.

INTRODUCTION — This topic will review the evaluation and management of patients with orbital fractures, mechanisms of injury to the orbit, fracture types, and associated injuries.

Other facial fractures in adults and children are discussed separately:

(See "Initial evaluation and management of facial trauma in adults".)

(See "Nasal trauma and fractures in children and adolescents".)

(See "Mandibular (jaw) fractures in children".)

EPIDEMIOLOGY — Orbital fractures occur more commonly among young adult and adolescent males [1,2]. Among adults with orbital fractures, the most frequent mechanisms of injury are assaults and motor vehicle collisions [1,3]. For children, falls, being struck by a ball, motor vehicle collisions, and assaults are the most common mechanisms of injury [4,5].

The low prevalence of orbital fractures among younger children may be related to the following factors [6]:

The face of a child is relatively small compared with the head, and thus, most fractures in young children tend to involve the upper face and skull.

In children, the proportion of cancellous to cortical bone is greater, providing more elasticity to the facial bones. In addition, sinus cavities are poorly developed. However, pneumatization of the frontal sinus may actually be protective for adults with injury to the superior orbital rim. (See 'Orbital roof fracture' below.)

A prominent buccal fat pad affords some protection to the malar region of the face.

Children are less likely to be exposed to occupational trauma, assaults, and major trauma associated with motor vehicle crashes.

Orbital fractures are often the result of significant trauma and are frequently associated with other serious injuries, especially:

Intracranial injury – Serious intracranial injury (eg, frontal cerebral contusion, epidural hematoma, subdural hematoma, and subarachnoid hemorrhage) is a frequent component of orbital roof fractures [1,7,8].

Intraocular injury – Injury to the globe (such as ruptured globe, hyphema, or injury to the retina) is commonly associated with an orbital fracture (29 to 50 percent of patients, depending upon the setting) [2,9-11]. (See "Approach to diagnosis and initial treatment of eye injuries in the emergency department" and "Overview of eye injuries in the emergency department".)

ANATOMY

Normal anatomy — The orbit is formed primarily by five bones of the skull (table 1 and figure 1). Other nearby structures that must be considered when evaluating a patient with an orbital fracture include the following (figure 2):

Extraocular muscles

Sinuses

Medial and lateral canthal (palpebral) ligaments (which maintain the shape of the palpebral fissure)

Lacrimal duct system

Infraorbital and supraorbital nerves

The thick frontal bone forms the superior orbital rim and the roof of the orbit. The frontal sinus is adjacent to the superior medial portion of the roof of the orbit. The supraorbital nerve runs through the supraorbital notch, which is located at the junction of the medial and middle thirds of the superior orbital rim.

The greater wing of the sphenoid bone and the zygoma (which is relatively thick) form the lateral wall of the orbit. The lateral canthal ligament attaches to the zygoma.

The zygoma and the thin maxillary bone comprise the infraorbital rim and the floor of the orbit. The inferior oblique and inferior rectus muscles lie above the floor of the orbit. The maxillary sinus is beneath the orbital floor. The infraorbital nerve travels in a groove in the maxillary bone, further weakening it.

The maxillary and ethmoid bones form the medial wall of the orbit. The medial rectus muscle is adjacent to the medial wall, which overlies the ethmoid sinus. The medial canthal ligament attaches to the maxillary bone. The lacrimal duct system overlies the maxillary bone beneath the medial canthal ligament.

Three pairs of extraocular muscles move each eye in three directions: vertically (superior and inferior), horizontally (medial and lateral), and torsionally (intorsion when the eye rotates toward the patient's nose and extorsion when the eye rotates toward the patient's shoulder) (table 2 and figure 3 and figure 4). (See "Overview of diplopia", section on 'Neuroanatomy'.)

Fracture types — Fractures of the orbit may involve one or more of the walls of the orbit, the orbital rim, or both [1]. Factors that influence the location and extent of the fracture include the mechanism of injury and the age of the patient. Injury to adjacent structures can also occur.

Orbital zygomatic fracture — The orbital zygomatic region is the most common location of a fracture of the orbital rim. This injury is typically the result of a high-impact blow to the lateral orbit. There is often an associated fracture of the orbital floor (image 1) [1].

Nasoethmoid fracture — Fractures in the nasoethmoidal region of the medial orbital rim are also common (image 2). In a retrospective series of adult patients, 32 percent of fractures occurred in this area [1]. Fracture of the maxillary bone in this portion of the orbital rim can result in disruption of the medial canthal ligament and the lacrimal duct system. In addition, the medial rectus muscle may become trapped in fractures of the medial wall of the orbit [12].

Orbital floor fracture — Fractures of the floor of the orbit, sometimes known as "blowout fractures," typically occur when a small, round object (eg, a baseball) strikes the eye. In one study, half of all orbital fractures involved the inferior wall or floor of the orbit [4]. Evidence suggests that orbital floor fractures may be caused by one or both of the following mechanisms [13]:

Increased intraocular pressure as the result of posterior displacement of the globe (hydraulic theory)

A direct blow to the infraorbital rim

In children, the floor of the orbit is more flexible. Consequently, it may fracture in a linear pattern, creating a bone fragment that snaps back to create a "trap-door" fracture. In adults, the floor of the orbit is thinner and more likely to shatter when exposed to force [14].

A significant consequence of fractures of the orbital floor is entrapment of the inferior rectus muscle and/or orbital fat (image 3). Ischemia and subsequent loss of muscle function may occur either because of entrapment of muscle within the fracture fragment (more likely in children) or as the result of edema and hemorrhage of muscle and extraocular fat that have prolapsed through the fracture into the maxillary sinus (more likely in adults) [3,14-16].

Enophthalmos (the eye is receded into the orbit (picture 1)) may develop when the globe is displaced posteriorly in association with an orbital floor fracture and prolapse of tissue into the maxillary sinus. Orbital dystopia (the eye on the affected side is lower in the horizontal plane than the other) may occur because entrapped muscle and orbital fat pull the eye downward.

Injury to the infraorbital nerve (resulting in decreased sensation along the cheek, upper lip, or upper gingiva) may occur as the result of an orbital floor fracture.

Orbital roof fracture — Orbital roof fractures are more common in younger patients (less than 10 years) [7,8]. This phenomenon is probably related to the high cranium-to-midface ratio of young children as compared with adults (thus exposing a larger upper surface for injury). In addition, pneumatization of the frontal sinus helps the adult skull dissipate energy from forces to the superior orbital rim. As expected, orbital roof fractures have a high association with intracranial injury. In addition, ocular injury (eg, orbital compartment syndrome, lid lacerations, optic neuropathy, and/or corneal abrasions) may occur in up to one-third of patients [17].

INITIAL STABILIZATION — The first priority in the evaluation of patients who may have orbital fractures is to identify life-threatening and/or serious associated injuries (see "Trauma management: Approach to the unstable child", section on 'Initial approach' and "Trauma management: Approach to the unstable child", section on 'Primary survey'). Patients with a possible injury to the cervical spine should undergo spine motion restriction. (See "Pediatric cervical spinal motion restriction".)

Once the patient's condition has been stabilized, careful evaluation of the orbital injury may proceed. Injuries that threaten vision must be urgently identified and treated [18]:

Ruptured globe (table 3) (see "Open globe injuries: Emergency evaluation and initial management")

Orbital hematoma (see "Overview of eye injuries in the emergency department", section on 'Orbital compartment syndrome')

Optic nerve sheath hematoma (see "Overview of eye injuries in the emergency department", section on 'Optic nerve injury')

Retinal detachment (see "Overview of eye injuries in the emergency department", section on 'Retinal trauma')

Hyphema (table 4) (see "Traumatic hyphema: Clinical features and diagnosis")

Common signs and symptoms of orbital fracture include bony tenderness and swelling, periocular ecchymosis, diplopia, decreased sensation in the distribution of the infraorbital or supraorbital nerves, and/or orbital emphysema. (See 'Evaluation' below.)

Other injuries related to the fracture must also be identified. These include the following:

Entrapment of extraocular muscle

Fracture into a sinus

Injury to the medial canthal ligament

Injury to the lacrimal duct system

EVALUATION

History — Specific information regarding when the injury occurred, area of the face that was injured, and mechanism of injury should be obtained. Key questions for patients who are alert and verbal include the following:

Where does it hurt?

Do you have blurry, double, or decreased vision?

Do you have difficulty with eye movement or double vision in a specific direction?

Do you have numbness of a particular region of your face?

Diffuse pain occurs with an orbital hematoma, whereas pain with eye movement suggests injury involving extraocular muscles. Any change in vision could indicate a serious intraocular injury. Diplopia, particularly with upward gaze, and numbness below the eye may occur with fractures of the orbital floor [19-21]. Numbness of the forehead suggests damage to the supraorbital nerve as the result of injury to the superior orbital rim or roof of the orbit.

Nausea and vomiting are common following eye injury. In addition, entrapment of extraocular muscles can stimulate the oculocardiac reflex, producing bradycardia as well as nausea and vomiting [4,22,23].

Physical examination — Once the patient has been evaluated for life-threatening injuries, a focused examination of the facial bones, soft tissues surrounding the eye, and the eye itself should be performed. The eye should be examined with visual acuity performed as quickly as possible because soft tissue swelling may make it difficult for the patient to open their eyes or for the clinician to separate the eyelids at a later time. Care should be taken not to put pressure on the eye, which, in the presence of a globe rupture, could cause extrusion of intraocular contents.

Examination of the eyelids and surrounding soft tissue may demonstrate crepitus, indicating orbital emphysema as the result of fracture into a sinus. Injury to the lacrimal ducts can occur as the result of lacerations or soft tissue injury along the medial canthus. Decreased sensation indicates injury to the supraorbital nerve (forehead) or infraorbital nerve (cheek) [24].

Pupillary reactivity, size, and shape, as well as extraocular movements and visual acuity should be evaluated. Funduscopic examination may identify vitreous hemorrhage or retinal injury. Finally, a slit-lamp examination should be performed whenever possible. Injuries that may be identified with the slit-lamp include hyphema, iritis, lens dislocation, and ruptured globe.

The following features are indications of significant eye injury (see "Approach to diagnosis and initial treatment of eye injuries in the emergency department"):

Proptosis (orbital hematoma) (picture 2 and figure 5)

Extrusion of intraocular contents, severe conjunctival hemorrhage, and/or a tear-shaped pupil (ruptured globe (picture 3))

Afferent pupillary defect

Signs of orbital compartment syndrome (eg, "rock hard" eyelids and decreased retropulsion [resistance to attempts to push the eye deeper into the orbit, sometimes referred to as a "tight orbit"])

Widened intercanthal distance (disruption of the medial canthal ligament)

Limited or painful extraocular motility (picture 4)

Orbital dystopia and/or enophthalmos (orbital floor fracture (picture 1))

During palpation of the face, deformity involving any of the facial bones should be noted (figure 6). Tenderness, crepitus, and/or step-off on palpation of the malar eminences, zygomatic arches, or orbital rims may indicate an underlying fracture.

Imaging — Computed tomography (CT) should be performed for a patient with periorbital trauma and any of the following findings:

Evidence of a fracture on physical examination

Limitation of extraocular movement

Decreased visual acuity

Severe pain

Inadequate examination (usually because of soft tissue swelling), particularly in patients with altered mental status

Thin-cut (1-millimeter slices) coronal CT of the orbit is the imaging modality of choice to diagnose orbital fractures (image 3 and image 4) [25]. In addition, CT may distinguish orbital edema from entrapped extraocular muscle for patients with diplopia and/or limitation of eye movement. Three-dimensional reconstruction may enhance the sensitivity of CT for the identification of certain types of orbital fractures and can help to guide operative intervention when indicated [26-28].

The sensitivity of plain radiographs for detecting orbital fractures is poor (about 50 percent) [29]. In addition, plain radiographs are often difficult to interpret and are inadequate to determine whether or not a patient requires operative intervention. They may be useful as a screening tool when CT is unavailable or for children with a minor mechanism of injury who would require sedation for CT. Clouding of the maxillary sinus indicates the possibility of blood or orbital fat in the sinus as the result of an orbital floor fracture.

DIAGNOSIS — The clinician should suspect an orbital fracture in any patient with facial trauma and any one of the following findings (see 'History' above and 'Physical examination' above):

Focal pain, swelling, or step-off on palpation of the bony prominences of the malar eminence, zygomatic arch, or orbital rim

Crepitus suggesting fracture into a sinus

Numbness of the forehead (supraorbital nerve damage with superior orbital roof or rim fracture)

Numbness below the eye (infraorbital nerve damage with orbital floor fracture)

Increased intercanthal distance

Findings of secondary eye injury such as decreased visual acuity, diplopia or pain on eye motion, proptosis, orbital dystopia, or enophthalmos

The diagnosis is confirmed by orbital fracture detected on thin-cut (1-millimeter slices) coronal computed tomography (CT) of the orbit. (See 'Imaging' above.)

INITIAL MANAGEMENT

Approach — The initial priority for the management of patients with orbital fracture is to identify and treat life-threatening conditions. (See 'Initial stabilization' above.)

Orbital fractures do not always require operative repair. However, bony disruption can cause orbital hematoma, cerebrospinal fluid leaks, and abnormal positioning of the eye such as [30]:

Enophthalmos (posterior eye displacement)

Hypophthalmos (inferior eye displacement)

Telecanthus (increased distance between the medial canthi of the eyes)

Epiphora (overflowing of tears)

When indicated, the timing of operation and method of repair is determined by findings on thin-cut computed tomography (CT) of the orbit and the presence of eye injury or dysfunction.

Specialty consultation — An ophthalmologist should be consulted during the initial evaluation for any patient with the following findings:

Decreased visual acuity.

Widened intercanthal distance (disruption of medial canthal ligament).

Evidence of orbital compartment syndrome – Patients with orbital hematomas warrant emergency lateral canthotomy to decompress the orbit. This procedure should not be delayed by diagnostic imaging. When an ophthalmologist is not immediately available, the procedure should be performed by the physician most experienced with eye injuries who is caring for the patient. (See "Approach to diagnosis and initial treatment of eye injuries in the emergency department", section on 'Orbital compartment syndrome'.)

Open globe – Emergency management of these injuries includes protection of the globe, elevation of the head, intravenous fluids as indicated for nausea and vomiting, and pain control. (See "Open globe injuries: Emergency evaluation and initial management".)

Severe vagal symptoms (nausea, vomiting, bradycardia) associated with extraocular muscle entrapment – Severe vagal symptoms, in the absence of intracranial injury, may be caused by the oculocardiac reflex associated with extraocular muscle entrapment. These debilitating symptoms are usually relieved with release of the muscle and thus warrant surgery [23,31]. Preoperatively, ondansetron may be used for nausea and vomiting and atropine for symptomatic bradycardia [32].

Discharge instructions and follow-up — For patients not requiring emergency specialty evaluation, follow-up with a specialist (generally an ophthalmologist or plastic surgeon) should be ensured within 24 hours for patients with the following injuries [33]:

Muscle entrapment as the result of orbital floor or medial wall fractures (picture 4) [12,18,34-37]

Enophthalmos or orbital dystopia that results in significant facial asymmetry [25]

Naso-orbital-ethmoid fractures with injury to the medial canthal ligament and/or lacrimal apparatus [38]

Phone consultation with the specialist prior to discharge from the emergency department can help facilitate this close follow-up and to determine the use of any medical therapy.

General instructions for these patients include:

Apply intermittent cold therapy over the injury site for the first 48 hours to reduce swelling.

Sleep with the head of the bed elevated

Avoid nose blowing and sniffing.

Therapies of uncertain benefit — Therapies of uncertain benefit for discharged patients include:

Corticosteroids – Corticosteroids have been used to decrease swelling in patients with limitation of extraocular movement caused by orbital blowout fractures [14,39]. As an example, in one small trial of 38 patients with blowout fractures, corticosteroids resulted in more rapid resolution of diplopia (median 5 versus 13 days) [40]. However, the results of this small study may be due to chance, and many experts do not routinely use corticosteroids for this indication.

Prophylactic oral antibiotics – Prophylactic oral antibiotics to cover sinus pathogens for patients with closed, nonoperative orbital fractures into a sinus have often been provided in the past although evidence for benefit was limited [14,39,41,42]. More recent evidence from small observational studies suggest that the risk of infection in adult patients with this injury is low and that antibiotic prophylaxis is not necessary although it may be reasonable for patients with recent sinusitis, immunocompromise, or uncertain follow-up [43-45]. If antibiotics are prescribed, suggested regimens are the same as for patients with sinusitis (table 5 and algorithm 1). (See "Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment" and "Acute bacterial rhinosinusitis in children: Microbiology and management".)

OUTCOMES — Patients with severe fractures, particularly in the zygomatic-maxillary or nasal-ethmoid regions, often have significant disruption of the orbit, with injury to associated structures [1]. Surgical repair is typically complex, and residual visual and cosmetic defects may occur.

Based upon limited evidence from observational studies, earlier operative repair for patients with ocular entrapment or persistent diplopia is associated with better ocular motility. In a meta-analysis of five retrospective observational studies (442 patients, including children), there was a significantly increased risk of persistent diplopia in patients undergoing surgical repair longer than 14 days after injury [46]. In a subsequent retrospective observational study of 197 patients (7O younger than 18 years of age), operative repair of orbital floor fractures with entrapment within eight days was associated with significantly improved postoperative ocular motility compared with later repair [47].

Substantial morbidity from vision loss may occur following even mild to moderate blunt eye trauma [9]. Loss of vision can occur either as a result of direct ocular injury (such as with retinal detachment) or vascular compromise to the optic nerve (as may occur in association with an orbital or optic nerve sheath hematoma). (See "Overview of eye injuries in the emergency department".)

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

(See "General principles of fracture management: Bone healing and fracture description".)

(See "General principles of fracture management: Fracture patterns and description in children".)

(See "General principles of definitive fracture management".)

(See "General principles of acute fracture management".)

(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General management of pediatric fractures" and "Society guideline links: Upper extremity, thoracic, and facial fractures in children" and "Society guideline links: Fractures of the skull, face, and upper extremity in adults" and "Society guideline links: Acute pain management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Facial fractures (The Basics)" and "Patient education: Black eye (The Basics)")

SUMMARY AND RECOMMENDATIONS

Epidemiology – Orbital fractures occur most commonly in adolescent and young adult males. Mechanisms of injury include motor vehicle collisions, assaults, and sports-related injuries. Because of the significant amount of force involved with these mechanisms, associated intracranial and intraocular injuries frequently occur (figure 1 and figure 2). (See 'Epidemiology' above and 'Anatomy' above.)

Initial stabilization – Identification of life-threatening and/or serious associated injuries is the first priority in the evaluation of patients who may have orbital fractures. Patients with a possible injury to the cervical spine should undergo spine motion restriction. Once the patient's condition has been stabilized, careful evaluation of the orbital injury may proceed. Injuries that threaten vision must be urgently identified and treated, including (see 'Initial stabilization' above):

Ruptured globe (table 3) (see "Open globe injuries: Emergency evaluation and initial management")

Orbital compartment syndrome (see "Overview of eye injuries in the emergency department", section on 'Orbital compartment syndrome')

Optic nerve sheath hematoma (see "Overview of eye injuries in the emergency department", section on 'Optic nerve injury')

Retinal detachment (see "Overview of eye injuries in the emergency department", section on 'Retinal trauma')

Hyphema (table 4) (see "Traumatic hyphema: Clinical features and diagnosis")

Evaluation

History – History should identify the location of pain, presence of visual disturbance (decreased vision, diplopia, or blurry vision), and whether it is associated with limitation of eye movement or facial numbness. Diplopia, particularly with upward gaze, and numbness below the eye may occur with fractures of the orbital floor. (See 'History' above.)

Physical examination – The clinician should perform visual acuity as soon as possible because subsequent soft tissue swelling may make it difficult for the patient to open their eyes and require lid retraction. During examination, pressure on the eye should be avoided.

Patients with suspected orbital fractures require sequential face examinations (figure 6) and eye examinations. The following features are indications of significant eye injury (see 'Physical examination' above and "Approach to diagnosis and initial treatment of eye injuries in the emergency department"):

-Proptosis: finding of orbital hematoma (picture 2 and figure 5)

-Extrusion of intraocular contents, severe conjunctival hemorrhage, and/or a tear-shaped pupil: findings of ruptured globe (picture 3)

-Afferent pupillary defect: suggests serious eye injury

-Tight "rock hard" eyelids and decreased retropulsion (resistance to attempts to push the eye deeper into the orbit sometimes referred to as a "tight orbit"): findings of orbital compartment syndrome

-Widened intercanthal distance: finding of disruption of the medial canthal ligament

-Limited or painful extraocular motility (picture 4): suggests one or more serious orbital injuries

-Orbital dystopia (loss of horizontal alignment of the eyes) and/or enophthalmos (eye receding into the orbit): findings of orbital floor fracture (picture 1)

Diagnosis – The working diagnosis of orbital fracture is made based on clinical findings and is confirmed by orbital computed tomography (CT). Thin-cut (1-millimeter slices) coronal CT of the orbit should be performed for a patient with periorbital trauma and any of the following findings (see 'Imaging' above and 'Diagnosis' above):

Evidence of a fracture on physical examination

Limitation of extraocular movement

Decreased visual acuity

Severe pain

Inadequate examination (usually because of soft tissue swelling), particularly in patients with altered mental status

Three-dimensional reconstruction may enhance the sensitivity of orbital CT for the identification of certain types of fractures and can help to guide operative intervention when fractures are identified.

Specialty consultation – An ophthalmologist should be consulted promptly for any patient with the following findings (see 'Specialty consultation' above):

Decreased visual acuity

Widened intercanthal distance (disruption of medial canthal ligament)

Evidence of orbital compartment syndrome

Open globe

Severe vagal symptoms (nausea, vomiting, bradycardia) associated with extraocular muscle entrapment

A specialist (typically an ophthalmologist or plastic surgeon) should be consulted to arrange for follow-up within 24 hours for patients with these injuries:

Muscle entrapment as the result of orbital floor or medial wall fractures (picture 4)

Enophthalmos or orbital dystopia that results in significant facial asymmetry

Naso-orbital-ethmoid fractures with injury to the medial canthal ligament and/or lacrimal apparatus

For most patients with nonoperative, closed fractures, we suggest not prescribing prophylactic antibiotics (Grade 2C). However, prophylactic antibiotics may be reasonable in patients with immunocompromise, recent sinusitis, or uncertain follow-up. (See 'Therapies of uncertain benefit' above.)

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Topic 6546 Version 33.0

References

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