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Floor Orbital Fracture Clinical Presentation

  • Author: Geoffrey M Kwitko, MD, FACS, FICS; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Jun 28, 2016
 

History

Patients may relay a history of the eye being struck by an object larger than the diameter of the orbital entrance. Fists, balls, or car dashboards are examples.

Patients may have no complaints. However, they may complain of vision loss or diplopia. The double vision is often vertical and worse with attempted up or downgaze.

Numbness (hypoesthesia) of the cheek and gum on the affected side may be present. Ecchymoses, ptosis (droopiness of the eyelid), and swelling around the eye may be noted.

The examiner should obtain a past ocular history to assess whether any loss of vision or diplopia is due to the present accident or was established prior to this incident.

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Physical

A complete ocular evaluation is essential to ensure that no injury to the globe or optic nerve has occurred.

Visual acuity and pupils should be evaluated to ensure that no loss of vision or traumatic optic neuropathy has occurred.[5]

The examiner should evaluate extraocular movements and document any restriction or palsy.

A complete slit lamp evaluation and measurement of intraocular pressures should be performed.

Most posterior segment injuries can be ruled out with a dilated funduscopic examination.

The physical findings may involve only periorbital edema and ecchymosis; however, more severe cases may demonstrate limited vertical movement, enophthalmos, ptosis, and possibly proptosis.

Unusually severe orbital edema may be associated with more severe fractures and can cause proptosis. Once the edema has subsided (usually 1-2 wk), enophthalmos may be present.

Limited vertical movement may be due to entrapment of the perimuscular fascia of the inferior rectus in the fracture site. However, traumatic palsy of the third nerve branch to the inferior rectus also may cause decreased extraocular movements. If a question exists, forced duction testing may differentiate between the two conditions.

Hertel exophthalmometry may demonstrate either proptosis or enophthalmos and should be documented.

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Causes

In a study of orbital fractures in an urban population, 70% of the fractures were due to assault with a blunt object (eg, fist, baseball bat), and 13% occurred due to a motor vehicle accident, usually involving striking the dashboard. Falls accounted for 10%, and gunshot wounds contributed to 6% of orbital floor fractures.

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Contributor Information and Disclosures
Author

Geoffrey M Kwitko, MD, FACS, FICS Clinical Associate Professor, Department of Ophthalmology, University of South Florida College of Medicine

Geoffrey M Kwitko, MD, FACS, FICS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, International College of Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Ron W Pelton, MD, PhD Private Practice, Colorado Springs, Colorado

Ron W Pelton, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, AO Foundation, American Society of Ophthalmic Plastic and Reconstructive Surgery, Colorado Medical Society

Disclosure: Nothing to disclose.

References
  1. Della Rocca RC, Nassif JM. Blowout fractures. Linberg JV, ed. Oculoplastic and Orbital Emergencies. Appleton & Lange; 1990. 155-165.

  2. Green RP Jr, Peters DR, Shore JW, et al. Force necessary to fracture the orbital floor. Ophthal Plast Reconstr Surg. 1990. 6(3):211-7. [Medline].

  3. Kersten RC. Blowout fracture of the orbital floor with entrapment caused by isolated trauma to the orbital rim. Am J Ophthalmol. 1987 Feb 15. 103(2):215-20. [Medline].

  4. Bansagi ZC, Meyer DR. Internal orbital fractures in the pediatric age group: characterization and management. Ophthalmology. 2000 May. 107(5):829-36. [Medline].

  5. Rubin PAD, Bilyk JR, Shore JW. Management of orbital trauma: fractures, hemorrhage, and traumatic optic neuropathy. Focal Points: Clinical Modules for Ophthalmologists. 1994. 12:7.

  6. Gilbard SM, Mafee MF, Lagouros PA, et al. Orbital blowout fractures. The prognostic significance of computed tomography. Ophthalmology. 1985 Nov. 92(11):1523-8. [Medline].

  7. Tan Baser N, Bulutoglu R, Celebi NU, Aslan G. Clinical management and reconstruction of isolated orbital floor fractures: The role of computed tomography during preoperative evaluation. Ulus Travma Acil Cerrahi Derg. 2011 Nov. 17(6):545-53. [Medline].

  8. Smith B, Regan WF. Blow-out fractures of the orbit: mechanism and correction of internal orbital fracture. Am J Ophthalmol. 1957. 44:733.

  9. Piombino P, Iaconetta G, Ciccarelli R, Romeo A, Spinzia A, Califano L. Repair of orbital floor fractures: our experience and new technical findings. Craniomaxillofac Trauma Reconstr. 2010 Dec. 3(4):217-22. [Medline]. [Full Text].

  10. Jordan DR, Allen LH, White J, et al. Intervention within days for some orbital floor fractures: the white-eyed blowout. Ophthal Plast Reconstr Surg. 1998 Nov. 14(6):379-90. [Medline].

  11. Egbert JE, May K, Kersten RC, et al. Pediatric orbital floor fracture : direct extraocular muscle involvement. Ophthalmology. 2000 Oct. 107(10):1875-9. [Medline].

  12. Magaña FG, Arzac RM, De Hilario Avilés L. Combined use of titanium mesh and resorbable PLLA-PGA implant in the treatment of large orbital floor fractures. J Craniofac Surg. 2011 Nov. 22(6):1991-5. [Medline].

 
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Coronal CT scan of orbits demonstrating loss of orbital floor on the left in contrast to the normal orbital floor on the right.
 
 
 
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