Medial Wall Orbital Fracture Workup

  • Author: Aftab Zafar, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Aug 4, 2010
 

Imaging Studies

  • Radiographic evaluation of suspected medial wall fractures has evolved over the past several years. Conventional radiography or routine orbital x-rays generally are not helpful because of the compact overlapping anatomy of this region and the thinness of the medial orbital wall. Nonetheless, x-ray signs to look for include a disruption in the medial orbital wall, opacification of the ethmoid sinus, and presence of air in the orbit.
  • CT scan has greatly improved the evaluation of orbital fractures, and it should be completed in all patients suspected of having medial wall fractures. Optimal information can be gained from both axial and coronal cuts of bone and soft tissue images (see the images below). With these appropriate views, the size, morphology, and exact seat of the fracture, which has the possibility to extend to the optic canal, can be visualized. Coronal CT scan of the orbits of a patient with anCoronal CT scan of the orbits of a patient with an injury to his right orbit as a result of blunt trauma from a fist reveals a right medial orbital wall fracture with the medial rectus entrapped. Axial CT section. Axial CT section.
  • CT scan accurately localizes the bone fragments of the fractured lamina papyracea even if the orbital sinus adjacent to the fracture is opacified. A variable degree of medial displacement of the thin lamina papyracea may be present, and density is often increased in the ethmoidal sinuses from edema and blood accumulation. CT scan also detects entrapment of the medial rectus muscle, recognized by displacement of the muscle into the fracture site, with or without bone displacement. In the pediatric trapdoor fractures described earlier, clinical evidence of entrapment will not necessarily correlate with the CT scan findings. In these cases, in which a trapdoor-type defect has occurred, there will be minimal or no evidence of bone displacement. In addition, the medial rectus could appear in a normal position, but the surrounding connective tissue is seen entrapped in the location of the fracture.
  • A CT scan reliably demonstrates whether acute proptosis in a patient is secondary to orbital hemorrhage or orbital emphysema. Echography also could aid in distinguishing these 2 distinct entities. B-scan ultrasound has proven to be reliable in diagnosing medial wall fractures because a good correlation between ultrasound and CT scan was found. However, edema, hemorrhage, emphysema, and swelling may influence the accuracy of the scan.
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Diagnostic Procedures

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Contributor Information and Disclosures
Author

Aftab Zafar, MD  Consulting Staff, Department of Ophthalmology, St Mary's General Hospital

Aftab Zafar, MD is a member of the following medical societies: Canadian Medical Association, Canadian Ophthalmological Society, College of Physicians and Surgeons of Ontario, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Coauthor(s)

Robert B Penne  MD, Director, Department of Ophthalmic Plastic Surgery, Wills Eye Institute, Philadelphia

Robert B Penne is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, and Philadelphia County Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

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, American Society of Ophthalmic Plastic and Reconstructive Surgery, AO Foundation, and Colorado Medical Society

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

Mark T Duffy, MD, PhD  Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic

Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience

Disclosure: Allergan - Botox Cosmetic Honoraria Speaking and teaching

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

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, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

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This 55-year-old man sustained an injury to his right orbit as a result of blunt trauma from a fist; shown in primary position.
Patient with an injury to his right orbit as a result of blunt trauma from a fist in right gaze, showing full abduction of the right eye.
Patient with an injury to his right orbit as a result of blunt trauma from a fist in left gaze, showing poor adduction of the right eye.
Coronal CT scan of the orbits of a patient with an injury to his right orbit as a result of blunt trauma from a fist reveals a right medial orbital wall fracture with the medial rectus entrapped.
Axial CT section.
 
 
 
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