Orbital Fracture in Emergency Medicine Clinical Presentation

Because orbital fractures are the result of trauma, primary survey and attention to ABCs take priority. Focus questions on patency of airway, control of cervical spine, breathing difficulties, and symptoms of shock or neurologic impairment such as loss of consciousness.

Once life threats have been addressed, obtain a thorough (AMPLE) history.

• Allergies
• Medications
• Past medical history
• Last meal
• Events leading to injury

Question patient about injury.

• Does patient have epistaxis or clear fluid running from nares or ears?
• Did patient lose consciousness? If so, for how long?
• Has patient had any visual problems, such as double or blurred vision?
• Has patient had any hearing problems, such as decreased acuity or tinnitus?
• Does patient have malocclusion and is the patient able to bite down without pain?
• Does patient have areas of numbness or tingling on the face?
• In women, ask if the injury was from a partner or if they feel threatened by anyone.
• In children, ask questions to determine if child abuse is an issue.

Ask questions specific to the eye.

• Does patient have diplopia, especially on lateral and upward gaze, indicating possible entrapment or lens dislocation?
• Does patient have pain with eye motion indicating possible entrapment or periorbital edema?
• Does patient have photophobia (iritis)?
• Has patient experienced flashes of light (retinal detachment)?
• Does patient have blurred vision (hyphema, retinal detachment, vitreous hemorrhage)?

• Perform a complete exam of the face. An asterisk (*) designates portions of the exam that are involved specifically with orbital fracture or associated eye injuries.^{[4, 8]}
• Inspect the face for asymmetry while looking down from the head of the bed. From this position, it is easiest to see enophthalmos (sunken eye) or proptosis (protruding eye).*
• Examine lids for lacerations. If present, consider the possibility of globe penetration.*
• Palpate bony structures of the supraorbital ridge and frontal bone for step-off fractures.*
• Examine ocular movements, especially in upward and lateral gaze, and test for diplopia.*
• Check visual acuity.*
• Check cornea, using fluorescein if needed, for abrasion (uptake of dye) or lacerations (streaming of fluid in dye).*
• Check pupils for roundness and reactivity, both direct and consensual.*
• Examine anterior chamber for presence of blood (flaring on slit-lamp exam) or hyphema (blood layering in inferior aspect of anterior chamber).*
• Examine limbus for signs of laceration (teardrop sign) or deformity.*
• Perform a funduscopic exam to check for blood in the posterior chamber, and examine retina for signs of detachment.*
• Inspect nares for telecanthus (widening of the nasal bridge), then palpate for tenderness and crepitus.
• Inspect nasal septum for clear rhinorrhea, indicating cerebrospinal fluid (CSF) leak, and for septal hematoma.
• Check facial stability by grasping the teeth and hard palate and gently pushing horizontally then vertically, feeling for movement or instability of midface.
• Test teeth for stability and inspect for bleeding at the gum line, a sign of fracture through the alveolar bone.
• Check teeth for malocclusion and step-off.
• Palpate mandible along its symphysis, body, angle, and coronoid process (anterior to ear canal) to check for tenderness, swelling, and step-off.
• Evaluate supraorbital, infraorbital*, inferior alveolar, and mental nerve distributions for anesthesia.
• Palpate zygoma along its arch, as well as its articulations with the frontal bone, temporal bone, and maxillae.