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Orbital Fracture in Emergency Medicine Clinical Presentation

  • Author: Thomas Widell, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Oct 23, 2014
 

History

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)?
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Physical

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.

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Contributor Information and Disclosures
Author

Thomas Widell, MD Vice Chairman, Assistant Professor, Department of Emergency Medicine, Chicago Medical School at Rosalind Franklin University of Medicine and Science; Associate Residency Director, University of Chicago Emergency Medicine Program; Program Director, Emergency Medical Education, Attending Physician, Mount Sinai Hospital Medical Center

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.

Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Professor Clinical, Department of Emergency Medicine, State University of New York Downstate College of Medicine

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, Council of Emergency Medicine Residency Directors, American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Michelle Ervin, MD Chair, Department of Emergency Medicine, Howard University Hospital

Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. Hendler BH. Maxillofacial trauma. Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. Mosby-Year Book; 1998. 1093-1103.

  2. McGill J, Ling LJ, Taylor S. Facial trauma. Diagnostic Radiology in Emergency Medicine. Mosby-Year Book; 1992. 51-76.

  3. Smith RG. Maxillofacial injuries. Harwood-Nuss A, ed. The Clinical Practice of Emergency Medicine. Lippincott Williams & Wilkins Publishers; 1996. 408-418.

  4. Spoor TC, Ramocki JM, Kwito GM. Ocular trauma. Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. 2nd ed. Lippincott, Williams & Wilkins; 1996. 225-241.

  5. Sullivan WG. Trauma to the face. Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. Lippincott, Williams & Wilkins; 1996. 242-269.

  6. Hasan N, Colucciello SA. Maxillofacial trauma. Tintinalli JE, Gabor KD, Stapczynski SJ, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. McGraw-Hill Co Inc; 2004. chap 257, p1583-1.

  7. McKay MP. Facial trauma. Marx JA, Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine, Concepts and Clinical Practice. 6th ed. Philadelphia, PA: Mosby Elsevier; 2006. Vol 1: 382-98/chap 39.

  8. Snell RS, Smith MS. The face, scalp, and mouth. Clinical Anatomy for Emergency Medicine. Mosby-Year Book; 1993. 206-241.

  9. Cheung CA, Rogers-Martel M, Golas L, Chepurny A, Martel JB, Martel JR. Hospital-based ocular emergencies: epidemiology, treatment, and visual outcomes. Am J Emerg Med. 2014 Mar. 32(3):221-4. [Medline].

  10. Glynn SM, Asarnow JR, Asarnow R, et al. The development of acute post-traumatic stress disorder after orofacial injury: a prospective study in a large urban hospital. J Oral Maxillofac Surg. 2003 Jul. 61(7):785-92. [Medline].

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Left orbital floor fracture. This patient presented with little motility disturbance; however, because of the large defect in the orbital floor, late enophthalmos was predicted. Surgical repair was undertaken. Note the pneumo-orbitum.
 
 
 
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