eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Orbital: Differential Diagnoses & Workup

Author: Thomas Widell, MD, Vice Chairman, Assistant Professor, Department of Emergency Medicine, Rosalind Franklin School of Medicine/The Chicago Medical School, North Chicago, Illinois; Associate Residency Director, University of Chicago Emergency Medicine Program, Chicago, Illinois; Program Director Emergency Medical Education, Attending Physician, Mount Sinai Hospital Medical Center, Chicago, Illinois
Contributor Information and Disclosures

Updated: Mar 6, 2008

Differential Diagnoses

Retinal Detachment

Other Problems to Be Considered

Choroid tear
Ciliary body tear or bruise
Hyphema
Iris disruption
Lens dislocation
Ocular muscle entrapment
Scleral tear

Workup

Laboratory Studies

  • Direct lab studies toward workup of trauma patient.

Imaging Studies

  • Radiographs
    • CT is replacing plain films in the evaluation of orbital trauma because of higher sensitivity and better definition of the injuries. When CT is not available or there is low suspicion without ocular symptoms plain films can be used.
    • Obtain routine facial views, including Waters, Caldwell, and lateral projections.
    • Waters view best displays inferior orbital rims, nasoethmoidal bones, and maxillary sinuses. If the patient is upright when the film is taken, an air-fluid level can often be seen in the maxillary sinus, which may indicate fracture of the maxillary sinus (orbital floor).
    • If the patient is immobilized on a backboard when the film is taken, blood layers form in the posterior of the sinus, making it appear clouded. Another sign of orbital blow-out fracture is the teardrop sign, an opacification in the upper maxillary sinus, which represents periorbital fat and possibly an entrapped extraocular muscle in the maxillary sinus.
    • Caldwell projection provides the best view of the lateral orbital rim and ethmoid bone.
    • Lateral views are the least helpful, but if the patient is lying supine on the backboard, he or she may show air-fluid levels in the posterior of the maxillary sinus.
    • Cervical spine radiographs may be indicated in patients with severe facial injuries or with a consistent mechanism and/or neck pain.
  • Computed tomography
    • Depending on the institution and severity of the incident, CT scanning is generally considered the test of choice to diagnose facial/orbital fractures. Benefits include increased sensitivity, improved ability to plan for operative repair when needed, and utility in diagnosing associated injuries.
    • Orbital blow-out fractures may require CT scanning to evaluate the floor and medial wall of the orbit. CT scanning may not be needed in the emergent setting if the patient has no ocular injury or entrapment. However, in patients with a decrease in visual acuity, this test is helpful in diagnosing direct optic nerve involvement in the fracture and the presence of retro-ocular edema or hematoma, which can stretch the optic nerve.
    • In severe injuries in the orbit area, facial CT scanning may identify associated orbital rim, nasoethmoidal, and zygomaticomaxillary fractures.
    • Consider CT scanning of the brain to exclude concomitant intracranial injuries.

Other Tests

  • Perform a slit-lamp examination of the eye to exclude eye injury.

More on Fracture, Orbital

Overview: Fracture, Orbital
Differential Diagnoses & Workup: Fracture, Orbital
Treatment & Medication: Fracture, Orbital
Follow-up: Fracture, Orbital
References
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References

  1. 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. Jul 2003;61(7):785-92. [Medline].

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

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

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

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

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

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

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

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

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Further Reading

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Keywords

blow-out fractures, fractures of the orbit, maxillary fracture, superior orbital rim fracture, frontal bone fracture, high-impact orbital injuries, tripod fractures, zygomaticomaxillary complex fractures, orbital fractures, eye injury

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Contributor Information and Disclosures

Author

Thomas Widell, MD, Vice Chairman, Assistant Professor, Department of Emergency Medicine, Rosalind Franklin School of Medicine/The Chicago Medical School, North Chicago, Illinois; Associate Residency Director, University of Chicago Emergency Medicine Program, Chicago, Illinois; Program Director Emergency Medical Education, Attending Physician, Mount Sinai Hospital Medical Center, Chicago, Illinois
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eric Legome, MD, Residency Director, Assistant Professor of Emergency Medicine, Department of Emergency Medicine New York University, New York University Hospital, Bellevue Hospital Center, Manhattan VA
Eric Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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