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Orbital Fracture in Emergency Medicine

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

Background

Orbit is composed of 7 facial bones: frontal, zygoma, maxilla, lacrimal, ethmoid, sphenoid and palatine.

  • Superior orbital ridge and upper medial orbital ridge are part of the frontal bone.
  • Lateral orbital rim is part of the zygoma.
  • Inferior and lower medial rims are part of the maxilla. Floor of the orbit is made of the upper border of the maxillary sinus.
  • Medial rim separating orbit from nares is the lacrimal bone.
  • Medial wall and part of the posterior wall of the orbit are formed by the ethmoid bone.
  • The rest of the posterior of the orbit is formed by the 2 wings of the sphenoid bone, the continuation of the lacrimal bone from the medial wall and orbital process of the palatine bone.

Optic nerve exits the optic foramen in the lesser wing of the sphenoid bone. Globe of the eye sits within the orbit surrounded with periorbital fat and the extraocular muscles that control its movement. Inferior orbital nerve courses through the maxilla in the orbital floor. Weakest portion of the orbit is the thin orbital floor (maxilla) and the lamina papyracea (ethmoid bone) medially and inferiorly.

See the image below.

Left orbital floor fracture. This patient presenteLeft 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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Pathophysiology

Blow-out fractures occur when a blow to the eye increases pressure in the orbit, causing the weak floor or lamina papyracea to "blow out" into the maxillary sinus or ethmoid bone.[1, 2, 3, 4, 5, 6, 7] This results in a fracture, though it often prevents globe rupture and loss of the eye.[4] Periorbital fat and extraocular muscles can become entrapped in the fracture, leading to problems of ocular movement.[4] When the medial wall (lamina papyracea) is fractured, the medial rectus becomes entrapped, leading to lateral gaze dysfunction.

In maxillary fracture, the orbit floor blows out and inferior rectus entrapment leads to problems in upward gaze.[1, 2, 3, 4, 5, 6, 7] The eye can be injured during compression before the ethmoid bone or the maxillary sinus fractures. About one third of blow-out fractures have an associated eye injury.[4] Superior orbital rim fracture is a frontal bone fracture that is associated with high-impact injuries to the brain, face, and cervical spine.[8] Tripod fractures and zygomaticomaxillary complex fractures occur from high-impact injury to the cheek's malar eminence (zygoma). Often these fractures are associated with eye and inferior orbital nerve injuries.

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Epidemiology

Mortality/Morbidity

The principal morbidity associated with orbital fractures is eye injury. Associated injuries include corneal abrasion, lens dislocation, iris disruption, choroid tear, scleral tear, ciliary body tear or bruise, retinal detachment and tear, hyphema, ocular muscle entrapment, and globe rupture.[4]

Sex

Males are at higher risk of eye injuries because of their increased incidence of trauma. In women, ask if the injury was from a partner or if they feel threatened by anyone, as the incidence of domestic violence and sexual assault is highly associated with this type of injury.

For more information, see Medscape's Trauma Resource Center.

Age

For all eye injuries, age distribution has 2 peaks: 10-40 years and older than 70 years.

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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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