eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Orbital

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

Introduction

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.

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. This results in a fracture, though it often prevents globe rupture and loss of the eye. Periorbital fat and extraocular muscles can become entrapped in the fracture, leading to problems of ocular movement. 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. 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. Superior orbital rim fracture is a frontal bone fracture that is associated with high-impact injuries to the brain, face, and cervical spine. 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.

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.

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.

Clinical

History

• Since 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 history.
  • Allergies
  • Medications
  • 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)?

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.
• 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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