eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Orbital

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

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.

Differential Diagnoses

Retinal Detachment

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.

Treatment

Prehospital Care

Airway, breathing, and circulation are the first priorities. Hold the airway open by jaw thrust or airway adjuncts, including endotracheal intubation. Because of the concern with intracranial placement of endotracheal tubes, severe facial injury is considered a relative contraindication to using the nasotracheal route of intubation.
Place patient on a backboard with a collar if cervical spine injury is a possibility.
Treat hypoventilation with intubation and bag ventilation.
Control actively bleeding wounds by applying direct pressure with a bandage.
If globe is open, cover it with a protective shield.

Emergency Department Care

Airway, breathing, and circulation are the first priorities. Reassess airway frequently. Intubation performed early on, before swelling occurs, makes airway control much easier than waiting until a problem arises from obstruction.
Do not focus on the obvious deformity, thereby neglecting to perform a complete primary survey. Rapidly diagnose other life threats and undertake appropriate resuscitation.
Diagnosis of orbital fracture in the ED is part of the secondary survey. Diagnose other injuries to the eye as well by performing a complete slit-lamp examination of the eye and tests for visual acuity.

Consultations

Depending on the institution, orbital fractures are cared for by an eye, ear, nose, throat (EENT) surgeon, oromaxillofacial surgeon, ophthalmologist, or plastic surgeon.
Patients with serious eye injuries and decreased visual acuity should have an ophthalmology consultation. Monitor minor injuries, such as corneal abrasions, on an outpatient basis.
Provide care for the patient with multiple injuries in conjunction with a surgeon with experience in trauma care.
The incidence of posttraumatic stress disorder is high in patients with facial injuries, and a consultation with a psychiatrist should be considered.

Medication

When airway control is needed, facilitate intubation using drugs for rapid sequence induction. A cricothyrotomy kit should be at the bedside in case problems arise.

Medication for pain control is appropriate, including NSAIDs, narcotics, and local anesthetics.

Complete exam of the eye may require dilation of the pupil using mydriatic solutions.

Administer tetanus toxoid for open wounds if patient is not current on vaccinations.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

These agents are used most commonly for relief of mild to moderately severe pain. Effects of NSAIDs in the treatment of pain tend to be patient specific, yet ibuprofen is usually DOC for the initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Ibuprofen (Ibuprin, Advil, Motrin)

Usually DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.

Dosing

Adult

200-400 mg PO q4-6h prn; not to exceed 3.2 g/d

Pediatric

6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults

Interactions

Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Ketoprofen (Oruvail, Orudis, Actron)

Used for relief of mild to moderately severe pain and inflammation. Administer small dosages initially to patients with small bodies, older persons, and those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe.

Dosing

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<3 months: Not established
3 months to 12 years: 0.1–1 mg/kg PO q6-8h
>12 years: 25-50 mg q6-8h prn; not to exceed 300 mg/d

Interactions

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.

Dosing

Adult

500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d

Pediatric

<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Interactions

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Flurbiprofen (Ansaid, Ocufen)

Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis.

Dosing

Adult

200-300 mg/d PO divided bid/qid

Pediatric

Not established

Interactions

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)

DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs or those with upper GI disease or taking oral anticoagulants.

Dosing

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d

Interactions

Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Contraindications

Documented hypersensitivity; known G-6-P deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for treatment of mild to moderately severe pain.

Dosing

Adult

30-60 mg/dose based on codeine content PO q4-6h or 1-2 tabs q4h; not to exceed 12 tabs/d

Pediatric

0.5-1 mg/kg/dose based on codeine content PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen

Interactions

CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Dosing

Adult

1-2 tab/cap PO q4-6h prn

Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen PO q4h; single dose not to exceed 10 mg of hydrocodone bitartrate; not to exceed 5 doses/d

Interactions

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Dosing

Adult

1-2 tab/cap PO q4-6h prn

Pediatric

0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone

Interactions

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/24 h of acetaminophen; higher doses may cause liver toxicity

Morphine sulfate (Duramorph, Astramorph, MS Contin)

DOC for narcotic analgesia due to its reliable and predictable effects, safety, and ease of reversibility with naloxone. Administered IV, may be dosed in a number of ways and commonly is titrated until desired effect obtained.

Dosing

Adult

Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg
IV/IM/SC and reassess hemodynamic effects of dose

Pediatric

Neonates: 0.05-0.2 mg/kg IV/IM/SC prn
Children: 0.1-0.2 mg/kg q2-4h prn

Interactions

Phenothiazines may antagonize analgesic effects; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

Tetanus toxoid

This agent is used for tetanus immunization. Booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

Tetanus toxoid

Used to induce active immunity against tetanus in selected patients. Tetanus and diphtheria toxoids are immunizing DOC for most adults and children >7 y. Necessary to administer booster doses to maintain tetanus immunity throughout life.
Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product.
In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is midthigh lateral.

Dosing

Adult

Primary immunization: 0.5 mL IM
Give 2 injections 4-8 wk apart and third dose 6-12 mo after second injection
Booster dose: 0.5 mL q10y

Pediatric

Primary immunization: 0.5 mL IM
Give 2 injections 4-8 wk apart and third dose 6-12 mo after second injection
Booster dose: 0.5 mL q10y

Interactions

Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of chloramphenicol since it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude its concurrent use)

Contraindications

Documented hypersensitivity; history of any type of neurological symptoms or signs following administration of this product
FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use to treat actual tetanus infections, or for immediate prophylaxis of unimmunized individuals (use instead tetanus antitoxin, preferably human tetanus immune globulin) diminished antibody response to active immunization may be seen in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons recommended

Immunoglobulins

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.

Tetanus immune globulins (Hyper-Tet)

Used for passive immunization of any person with a wound that may be contaminated with tetanus spores.

Dosing

Adult

For prophylaxis: 250-500 U IM in opposite extremity to tetanus toxoid
For clinical tetanus: 3,000-10,000 U IM

Pediatric

For prophylaxis: 250 U IM in opposite extremity as tetanus toxoid
For clinical tetanus: 3,000-10,000 U IM

Interactions

None reported

Contraindications

Since antibodies in globulin preparation may interfere with immune response to vaccination, do not administer within 3 mo of live virus immune globulin administration; may be necessary to revaccinate persons who received immune globulin shortly after live virus vaccination

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Persons with isolated IgA deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing since intradermal injection of concentrated gamma globulin may cause localized area of inflammation and can be misinterpreted, causing medication to be withheld from patient not allergic to this material; true allergic responses to human gamma globulin given in prescribed IM manner are extremely rare; do not admix with other medications since usually incompatible

Follow-up

Further Inpatient Care

Blow-out fractures without associated serious eye injury do not require admission.
Admit patient with serious eye injury to ophthalmology service for further care, unless other significant injuries mandate admission to trauma service.

Further Outpatient Care

Patient with simple blow-out fracture without eye injury can be discharged home, even if patient has signs of entrapment, because most resolve as swelling goes down. Instruct patient to return if he or she notes a change in visual acuity, increasing pain, or flashing lights.
Follow-up exam in 2 weeks allows for swelling to resolve. If entrapment is confirmed at that time, open reduction of fracture with bone graft may be needed.
Because the incidence of posttraumatic stress disorder is high, referral to a psychiatrist should be considered if symptoms occur.

Transfer

If appropriate specialists are not available in the receiving institution, arrange transfer to a higher level hospital.

Deterrence/Prevention

Use safety glasses at work and while participating in sports that use balls or pucks to reduce incidence of blow-out fractures.

Complications

Corneal abrasion
Lens dislocation
Iris disruption
Choroid tear
Scleral tear
Ciliary body tear or bruise
Retinal detachment and tear
Hyphema
Ocular muscle entrapment
Globe rupture

Patient Education

Instruct patients to use ice to reduce edema.
Instruct patient to return if visual problems develop.
If injury occurred at work or in a sporting accident, instruct patient to wear safety glasses or goggles.
For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Facial Fracture.
Patients should be informed of the high risk of posttraumatic stress disorder and should be referred to a psychiatrist should symptoms occur.

Miscellaneous

Medicolegal Pitfalls

Failure to diagnose orbital fracture
Failure to diagnose associated intracranial or cervical spine injuries
Failure to diagnose an eye injury secondary to poor patient cooperation, extensive edema, or lack of familiarity with eye exam

Special Concerns

Always consider and check for loss of airway, intraabdominal injury, and intracranial injury.
Consult an ophthalmologist in the ED if the patient has experienced loss of vision or significant decrease in visual acuity or signs of entrapment, retinal detachment, hemorrhage, or retrobulbar swelling.

References

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].
Hendler BH. Maxillofacial trauma. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. Mosby-Year Book; 1998:1093-1103.
McGill J, Ling LJ, Taylor S. Facial trauma. In: Diagnostic Radiology in Emergency Medicine. Mosby-Year Book; 1992:51-76.
Smith RG. Maxillofacial injuries. In: Harwood-Nuss A, ed. The Clinical Practice of Emergency Medicine. Lippincott Williams & Wilkins Publishers; 1996:408-418.
Snell RS, Smith MS. The face, scalp, and mouth. In: Clinical Anatomy for Emergency Medicine. Mosby-Year Book; 1993:206-241.
Spoor TC, Ramocki JM, Kwito GM. Ocular trauma. In: Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. 2^nd ed. Lippincott, Williams & Wilkins; 1996:225-241.
Sullivan WG. Trauma to the face. In: Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. Lippincott, Williams & Wilkins; 1996:242-269.
Hasan N, Colucciello SA. Maxillofacial trauma. In: Tintinalli JE, Gabor KD, Stapczynski SJ, eds. Emergency Medicine: A Comprehensive Study Guide. 6^th ed. McGraw-Hill Co Inc; 2004:chap 257, p1583-1.
McKay MP. Facial trauma. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine, Concepts and Clinical Practice. Vol 1. 6^th ed. Philadelphia, PA: Mosby Elsevier; 2006:382-98/chap 39.

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

Contributor Information and Disclosures

Author

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

Further Reading

eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Orbital

Introduction

Background

Pathophysiology

Mortality/Morbidity

Sex

Age

Clinical

History

Physical

Differential Diagnoses

Other Problems to Be Considered

Workup

Laboratory Studies

Imaging Studies

Other Tests

Treatment

Prehospital Care

Emergency Department Care

Consultations

Medication

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Ibuprofen (Ibuprin, Advil, Motrin)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Ketoprofen (Oruvail, Orudis, Actron)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Naproxen (Anaprox, Naprelan, Naprosyn)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Flurbiprofen (Ansaid, Ocufen)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Analgesics

Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Acetaminophen and codeine (Tylenol #3)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Dosing