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Orbital Fracture in Emergency Medicine Workup

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

Laboratory Studies

Direct lab studies toward workup of trauma patient.

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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.

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Other Tests

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

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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
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  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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