Orbital Fracture Management in the ED

Updated: Jan 07, 2022
  • Author: Thomas Widell, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Practice Essentials

Orbital fractures are very common after facial trauma. Approximately 20% of patients with severe facial trauma injuries also have an ophthalmic injury. For such patients who present to the ED, eye injury, including retrobulbar hemorrhage and penetrating globe injury, should be quickly ruled out. [1, 2]  Assessment of a patient with a suspected orbital wall injury includes a detailed oculofacial examination as well as radiologic imaging. Surgical repair with or without an implant may be indicated for diplopia (double vision), enophthalmos (sunken eye), or both. [3]  

blow-out fracture occurs when a blow to the eye increases pressure in the orbit, causing the weak floor or the medial wall (lamina papyracea) to "blow out" into the maxillary sinus or ethmoid bone. [4, 5, 6, 7, 8, 9, 10]  This results in a fracture, although it often prevents globe rupture and loss of the eye. [7]  Periorbital fat and extraocular muscles can become entrapped in the fracture, leading to problems of ocular movement. [7]  When the medial wall is fractured, the medial rectus becomes entrapped, leading to lateral gaze dysfunction. About one third of blow-out fractures have an associated eye injury. [7]   

In maxillary fracture, the orbit floor is blown out, and inferior rectus entrapment leads to problems in upward gaze. [4, 5, 6, 7, 8, 9, 10]  The eye can be injured during compression before ethmoid bone or maxillary sinus fracture occurs. Superior orbital rim fracture is a frontal bone fracture that is associated with high-impact injuries to the brain, face, and cervical spine. [11]  Tripod fractures and zygomaticomaxillary complex fractures occur as the result of high-impact injury to the cheek's malar eminence (zygoma). Often, these fractures are associated with eye and inferior orbital nerve injuries.


The orbit is composed of 7 facial bones: frontal bone, zygoma, maxilla, lacrimal bone, ethmoid bone, sphenoid bone, and palatine bone. The frontal bone includes the superior orbital ridge and the upper medial orbital ridge. The lateral orbital rim is part of the zygoma. The maxilla includes the inferior and lower medial rims, and the upper border of the maxillary sinus forms the floor of the orbit.

The medial rim separating the orbit from the nares is the lacrimal bone. The medial wall and part of the posterior wall of the orbit are formed by the ethmoid bone. The remainder of the posterior wall of the orbit is formed by the 2 wings of the sphenoid bone and by continuation of the lacrimal bone from the medial wall, as well as by the orbital process of the palatine bone.

The optic nerve exits the optic foramen in the lesser wing of the sphenoid bone. The globe of the eye sits within the orbit surrounded by periorbital fat and by the extraocular muscles that control its movement. The inferior orbital nerve courses through the maxilla in the orbital floor. The weakest portion of the orbit consists of the thin orbital floor (maxilla) and the lamina papyracea (ethmoid bone) medially and inferiorly.


When the patient presents to the ED, airway, breathing, and circulation are the first priorities. Reassess the airway frequently. Performing intubation early on, before swelling occurs, makes airway control much easier than waiting until a problem arises from obstruction.

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

Do not focus on the obvious deformity, thereby neglecting to perform a complete primary survey. Rapidly diagnose other life threats and undertake appropriate resuscitation.

Once you have addressed life-threatening issues, obtain a thorough AMPLE history (allergies, medications, past medical history, last meal, events leading to injury). Ask the patient questions about the injury as well as questions specific to the eye (eg, Did you lose consciousness? If so, for how long? Have you had any visual problems, such as double or blurred vision? Do you have pain with eye motion? Have you experienced flashes of light?).

Perform a complete examination of the face. 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 by testing for visual acuity.

Coon et al identified 4 indications for surgical intervention in pediatric patients with orbital fracture [12] :

  • Rectus muscle entrapment
  • Early enophthalmos
  • Central-gaze diplopia or extraocular movement restriction after resolution of swelling
  • Loss of orbital support likely to produce secondary changes in globe position and/or binocular stereo vision

Use medication, including NSAIDs, narcotics, and local anesthetics, as appropriate for pain control.

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

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

Consider consultation with an EENT surgeon, an oromaxillofacial surgeon, an ophthalmologist, a plastic surgeon, and a psychiatrist.

Follow-up exam in 2 weeks allows swelling to resolve. If entrapment is confirmed at that time, open reduction of fracture with a bone graft may be needed.

(See the image below.)

Left orbital floor fracture. This patient presente 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.

Instruct patients to use ice to reduce edema. Instruct patients to return if visual problems develop. If injury occurred at work or in a sporting accident, instruct patients to wear safety glasses or goggles. Patients should be informed of the high risk of posttraumatic stress disorder and should be referred to a psychiatrist should symptoms occur. [13]



The principal morbidity associated with orbital fracture 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. [7] Males are at higher risk of eye injury because of their increased incidence of trauma. Ask women if a partner caused the injury 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 all eye injuries, age distribution has 2 peaks: 10-40 years and older than 70 years. [12, 14]

Rossin and colleagues reported that 5 variables were associated with increased risk of serious ocular injury in the setting of orbital fracture: blunt trauma with a foreign object (odds ratio [OR], 19.4; 95% CI, 6.3-64.1; P< 0.001), inability to count fingers (OR, 10.1; 95% CI, 2.8-41.1; P = 0.002), roof fracture (OR, 9.1; 95% CI, 2.8-30.0; P = 0.002), diplopia on primary gaze (OR, 6.7; 95% CI, 1.7-25.1; P = 0.003), and conjunctival hemorrhage or chemosis (OR, 4.2; 95% CI, 2.2-8.5; P< 0.001). Researchers are seeking to develop a predictive tool to estimate risk of concurrent ocular injury among patients with orbital fracture. [15]   

Noh and associates studied the occurrence of ocular injury and orbital fracture in patients with orbital blunt trauma seen at a tertiary care center emergency room. Findings show that the incidence of ocular injury was significantly higher in patients without orbital fracture than in those with fracture of the orbit. Study authors concluded that orbital fracture may play a protective role against ocular injury by providing a compressive effect on orbital tissue. [16]