Orbital Fracture Management in the ED

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]

Because orbital fractures are the result of trauma, primary survey and attention to ABCs take priority. Focus questions on patency of the airway, control of the cervical spine, breathing difficulties, and symptoms of shock or neurologic impairment, such as loss of consciousness.

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 such as these:

• Do you have epistaxis or clear fluid running from the nares or ears?

• Did you lose consciousness? If so, for how long?

• Have you had any visual problems, such as double or blurred vision?

• Have you had any hearing problems, such as decreased acuity or tinnitus?

• Do you have crooked teeth or a poor bite? Can you bite down without pain?

• Do you have areas of numbness or tingling on your face?

• (For women) Was this injury caused by a partner? Do you feel threatened by anyone?

• (For children) Was this injury caused by someone you know? Are you afraid of anyone because they have hurt you?

Ask the patient questions specific to the eye:

• (To assess for diplopia indicating possible entrapment or lens dislocation) Do you ever see 2 images of 1 object, especially when you look to the right or the left or upward?

• (To assess for possible entrapment or periorbital edema) Do you have pain with eye motion?

• (To assess for iritis/photophobia) Do you sometimes have redness of the eye, eye pain, sensitivity to light, blurred vision, or dark floating spots in your field of vision?

• (To assess for retinal detachment) Have you experienced flashes of light?

• (To assess for hyphema, retinal detachment, or vitreous hemorrhage) Do you have blurred vision?

Perform a complete exam of the face. [Asterisks (*) designate portions of the exam that are involved specifically with orbital fracture or associated eye injuries.][7, 11, 17]

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 the 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 the anterior chamber for the presence of blood (flaring on slit-lamp exam) or hyphema (blood layering in the inferior aspect of the anterior chamber).*

Examine the limbus for signs of laceration (teardrop sign) or deformity.*

Perform a funduscopic exam to check for blood in the posterior chamber, and examine the retina for signs of detachment.*

Inspect the nares for telecanthus (widening of the nasal bridge), then palpate for tenderness and crepitus.

Inspect the 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 the midface.

Test the teeth for stability and inspect for bleeding at the gum line—a sign of fracture through the alveolar bone.

Check the teeth for malocclusion and step-off.

Palpate the 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 the zygoma along its arch, as well as its articulations with frontal bone, temporal bone, and maxillae.

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

Complications include the following:

• 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

Intraoperative Imaging

Assessment of a patient with 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, enophthalmos, or both.[3]  Intraoperative imaging is gaining widespread use in the management of facial fracture repair. Use of intraoperative imaging allows the surgeon to make real-time changes in operative management ranging from repositioning the orbital plate to deciding whether to proceed with orbital floor exploration. This not only allows for immediate optimization of repair but also could decrease the need for revision procedures, thus decreasing patient morbidity and improving patient outcomes. Long-term follow-up management for patients with orbital fracture with intraoperative computed tomography (CT) is suggested.[18, 19]

Radiographs

Computed tomography is replacing plain films in evaluation of orbital trauma because of higher sensitivity and better definition of injuries. When CT is not available, or when 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 that 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 the 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 the severity of the incident, CT scanning is generally considered the test of choice to diagnose facial/orbital fractures. Benefits over other imaging approaches include increased sensitivity, improved ability to plan for operative repair when needed, and utility in diagnosing associated injuries.[2, 14]

Orbital blow-out fractures may require CT scanning for evaluation of the floor and medial wall of the orbit. In the emergent setting, CT scanning may not be needed if the patient has no ocular injury or entrapment. However, for patients with decreased 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.

For 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.

Airway, breathing, and circulation are the first priorities. Hold the airway open by jaw thrust or airway adjuncts, including endotracheal intubation. Because of concern about intracranial placement of endotracheal tubes, severe facial injury is considered a relative contraindication to using the nasotracheal route of intubation.

Place the 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 the globe is open, cover it with a protective shield.

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.

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 by testing for visual acuity.

Blow-out fractures without associated serious eye injury do not require admission. Admit patients with serious eye injury to the ophthalmology service for further care unless other significant injuries mandate admission to the trauma service.[7]  

If appropriate specialists are not available in the receiving institution, arrange transfer to a higher-level hospital. Because the incidence of posttraumatic stress disorder is high, consider referring the patient to a psychiatrist if symptoms should occur.[13]

Patients with simple blow-out fractures without eye injury can be discharged home, even if they have signs of entrapment, because most resolve as swelling goes down. Instruct the 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 swelling to resolve. If entrapment is confirmed at that time, open reduction of fracture with a bone graft may be needed.

Consultations

Depending on the institution, orbital fractures are cared for by an eye, ear, nose, throat (EENT) surgeon, an oromaxillofacial surgeon, an ophthalmologist, or a plastic surgeon.

Patients with serious eye injury and decreased visual acuity should have an ophthalmology consultation. Monitor minor injuries, such as corneal abrasions, on an outpatient basis.[7]  Additional factors such as retrobulbar hemorrhage, abnormal pupillary reaction, and inability to open the injured eye can guide the decision of when an urgent ophthalmology consult is needed.[20]

Provide care for the patient with multiple injuries in collaboration with a surgeon with experience in trauma care.

The incidence of posttraumatic stress disorder is high among patients with facial injuries, and consultation with a psychiatrist should be considered.[8, 10, 13]

Diverse alloplastic materials, each with its own unique characteristics, can be used for repair of different types of orbital fractures. Use of bioresorbables, titanium plate, and porous polyethylene over titanium mesh for simple fractures, and prefabricated anatomic titanium implants over other implants for complex fractures, led to statistically significant improvement in diplopia, enophthamos, ocular motility, and infraorbital hypoesthesia (P< 0.001) 1 year following orbital fracture reconstruction in a 10-year series.[21]

The decision regarding open reduction and internal fixation (ORIF) of orbital fractures is usually based on clinical severity and soft tissue and bony findings. Yang and associates sought to identify prognostic factors affecting outcomes of orbital fracture surgery in a multidisciplinary “real-world” setting. They concluded that careful ocular motility evaluation to ascertain neurogenic injury and muscle compartment syndrome, along with radiologic analysis of the integrity of the posterior ledge and the inferior orbital fissure, can facilitate management and expectations of ORIF surgery.[22]

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.

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.

Class Summary

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 the drug of choice (DOC) for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Ibuprofen (Ibuprin, Advil, Motrin)

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

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 observe closely.

Naproxen (Anaprox, Naprelan, Naprosyn)

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

Flurbiprofen (Ansaid, Ocufen)

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

Class Summary

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

Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)

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

Acetaminophen and codeine (Tylenol #3)

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

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

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

Oxycodone and acetaminophen (Percocet)

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

Morphine sulfate (Duramorph, Astramorph, MS Contin)

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

Class Summary

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

Tetanus toxoid adsorbed or fluid

Used to induce active immunity against tetanus in selected patients. Tetanus and diphtheria toxoids are the immunizing DOCs for most adults and children >7 years. Booster doses are needed to maintain tetanus immunity throughout life.

Pregnant patients should receive only tetanus toxoid--not a diphtheria antigen-containing product.

For children and adults, tetanus toxoid may be administered into deltoid or midlateral thigh muscles. For infants, the preferred site of administration is midthigh lateral.

Class Summary

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

Tetanus immune globulin (TIG)

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