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 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.
Emergency Department Care
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]
Surgical Care
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]
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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.
