An orbital blowout fracture is a fracture of the orbital floor (and/or medial wall) resulting from blunt trauma that increases intraorbital pressure, forcing orbital contents through the thin bone into the maxillary sinus. The classic triad is diplopia, infraorbital hypoesthesia, and enophthalmos. [1-2] This is a common facial injury with significant potential for missed diagnosis, particularly in pediatric patients (missed in up to 40% of children). [3]
1. History
- Mechanism: Direct blunt trauma to the orbit or periorbital region — assault, sports (baseball, tennis ball, elbow/knee), MVA, falls [1][4]
- Symptom characterization: Double vision (especially on upgaze), pain with eye movement, numbness of the cheek/upper lip/teeth (V2 distribution), sunken appearance of the eye
- Timing: Onset of diplopia and restricted gaze typically immediate; enophthalmos may develop acutely or over days to weeks as edema resolves
- Associated symptoms: Nausea, vomiting, syncope (suggest oculocardiac reflex — especially in children); subcutaneous emphysema (especially after nose blowing) [1][5-6]
- Important negatives: Ask about vision loss, flashing lights, floaters (retinal injury), epistaxis, clear rhinorrhea (CSF leak if roof involved)
2. Alarm Features
- Oculocardiac reflex: Bradycardia, nausea/vomiting, syncope — indicates muscle entrapment requiring emergent surgical repair [5-7]
- White-eyed blowout fracture: Minimal periorbital ecchymosis/edema but significant motility restriction — a trapdoor fracture with entrapment, common in children, easily missed, requires urgent repair [3][8]
- Orbital compartment syndrome: Proptosis, vision loss, afferent pupillary defect (APD), ophthalmoplegia, tense orbit, elevated IOP — requires immediate lateral canthotomy and cantholysis [9-11]
- Globe rupture: Irregular pupil, shallow anterior chamber, hyphema, decreased visual acuity — do NOT apply pressure; shield the eye
- Traumatic optic neuropathy: APD with vision loss, especially with lateral/superior wall fractures [12]
- Serious ocular injury occurs in approximately 24% of blowout fracture cases [7]
3. Medications
- Analgesics: Acetaminophen, NSAIDs; opioids for severe pain
- Nasal decongestant sprays: To relieve congestion without nose blowing [13]
- Systemic steroids: May be used to decrease orbital edema (weak recommendation, low-quality evidence) [13]
- Antiemetics: Ondansetron for nausea/vomiting (especially if oculocardiac reflex suspected)
- Atropine/glycopyrrolate: For refractory bradycardia from oculocardiac reflex [14]
- Antibiotics: Prophylactic antibiotics are not recommended for closed, nonoperative orbital fractures per AAST consensus. Infection (orbital cellulitis) is rare (~0.8%) [15-17]
- Avoid: Aspirin/anticoagulants acutely (risk of retrobulbar hemorrhage)
4. Diet
- Soft diet if concurrent mandibular or maxillary fractures
- No specific dietary restrictions for isolated orbital floor fractures
- Adequate hydration; avoid straining (Valsalva) which can worsen orbital emphysema
5. Review of Systems
- Eyes: Vision changes, diplopia, pain with eye movement, tearing
- Neuro: Facial numbness (V2), headache, LOC, amnesia (concurrent TBI)
- ENT: Epistaxis, nasal congestion, clear rhinorrhea, malocclusion
- GI: Nausea/vomiting (oculocardiac reflex vs. concurrent head injury)
- Cardiac: Syncope, presyncope, palpitations (bradycardia)
- MSK: Neck pain, cervical spine tenderness
6. Collateral History and Family History
- Witnesses to mechanism (assault vs. fall — consider non-accidental trauma, especially in children) [18]
- Anticoagulant/antiplatelet use (risk of retrobulbar hemorrhage)
- Prior orbital surgery or fractures (altered sinus aerodynamics increase risk of barotraumatic fracture) [19]
- In pediatric patients, consider child abuse if mechanism inconsistent with injury pattern [18]
7. Risk Factors
- Assault and MVA are the leading causes, followed by sports and falls [4]
- Male sex (2:1 male-to-female ratio) [4]
- Sports involving projectiles (baseball, tennis, racquetball, hockey)
- Younger patients: more elastic bone → trapdoor fractures with entrapment [3][8]
- Older patients: more comminuted/open fractures, less entrapment risk
- Osteoporosis or prior orbital surgery
8. Differential Diagnosis
- Zygomaticomaxillary complex (ZMC) fracture: Impure blowout with rim involvement, trismus, malar flattening [12]
- Le Fort II/III fracture: Midface mobility, malocclusion, CSF leak
- Nasoethmoidal complex fracture: Telecanthus, epistaxis
- Globe rupture: Irregular pupil, decreased VA, hyphema — do not apply pressure
- Retrobulbar hemorrhage/orbital compartment syndrome: Proptosis (vs. enophthalmos in blowout), elevated IOP, APD [10]
- Traumatic optic neuropathy: Vision loss with APD, may occur without fracture
- Orbital roof fracture: More common in children <3 years; consider intracranial extension [18]
- Cranial nerve palsy (III, IV, VI): Paretic (not restrictive) motility pattern; no forced duction abnormality
9. Past Medical History
- Prior orbital/facial fractures or surgery
- Pre-existing strabismus or amblyopia
- Bleeding disorders or anticoagulant use
- Sinus disease (increases risk of post-fracture orbital cellulitis) [17]
- History of osteoporosis
10. Physical Exam
- Inspection: Periorbital ecchymosis, edema, subcutaneous emphysema, enophthalmos, hypoglobus, facial asymmetry. Note: children may have minimal external signs ("white-eyed" fracture) [3][8]
- Visual acuity: Mandatory — document before any intervention
- Pupils: Check for APD (swinging flashlight test) — critical for detecting optic neuropathy or orbital compartment syndrome
- Extraocular movements (EOM): Restriction of upgaze is classic (inferior rectus entrapment); test all cardinal positions. Diplopia on upgaze strongly associated with floor fractures [20]
- Forced duction test: Differentiates restrictive (entrapment) from paretic motility limitation [2][21]
- Infraorbital sensation: Test V2 distribution (cheek, upper lip, upper teeth) — hypoesthesia in ~50% of cases
- IOP measurement: Elevated IOP suggests orbital compartment syndrome (>30–40 mmHg warrants intervention) [22-23]
- Anterior segment/fundoscopy: Hyphema, lens dislocation, retinal detachment, vitreous hemorrhage
- Palpation: Orbital rim integrity (intact rim = pure blowout; disrupted = impure/ZMC fracture)
- Heart rate: Monitor for bradycardia (oculocardiac reflex), especially during EOM testing [6]
11. Lab Studies
- Labs are generally not required for isolated orbital floor fractures
- If significant hemorrhage or polytrauma: CBC, coagulation studies, type and screen
- If on anticoagulants: INR/PT, anti-Xa levels as appropriate
- Pre-operative labs if surgical repair anticipated
12. Imaging
- First-line: CT maxillofacial without contrast with thin-section axial images and coronal/sagittal reformats — gold standard [12][24-25]
- Identifies fracture location and size, herniation of orbital contents, muscle position relative to fracture, orbital emphysema, retrobulbar hemorrhage
- Fractures >50% of floor or >2 cm associated with enophthalmos [12][26]
- Cranial-caudal discrepancy >0.8 cm predictive of need for surgical repair [27]
- CT head without contrast: Add if concern for intracranial injury [24]
- Head CT screening: Absence of maxillary hemosinus on head CT has a 99.7% NPV for excluding orbital floor fracture [28]
- Plain radiographs (Waters view): Low sensitivity, largely replaced by CT
- MRI: Not first-line; useful for soft tissue detail if CT equivocal; contraindicated if metallic foreign body suspected [25]
- Imaging is unnecessary if clinical suspicion is very low and no symptoms
13. Special Tests
- Forced duction test: Gold standard for confirming mechanical entrapment — positive when passive movement of the globe is restricted [2][29]
- Forced generation test: Assesses muscle function (paresis vs. restriction)
- Hess chart/Lancaster red-green test: Quantifies and documents ocular motility deficits
- Hertel exophthalmometry: Measures enophthalmos (>2 mm considered significant) [26]
- Tonometry: IOP measurement — critical if orbital compartment syndrome suspected
- Slit lamp examination: Anterior segment evaluation for hyphema, lens subluxation, iritis
14. ECG
- Indicated if: Bradycardia, syncope, nausea/vomiting suggesting oculocardiac reflex [5-6]
- Findings: Sinus bradycardia, AV block, junctional rhythm, or rarely asystole
- Continuous cardiac monitoring recommended if oculocardiac reflex is elicited during examination
- The reflex is triggered via the trigeminal-vagal arc (V1 afferent → vagus efferent) [6]
The following figure illustrates the oculocardiac reflex pathway:
15. Assessment
Severity stratification
- Emergent: Orbital compartment syndrome, nonresolving oculocardiac reflex, globe rupture, white-eyed blowout with entrapment [7][21]
- Urgent (repair within 2 weeks): Symptomatic diplopia with positive forced ductions/CT entrapment, large floor fractures (>50%), early enophthalmos/hypoglobus, progressive infraorbital hypoesthesia [7][26]
- Non-urgent/observation: Minimal diplopia not in primary or downgaze, good motility, no significant enophthalmos [7]
Most orbital floor fractures (~78%) are managed nonoperatively. [31] Approximately 17% undergo early repair and 4% late repair. [31] Persistent diplopia after surgical repair occurs in ~37% of cases. [7]
16. Treatment Plan
Initial stabilization
- ABCs, cervical spine precautions if polytrauma
- Orbital compartment syndrome → immediate lateral canthotomy and cantholysis at bedside; do not delay for imaging. Ischemic tolerance of retina/optic nerve is ~90 minutes. Decompression within 2 hours associated with best visual recovery [9][11][32-33]
- Shield the eye if globe rupture suspected (no pressure)
Medical management
- Ice packs to reduce swelling (20 min on/off)
- Head of bed elevation 30°
- Strict avoidance of nose blowing (prevents orbital emphysema and worsening herniation) [13]
- Nasal decongestant spray for congestion [13]
- Analgesics (acetaminophen ± NSAIDs)
- Antiemetics as needed
- Prophylactic antibiotics are not indicated for nonoperative closed fractures [15-16]
Surgical indications and timing per AAO guidelines: [7][21]
- Immediate: Nonresolving oculocardiac reflex with entrapment, white-eyed blowout (trapdoor with entrapment), globe subluxation into maxillary sinus
- Within 2 weeks: Persistent symptomatic diplopia with positive forced ductions or CT-confirmed entrapment; large fractures (>50% of floor); early enophthalmos >2 mm or hypoglobus
- Delayed (>2 weeks): Restrictive strabismus, unresolved enophthalmos
- Observation: Minimal diplopia not in primary/downgaze, good motility, no significant enophthalmos
Pediatric considerations: Surgical repair within 24 hours for confirmed extraocular muscle entrapment yields significantly better motility outcomes. [34] Trapdoor fractures in children should be repaired as soon as possible, ideally within 24–48 hours. [34-36]
17. Disposition
Admission criteria
- Orbital compartment syndrome (post-canthotomy, awaiting definitive surgery)
- Nonresolving oculocardiac reflex with bradycardia
- Concurrent significant ocular injury (globe rupture, retinal detachment)
- Polytrauma requiring inpatient management
- Pediatric trapdoor fracture with entrapment awaiting urgent OR
Observation indications
- Borderline motility restriction with equivocal entrapment — serial exams over hours
- Nausea/vomiting concerning for evolving oculocardiac reflex
Discharge criteria
- Stable visual acuity, no APD
- No evidence of entrapment or oculocardiac reflex
- Minimal or improving diplopia
- No signs of orbital compartment syndrome
- Reliable follow-up arranged within 1–2 weeks with ophthalmology or oculoplastics/OMFS
Specialist consultation triggers
- Ophthalmology: All orbital fractures with diplopia, motility restriction, vision changes, or elevated IOP
- Oculoplastics/OMFS/ENT: Fractures meeting surgical criteria
- Neurosurgery: Concurrent intracranial injury or orbital roof fracture with dural involvement
18. Follow Up / Return Precautions
Follow-up timing
- 1–2 weeks with ophthalmology or surgical specialist for reassessment of motility, diplopia, enophthalmos, and infraorbital sensation [7][21]
- Earlier if symptoms worsen
Return precautions — instruct patients to return immediately for:
- New or worsening vision loss
- Increasing eye pain, swelling, or proptosis
- Worsening double vision
- Fever, increasing redness/swelling (orbital cellulitis — rare but serious) [17]
- Nausea, vomiting, dizziness, or fainting (oculocardiac reflex)
Patient counseling
- Do not blow nose until cleared by specialist (risk of orbital emphysema and infection) [13]
- Sneeze with mouth open
- Avoid strenuous activity, heavy lifting, and straining
- Apply ice packs intermittently for 48 hours
- Sleep with head elevated
- Diplopia often improves as swelling resolves over 1–2 weeks; persistent diplopia beyond 2 weeks may require surgical intervention [7]
- Infraorbital numbness may take weeks to months to resolve, and some hypoesthesia may be permanent
Expected recovery
- Most nonoperative fractures: Diplopia and edema improve over 1–4 weeks
- Post-surgical: ~85% of pediatric patients with preoperative diplopia recover completely; ~63% of adults are diplopia-free after repair [7][36]
- Late enophthalmos may develop as orbital edema resolves and fat atrophy occurs [36]
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