Orbital fractureMANAGEMENT

TRAUMA PRESENTATIONS · 12 SECTIONS

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485 items

☷ Legend

01Approach to the Critical Patient/attcp44

Immediate priorities

›Stabilization priorities

›Airway compromise from facial trauma

›Cervical spine precautions with high-energy mechanism

›Hemorrhagic shock triggers

›Altered mental status with head injury concern

›Eye shield for suspected ocular injury

›Avoid globe pressure from dressings or ultrasound probe

›Head of bed elevation

›Ice packs to periorbital soft tissue

›Nausea control to reduce Valsalva

›Analgesia to limit agitation and Valsalva

›Time-critical threats

›Orbital compartment syndrome

›Sudden vision decrease

›Afferent pupillary defect

›Proptosis with tight orbit

›Rock-hard eyelids

›Severe pain

›Ophthalmoplegia

›Intraocular pressure elevation

›If suspected, immediate lateral canthotomy and cantholysis (Class I recommendation, expert consensus)

›Open globe injury

›Teardrop pupil

›Extruded ocular contents

›Positive Seidel sign

›360-degree subconjunctival hemorrhage

›If suspected, rigid eye shield and urgent ophthalmology

›Entrapment with oculocardiac reflex

›Bradycardia

›Nausea or vomiting

›Syncope with eye movement

›If present, urgent surgical evaluation (Class I recommendation, expert consensus)

›Consultation triggers

›Ophthalmology for visual deficit

›Ophthalmology for suspected open globe

›Ophthalmology for hyphema

›Ophthalmology for retinal symptoms

›Maxillofacial or ENT for operative orbital fracture patterns

›Neurosurgery for CSF leak concern

Key concepts

›Clinical decision points

›Vision-threatening complications outweigh fracture pattern

›Normal external appearance does not exclude ocular injury

›Diplopia requires distinction between pain-limited motility and true entrapment

›Pediatric trapdoor fractures may have minimal ecchymosis with severe entrapment

02History/hx58

Mechanism and symptoms

›Injury context

›Mechanism

›Blunt assault

›Sports ball impact

›Fall

›Motor vehicle collision

›High-velocity projectiles

›Time since injury

›Eye protection use

›Foreign body risk

›Visual symptoms

›Vision loss

›Blurred vision

›Diplopia

›Primary gaze diplopia

›Vertical diplopia on upgaze

›Diplopia with specific gaze direction

›Photophobia

›Floaters

›Flashes

›Curtain or field defect

›Pain and associated symptoms

›Pain severity

›Pain with extraocular movement

›Headache

›Nausea or vomiting

›Syncope episodes

›Epistaxis

›Clear rhinorrhea

›Risk modifiers

›Anticoagulant or antiplatelet use

›Bleeding disorder

›Prior ocular surgery

›Contact lens use

›Diabetes mellitus

›Immunocompromise

›Sinus disease or recent sinus surgery

›Tetanus immunization status

Classic and atypical presentations

›Presentation patterns

›Blowout fracture pattern

›Periorbital ecchymosis

›Diplopia

›Infraorbital numbness

›Trapdoor fracture pattern

›Minimal swelling

›Marked motility restriction

›Nausea or vomiting

›Bradycardia with gaze

›Orbital compartment syndrome pattern

›Rapid vision decline

›Severe pain

›Proptosis

›Tight lids

PITFALLS

›Miss patterns

›Children with minimal bruising

›Sedated or intoxicated patients unable to report diplopia

›Assumption that CT excludes open globe

›Nose blowing after injury worsening orbital emphysema

03Physical Exam/exam50

Eye and orbit exam

›Visual function

›Visual acuity

›Color vision comparison

›Visual fields by confrontation

›Relative afferent pupillary defect

›External orbit

›Periorbital edema and ecchymosis

›Proptosis

›Enophthalmos

›Globe position asymmetry

›Subcutaneous emphysema crepitus

›Extraocular motility

›Versions in all gaze directions

›Pain-limited movement

›Mechanical restriction pattern

›Diplopia reproduction

›Anterior segment

›Conjunctival hemorrhage distribution

›Corneal abrasion with fluorescein

›Seidel sign

›Hyphema height

›Lens position

›Posterior segment

›Fundus view if feasible

›Vitreous hemorrhage signs

›Retinal detachment signs

›Intraocular pressure

›Avoid if open globe suspected

›If orbital compartment syndrome suspected, elevated pressure supports diagnosis

Face and neurologic exam

›Midface assessment

›Orbital rim step-off

›Zygomatic tenderness and mobility

›Maxillary instability

›Malocclusion

›Trismus

›Sensory exam

›Infraorbital nerve distribution numbness

›Supraorbital nerve distribution numbness

›Nasal exam

›Septal hematoma

›Active epistaxis

›Clear rhinorrhea

›Neurologic screening

›Cranial nerve deficits

›Mental status

›Focal deficits

PITFALLS

›Exam limitations

›Swelling obscuring proptosis and enophthalmos

›Incomplete motility exam due to pain without antiemetic and analgesia

›Contact lens masking corneal abrasion

04Differential Diagnosis/ddx19

Vision-threatening and emergent

›High-risk diagnoses

›Open globe injury (ICD-10 S05.3)

›Orbital compartment syndrome from retrobulbar hemorrhage (ICD-10 H05.23)

›Traumatic optic neuropathy (ICD-10 H46.8)

›Hyphema (ICD-10 H21.0)

›Retinal detachment (ICD-10 H33.0)

›Lens dislocation (ICD-10 H27.1)

Mimics and associated fractures

›Structural mimics

›Zygomaticomaxillary complex fracture (ICD-10 S02.4)

›Naso-orbito-ethmoid fracture (ICD-10 S02.2)

›Le Fort fractures (ICD-10 S02.4)

›Nasal bone fracture (ICD-10 S02.2)

›Basilar skull fracture with CSF leak (ICD-10 S02.10)

›Soft tissue and vascular

›Orbital cellulitis (ICD-10 H05.01)

›Traumatic iritis (ICD-10 H20.9)

›Corneal abrasion (ICD-10 S05.0)

›Carotid-cavernous fistula (ICD-10 I67.1)

›Cavernous sinus thrombosis (ICD-10 G08)

05Laboratory Tests/lt19

Targeted labs by scenario

›Labs guided by complications and comorbidity

›Complete blood count for significant hemorrhage or operative planning

›Hemoglobin trend if expanding hematoma concern

›Leukocytosis as supportive only for infection concern

›Coagulation profile for anticoagulant use or bleeding concern

›INR for warfarin exposure

›aPTT for heparin exposure

›Type and screen for anticipated operative intervention

›Early for polytrauma activation

›Crossmatch if transfusion likely

›Serum glucose for diabetes or altered mental status

›Hyperglycemia association with infection risk

›Hypoglycemia mimic for altered mental status

›Pregnancy test for imaging and medication planning

›Urine hCG

›Serum hCG if high suspicion with negative urine

PITFALLS

›Lab limitations

›Labs do not exclude retrobulbar hemorrhage

›Normal coagulation tests do not exclude clinically significant bleeding

06Diagnostic Tests/dt60

Scoring Systems

›Decision tools and classifications

›Ocular Trauma Score for associated globe injury severity

›Uses initial visual acuity and key injury variables

›Prognostic estimate rather than management trigger

›Limited role in isolated orbital wall fracture

›Orbital fracture surgical urgency classification

›Emergent group

›Orbital compartment syndrome

›Open globe

›Entrapment with oculocardiac reflex

›Urgent group

›Pediatric trapdoor with entrapment

›Progressive vision deficit

›Elective group

›Persistent diplopia after edema improves

›Significant enophthalmos risk

MRI

›MRI indications and constraints

›Indications

›Optic nerve sheath pathology when CT non-diagnostic

›Soft tissue orbital apex pathology when stable

›Contraindications

›Suspected metallic intraocular foreign body

›Unstable patient needing rapid CT-based decisions

›Practical considerations

›Not first-line for acute bony injury

›Timing after CT and ophthalmology input

›CT as first-line imaging for orbital fracture

›Technique

›Non-contrast CT orbits with thin cuts

›Coronal and sagittal reconstructions

›Include facial bones when midface fracture concern

›Key CT targets

›Orbital floor defect size

›Medial wall defect

›Inferior rectus position and contour

›Entrapment signs

›Orbital emphysema extent

›Retrobulbar hematoma

›Optic canal fracture

›Sinus opacification and hemosinus

›Interpretation pearls

›Soft tissue herniation does not equal entrapment

›Entrapment suggested by muscle rounding, tethering, or dislocation pattern

›Large defects increase enophthalmos risk

›Posterior fractures increase orbital apex risk

›Evidence statement

›CT is the imaging standard for acute orbital wall fracture characterization (ACEP Level C, expert consensus)

Ultrasound

›Point-of-care ultrasound roles

›Ocular ultrasound for posterior segment pathology

›Retinal detachment pattern

›Vitreous hemorrhage pattern

›Lens dislocation pattern

›Orbital soft tissue ultrasound

›Preseptal hematoma characterization

›Dynamic assessment limited for entrapment

›Safety constraints

›Avoid ocular ultrasound when open globe suspected

›Use copious gel and minimal pressure when permissible

›Evidence statement

›Ocular ultrasound supports detection of retinal detachment in trained hands, but does not replace ophthalmology (ACEP Level C)

07Disposition/dispo31

Level of care and follow-up

›Admission or transfer criteria

›Vision loss or afferent pupillary defect

›Immediate ophthalmology involvement

›Higher level of care if no specialty coverage

›Orbital compartment syndrome concern

›Post-decompression monitoring

›Repeat visual checks

›Suspected open globe

›NPO status

›OR pathway coordination

›Entrapment with significant motility restriction

›Pediatric trapdoor concern

›Oculocardiac symptoms

›Polytrauma with additional facial fractures

›Trauma admission pathway

›Neurosurgical consult if cranial involvement

›Discharge criteria

›Normal or baseline vision

›No open globe signs

›No orbital compartment syndrome signs

›No severe motility restriction suggesting entrapment

›Pain and nausea controlled

›Reliable follow-up within 24 to 72 hours

›Follow-up timing

›Ophthalmology within 24 to 72 hours for most orbital fractures

›Earlier ophthalmology for diplopia, hyphema, retinal symptoms, or decreased acuity

›Maxillofacial or ENT for operative fracture patterns within 3 to 7 days

PITFALLS

›Disposition errors

›Discharge with unrecognized pediatric entrapment

›Failure to warn against nose blowing with orbital emphysema

›Failure to arrange timely specialty follow-up

08Treatment/t95

Supportive and precautions

›Non-operative initial care

›Rigid eye shield if ocular injury concern

›No pressure patching

›No topical ointment across suspected laceration without ophthalmology

›Head elevation

›Reduce edema

›Reduce venous congestion

›Cold packs intermittently for 24 to 48 hours

›Soft tissue edema reduction

›Skin protection to prevent frost injury

›Activity precautions

›No nose blowing

›Sneeze with mouth open

›Avoid heavy lifting and Valsalva

Medications

›Analgesia and antiemesis

›Acetaminophen oral 1000 mg every 6 hours as needed

›Maximum 4000 mg per day

›Lower maximum in chronic liver disease

›Ibuprofen oral 400 mg every 6 hours as needed

›Avoid in significant bleeding risk

›Avoid in advanced chronic kidney disease

›Ondansetron oral or ODT 4 mg every 8 hours as needed

›QT prolongation risk consideration

›Alternative antiemetic if prolonged QT concern

›Nasal and sinus measures

›Oxymetazoline intranasal 1 to 2 sprays each nostril every 12 hours for up to 3 days

›Avoid prolonged use to prevent rebound congestion

›Caution in severe hypertension

›Saline nasal spray as needed

›Gentle use without forceful sniffing

›Avoid irrigation if CSF leak concern

›Antibiotics

›Selective use strategy

›Consider if open fracture or laceration communicating with sinus

›Consider if gross sinus contamination

›Not routinely required for isolated closed blowout fracture without sinusitis (ACEP Level C, observational data and expert consensus)

›Amoxicillin-clavulanate oral 875 mg every 12 hours for 5 to 7 days

›Alternative if renal impairment

›Counsel for gastrointestinal adverse effects

›Clindamycin oral 300 mg every 6 hours for 5 to 7 days

›Option for penicillin allergy

›C difficile risk counseling

›Tetanus prophylaxis

›Indicated for open wounds per immunization status

›Booster if indicated by wound type and vaccine history

›Tetanus immune globulin if incomplete immunization with high-risk wound

Emergent procedures

›Orbital compartment syndrome decompression

›Lateral canthotomy and cantholysis pathway

›Indications

›Rapid vision decrease

›Afferent pupillary defect

›Marked proptosis with tight lids

›Intraocular pressure elevation with compatible findings

›Timing principle

›Irreversible ischemic injury risk increases with prolonged optic nerve and retinal ischemia

›Do not delay for imaging when clinical syndrome present (Class I recommendation, expert consensus)

›Post-procedure monitoring

›Repeat visual acuity checks

›Repeat pupillary assessment

›Recheck intraocular pressure if safe

›Ongoing ophthalmology involvement

›Open globe pathway

›Rigid shield and NPO

›Avoid topical drops unless ophthalmology directs

›Avoid pressure and ultrasound

›Antiemesis and analgesia to reduce Valsalva

›Minimize vomiting and coughing

›Gentle handling during transport

›Systemic antibiotics per local open globe protocol

›Broad-spectrum coverage coordinated with ophthalmology

›Timing prioritized before OR when feasible

Operative considerations

›Indications for urgent surgical evaluation

›Entrapment with oculocardiac reflex

›Bradycardia with gaze

›Recurrent vomiting triggered by eye movement

›Pediatric trapdoor fracture with entrapment

›Marked motility restriction

›Severe nausea or vomiting

›Minimal external bruising

›Progressive vision deficit with optic canal involvement

›Urgent specialty coordination

›Consideration of decompression based on imaging and exam

›Indications for early elective repair discussion

›Persistent diplopia after swelling improves

›Typically reassessment at 7 to 14 days

›Forced duction findings by specialists

›Large orbital floor defect with enophthalmos risk

›Globe malposition concern

›Cosmetic and functional impact

›Enophthalmos apparent after edema resolution

›Document measurements when feasible

›Shared decision-making with specialist

Controversies

›Traumatic optic neuropathy therapy uncertainty

›High-dose steroid use not routine due to mixed evidence and adverse effect concerns

›Management individualized with ophthalmology and neurosurgery (ACEP Level C)

09Special Populations/sp33

Pregnancy

›Pregnancy-specific considerations

›Imaging balance

›CT orbit radiation focused away from uterus

›Shielding per local radiology protocol

›Medication choices

›Acetaminophen preferred for pain

›NSAID avoidance in later pregnancy

›Antiemetic selection consistent with obstetric guidance

›Disposition planning

›Obstetric consultation if abdominal trauma or concerning mechanism

›Fetal assessment per gestational age and trauma protocol

Geriatric

›Older adult considerations

›Anticoagulant use prevalence

›Lower threshold for retrobulbar hemorrhage concern

›Reversal coordination if life- or vision-threatening bleed

›Baseline vision impairment

›Document baseline acuity and assistive devices

›Higher risk of missed new deficit

›Frailty and fall risk

›Assess for syncope contributors

›Safe discharge planning and supports

Pediatrics

›Pediatric-specific patterns

›Trapdoor fractures

›Minimal ecchymosis possible

›Entrapment common

›Oculocardiac reflex features

›Exam adaptations

›Age-appropriate acuity testing

›Caregiver-assisted symptom history

›Early analgesia and antiemetic to enable motility exam

›Disposition emphasis

›Lower threshold for specialty evaluation with vomiting or motility restriction

›Return precautions emphasized to caregivers

10Background/b38

Epidemiology

›Frequency and context

›Orbital fractures common in blunt facial trauma

›Orbital floor and medial wall frequent sites due to thin bone

›Assaults, falls, and sports common mechanisms

›Coexisting ocular injury risk with periorbital trauma

Pathophysiology

›Mechanisms and complications

›Blowout fracture concept

›Orbital wall fails while rim remains intact

›Orbital contents herniate into sinus

›Entrapment mechanism

›Muscle or soft tissue pinched in fracture defect

›Ischemia risk with prolonged entrapment

›Infraorbital nerve injury

›Numbness of cheek and upper lip

›Often improves over weeks to months

›Orbital emphysema

›Air entry from sinus via fracture

›Worsening with Valsalva and nose blowing

›Retrobulbar hemorrhage

›Increased orbital pressure

›Optic nerve and retinal perfusion compromise

Therapeutic Considerations

›Timing principles

›Emergent decompression for orbital compartment syndrome

›Vision salvage depends on rapid pressure relief

›Clinical diagnosis priority over imaging delay (Class I recommendation, expert consensus)

›Early repair for pediatric entrapment

›Prevent persistent motility deficit

›Reduce ischemic muscle injury risk

›Delayed repair window for many fractures

›Reassessment after edema reduction

›Diplopia and enophthalmos reevaluation timing

›Antibiotic strategy

›Routine prophylaxis not consistently supported in closed fractures

›Selective use for open wounds or high contamination scenarios

›Shared decision-making with specialist when uncertain

›Steroid strategy

›Not routine for traumatic optic neuropathy

›Specialist-directed individualized approach

11Patient Discharge Instructions/pdi27

Copy discharge instructions

›Discharge packet

›Activity restrictions

›No nose blowing for at least 10 to 14 days

›Sneeze with mouth open

›Avoid heavy lifting and straining for 1 to 2 weeks

›Avoid contact sports until cleared

›Symptom care

›Cold packs 10 to 15 minutes at a time for first 48 hours

›Sleep with head elevated

›Pain medicines as prescribed

›Antiemetic use to prevent vomiting and straining

›Medications

›Decongestant spray only as directed for up to 3 days

›Antibiotics only if prescribed

›Avoid aspirin unless directed

›Follow-up

›Ophthalmology appointment within 24 to 72 hours

›Maxillofacial or ENT follow-up if arranged

›Return to emergency immediately

›Any new or worsening vision change

›Increasing eye pain or headache not controlled

›New double vision in primary gaze

›Worsening swelling with tight eyelids or eye bulging

›Repeated vomiting or fainting

›Fever or worsening redness around the eye

›Clear fluid leaking from the nose

›New weakness, confusion, or severe drowsiness

12References/r11

Clinical guidelines and core sources

›Key references

›American Academy of Ophthalmology resources on orbital trauma and orbital fractures

›EyeWiki orbital floor fracture and orbital trauma summaries

›AO CMF surgery reference for orbital fracture classification and repair principles

›ATLS guidance for facial trauma evaluation and associated injuries

›Reviews on orbital compartment syndrome recognition and emergent decompression timing

›Reviews on pediatric trapdoor fractures and oculocardiac reflex management

Evidence notes

›Evidence level framing

›Many orbital fracture recommendations derive from observational studies and expert consensus (ACEP Level C)

›Emergent decompression for orbital compartment syndrome is widely accepted as standard of care (Class I recommendation, expert consensus)

›Antibiotic prophylaxis practice varies due to limited high-quality comparative trials (ACEP Level C)

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.