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)
Laboratory Tests
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
Diagnostic Tests
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
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)
Disposition
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
Treatment
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)
Special Populations
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
Background
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
Patient Discharge Instructions
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
References
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)
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.