Symptoms and Diagnosis
- Double vision, especially when looking up
- Numbness of the lateral nose skin, cheek below the eyelid, and upper lip
- Bloody nose
- Lateral subconjunctival hemorrhage (bright red blood over the sclera)
- Sunken ocular globes
- Swelling and bruising around the eye
- Restricted eye movement
- Pain and tenderness around the eye
- Physical examination of the eye and surrounding area
- Imaging tests such as CT scan or MRI
- Evaluation of eye movement and visual acuity
- Assessment of facial sensation
- Assessment of facial symmetry
Causes and Mechanism
- Direct trauma to the eye socket
- Impact of a blunt object larger than the orbital aperture
- Proximity of maxillary and ethmoidal sinus
- Assault
- Motor vehicle accidents
- Hydraulic theory (force applied to the globe, resulting in equatorial expansion and release of pressure at weaker points)
- Buckling theory (force transmitted to facial skeleton causing buckling in orbit)
- Trapdoor fractures in children
Types and Treatment
- Open door fractures (large, displaced, and comminuted)
- Trapdoor fractures (linear, hinged, and minimally displaced)
- Pure orbital blowout fractures
- Impure fractures involving the orbital rim
- White-eyed orbital blowout fractures
- Diagnosis based on clinical and radiographic evidence
- Periorbital bruising and subconjunctival hemorrhage as signs of fracture
- Thin cut CT scan with axial and coronal views for imaging
- Initial management includes follow-up with ophthalmologist, avoiding blowing of the nose, and use of nasal decongestants
- Surgery indicated for specific conditions such as enophthalmos, double vision, and muscle entrapment
- Observation and conservative management for mild fractures
- Surgical repair for severe fractures
- External approach surgery
- Endoscopic transantral repair
- Use of orbital implants during surgery
Surgical Approaches
- Transcutaneous surgery:
- Infraciliary incision with barely perceivable scar
- Higher rate of ectropion after repair
- Subtarsal incision at the lower eyelid crease
- More visible scar but lower risk of ectropion
- Infraorbital incision with the most visible scar but easiest access to the orbit
- Transconjunctival surgery:
- Direct access to the orbit
- No skin incision
- Purported decreased view of the orbit
- Canthotomy can increase the view of the orbit
- Endoscopic approaches:
- Transnasal and transantral approaches used for reduction and support of fractured walls
- Improvement in enophthalmos in the endoscopic group
- No significant complications in the endoscopic group
- Ectropions, facial scars, and hematoma in the external group
- Working towards the globe rather than away with instruments
Epidemiology and History
- Orbital fractures more prevalent in men than women
- In children, 81% of cases were boys
- In adults, men accounted for 72% of orbital fractures
- Orbital medial wall fractures more common in African Americans
- Lamina papyracea commonly broken in African Americans
- Orbital floor fractures investigated and described by MacKenzie in Paris in 1844
- Term 'blow out fracture' coined in 1957 by Smith & Regan
- Putterman advocated for repair of virtually no orbital floor fractures in the 1970s
- Plastic surgeons recommended repair of every orbital floor fracture in the 1970s
- Softening from both sides and an agreement in the middle now
An orbital blowout fracture is a traumatic deformity of the orbital floor or medial wall that typically results from the impact of a blunt object larger than the orbital aperture, or eye socket. Most commonly this results in a herniation of orbital contents through the orbital fractures. The proximity of maxillary and ethmoidal sinus increases the susceptibility of the floor and medial wall for the orbital blowout fracture in these anatomical sites. Most commonly, the inferior orbital wall, or the floor, is likely to collapse, because the bones of the roof and lateral walls are robust. Although the bone forming the medial wall is the thinnest, it is buttressed by the bone separating the ethmoidal air cells. The comparatively thin bone of the floor of the orbit and roof of the maxillary sinus has no support and so the inferior wall collapses mostly. Therefore, medial wall blowout fractures are the second-most common, and superior wall, or roof and lateral wall, blowout fractures are uncommon and rare, respectively. They are characterized by double vision, sunken ocular globes, and loss of sensation of the cheek and upper gums from infraorbital nerve injury.
| Blowout fracture | |
|---|---|
| Other names | Orbital floor fracture |
 | |
| An orbital blowout fracture of the floor of the left orbit. | |
| Specialty | Oral & Maxillofacial Surgery, ENT surgery, plastic surgery, ophthalmology |
| Symptoms | Double vision especially when looking up, numbness of the lateral nose skin, the cheek below the eyelid, and the upper lip, Bloody nose, lateral subconjunctival hemorrhage (bright red blood over the sclera (white of the eye)) |
| Causes | Direct trauma to the eye socket. |
The two broad categories of blowout fractures are open door and trapdoor fractures. Open door fractures are large, displaced and comminuted, and trapdoor fractures are linear, hinged, and minimally displaced. The hinged orbital blowout fracture is a fracture with an edge of the fractured bone attached on either side.
In pure orbital blowout fractures, the orbital rim (the most anterior bony margin of the orbit) is preserved, but with impure fractures, the orbital rim is also injured. With the trapdoor variant, there is a high frequency of extra-ocular muscle entrapment despite minimal signs of external trauma, a phenomenon that is referred to as a "white-eyed" orbital blowout fracture. The fractures can occur of pure floor, pure medial wall or combined floor and medial wall.They can occur with other injuries such as transfacial Le Fort fractures or zygomaticomaxillary complex fractures. The most common causes are assault and motor vehicle accidents. In children, the trapdoor subtype are more common. Smaller fractures are associated with a higher risk of entrapment of the nerve and therefore often smaller fracture are more serious injuries. Large orbital floor fractures have less chance of restrictive strabismus due to nerve entrapment but a greater chance of enopthalmus.
There are a lot of controversies in the management of orbital fractures. the controversies debate on the topics of timing of surgery, indications for surgery, and surgical approach used. Surgical intervention may be required to prevent diplopia and enophthalmos. Patients not experiencing enophthalmos or diplopia and having good extraocular mobility may be closely followed by ophthalmology without surgery.
