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