Orbital Wall Fracture

What is it?

Traumatic break in orbital bony wall
Usually caused by blunt trauma to upper face
Orbital floor most common site ("blow-out fracture")
Eye movement often reduced because of contused or entrapped extraocular muscle
Main concerns are associated damage to eye and impaired ocular blood supply from pressure of heavy bleeding in orbit ("orbital compartment syndrome")
Timing and indications for surgical repair are controversial

Onset of reduced vision, pain, double vision, swollen lids, reduced eye movements, numbness on cheek within hour of trauma
Discontinuity in orbital wall on CT

Orbital cellulitis, BUT...no history of trauma
Cavernous sinus arteriovenous fistula, BUT...swelling has delayed onset and patient often reports pulse-synchronous tinnitus; difficult to exclude without imaging

Suspect orbital fracture in anyone with exposure to severe blunt face trauma plus reduced vision, pain, double vision, swollen lids, reduced eye movements, numbness on cheek
Suspect orbital compartment syndrome if marked swelling, bleeding into skin ("raccoon eyes")
Order CT of maxillofacial region and brain for detection of fractures, intracranial hemorrhage

Orbital compartment syndromes require immediate surgical release of lids (canthotomy and cantholysis) by ophthalmologist
Orbital fractures with marked inward displacement (enophthalmos) or downward displacement (inferior dystopia) may require prompt surgical repair
Slit-like orbital fracture with soft tissue entrapment and impaired vertical eye movements may require prompt surgical repair
Other orbital fractures may require repair after 7-10 days if orbital rim displacement or extraocular muscle entrapment is present
Surgical repair otherwise deferred to see if eye movements recover