Blow-out fracture

Intro

A ‘blow-out fracture’ of the orbital floor is the most common orbital fracture, occurring after trauma.

Presentation

  • Blurred vision
  • Visual disturbance
  • Restriction of eye movements
  • Displacement of globe

History

  • History of facial trauma
  • Mechanism of injury, force involved, time since injury
  • Oculovagal symptoms: bradycardia, hypotension, nausea/vomiting (due to vagal stimulation by pressure on infraorbital structures)

Vital signs

  • Bradycardia/ Hypotension may be present

Examination

  • Deformity of facial bones
  • Peri-orbital ecchymosis/ oedema
  • Sensory loss to upper lip and face (damage to infra-orbital nerve)
  • Globe malposition: exophthalmos/ enophthlamos/ hypoglobus
  • Subconjunctival haemorrhage/ hyphaema
  • Diplopia, especially in upward gaze
  • Limitation of eye movements, especially in upward gaze
  • Visual acuity (VA) loss/ disturbance
  • Assess optic nerve damage: colour vision, RAPD
  • Assess pupil responses
  • Assess cranial nerves

Radiological investigations

Face radiograph

  • Teardrop sign: protrusion of orbital mass into the maxillary antrum
  • Fluid may be present

Orbit CT scan

  • Fracture of orbital floor
  • Herniation of orbital contents in maxillary sinus

Management

Severe injury with prominent oculovagal response

  • ATLS protocol to stabilise patient
  • Urgent surgical intervention
  • Consider antibiotic prophylaxis and atropine (for oculovagal symptoms)

Non-severe injury

  • Conservative management and review in 1 week
  • Pain relief: NSAIDs
  • Delayed surgical intervention
  • Consider Antibiotic prophylaxis

Complications

  • Persistent/ permanent diplopia
  • Enophthalmos
  • Permanent restriction of eye movements
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