Orbital Fracture

An orbital fracture is a break in one or more of the bones that form the eye socket (orbit). These fractures usually result from blunt trauma—such as a punch, ball, or motor vehicle accident. While the bony injury itself is often manageable, associated injuries to the eye and surrounding structures must be carefully evaluated and treated.

Anatomy of the Orbit

The Bony Eye Socket

The orbit is formed by seven bones:

• Frontal bone (roof)
• Maxillary bone (floor)
• Zygomatic bone (lateral wall)
• Ethmoid bone (medial wall)
• Lacrimal bone (medial wall)
• Sphenoid bone (back/apex)
• Palatine bone (floor)

Weak Points

The floor and medial wall are the thinnest areas, making them most susceptible to fracture.

Types of Orbital Fractures

Blowout Fracture

Floor blowout:

• Most common site
• Breaks into maxillary sinus
• Inferior rectus muscle may become trapped

Medial wall blowout:

• Second most common
• Breaks into ethmoid sinus
• Medial rectus muscle may be affected

Orbital Rim Fracture

• Fracture of the thick bony rim
• Usually from direct, high-energy impact
• May involve surrounding facial bones

Roof Fracture

• Less common
• High-energy trauma (motor vehicle accidents)
• Associated with brain injury
• Requires neurosurgical evaluation

Trapdoor Fracture

Symptoms

Common Symptoms

• Swelling of eyelids and face
• Bruising (periorbital ecchymosis/"black eye")
• Double vision (diplopia)
• Restricted eye movement
• Numbness of cheek/upper lip/teeth (infraorbital nerve injury)
• Pain, especially with eye movement
• Nosebleed (if ethmoid sinus involved)
• Sunken appearance (enophthalmos)—may be masked initially by swelling

Warning Signs

• Limited eye movement (especially looking up or down)
• Double vision
• White of eye bulges forward (may indicate fracture or other injury)
• Changes in vision
• Severe pain with eye movement
• Nausea/vomiting with eye movement (especially in children—suggests muscle entrapment)

Diagnosis

Clinical Examination

Eye examination:

• Visual acuity
• Eye movement testing (restricted movement?)
• Pupil examination
• Check for open globe injury
• Examine for hyphema
• Dilated exam if possible

Orbital examination:

• Palpate orbital rim for step-off or tenderness
• Check for enophthalmos (sunken eye)
• Assess facial sensation (infraorbital nerve)
• Look for crepitus (crackling under skin from air)

Imaging

CT Scan (Gold Standard):

• Thin-cut CT of orbits
• Shows fracture location and size
• Reveals muscle or fat herniation
• Identifies other facial fractures
• No MRI if metallic foreign body possible

Associated Injuries

Eye Injuries (Must Rule Out)

• Open globe injury (surgical emergency)
• Hyphema (blood in anterior chamber)
• Retinal detachment
• Lens dislocation
• Optic nerve injury
• Corneal abrasion

Other Injuries

• Other facial fractures (zygomatic, nasal, frontal)
• Brain injury (especially with roof fractures)
• Lacrimal system injury

Treatment

Observation (Non-Surgical)

Many orbital fractures do not need surgery:

• Small fractures without muscle entrapment
• Minimal diplopia that's improving
• No significant enophthalmos
• Stable appearance

Conservative Management:

• Ice packs for swelling
• Nasal decongestants (reduce sinus pressure)
• Do not blow nose (forces air through fracture)
• Antibiotics (controversial but often given)
• Close follow-up

Surgical Repair

Indications for Surgery:

• Muscle entrapment with restricted movement
• Significant enophthalmos (>2mm sunken eye)
• Large fracture (>50% of floor)
• Persistent diplopia not improving
• Cosmetic deformity

Timing:

• Urgent (24-48 hours) for trapdoor fractures with muscle entrapment
• Can wait 1-2 weeks for most fractures (allows swelling to subside)
• Some recommend waiting but operating before scar tissue forms

Surgical Approach:

• Usually through eyelid or inside lower lid (conjunctival)
• Fracture is visualized
• Herniated tissue is repositioned
• Implant placed to cover defect (titanium, porous polyethylene, etc.)

Recovery

After Conservative Treatment

• Swelling improves over 1-2 weeks
• Bruising resolves over 2-3 weeks
• Double vision often improves as swelling decreases
• Follow-up to ensure no late enophthalmos

After Surgery

• Swelling and bruising expected initially
• Activity restrictions (no nose blowing, straining)
• Follow-up for wound check
• Eye movement exercises may be recommended
• Final results assessed after swelling resolves (weeks to months)

Complications

Without Treatment

• Persistent double vision
• Enophthalmos (sunken eye)
• Chronic infraorbital numbness
• Cosmetic deformity

From Surgery

• Infection
• Implant complications (migration, extrusion)
• Persistent diplopia
• Ectropion (lower lid turning out)
• Numbness

Prevention

Protective Eyewear

• Sports-specific eye protection
• Polycarbonate lenses
• Properly fitted face shields/helmets
• Seat belts (reduce MVA facial injuries)

Frequently Asked Questions

When can I blow my nose?

Avoid blowing your nose for at least 2-3 weeks after an orbital fracture. Blowing forces air through the fracture site, increasing swelling and risk of infection. Gentle wiping is okay.

Will my double vision go away?

In many cases, double vision improves as swelling resolves (over 1-2 weeks). If double vision persists beyond 2 weeks or is associated with restricted eye movement, surgical evaluation is recommended.

When is surgery necessary?

Surgery is needed if:

• Muscle is trapped (especially urgent in children)
• Eye appears sunken (or will once swelling resolves)
• Persistent double vision despite time for healing
• Large fracture unlikely to heal well without repair

How long does recovery take?

Swelling and bruising typically improve over 2-3 weeks. Final results, especially after surgery, may take 2-3 months to fully manifest. Numbness may persist longer or be permanent.

Can the fracture heal on its own?

Many orbital fractures heal without surgery if they're small, don't entrap muscle, and don't cause significant deformity. The body forms fibrous tissue over the defect. Follow-up ensures healing progresses appropriately.

References