66-year-old with acute onset, periorbital deformity
Patient will present as → a 13-year-old who was hit in the right eye by a baseball. The area is ecchymotic and swollen. He complains of pain, rated 6 out of 10. On physical exam, the patient has eyelid swelling, decreased visual acuity, enophthalmos (sunken eye), and anesthesia/paresthesia in the gums and upper lips.
Fractures of the floor of the orbit, sometimes known as "blowout fractures" are caused by a high-speed blunt force trauma to the globe or infra-orbital rim
- Typically occur when a small, round object (eg, a baseball) strikes the eye
- Half of all orbital fractures involved the inferior wall or floor of the orbit
- Patients with a blowout fracture may experience paresthesia in the gums, upper lips, and cheeks due to damage to the infraorbital nerve
- May result in inferior rectus muscle entrapment causing loss of extraocular movements
Fractures of the orbit may involve one or more of the walls of the orbit, the orbital rim, or both
- Orbital zygomatic fracture — The orbital zygomatic region is the most common location of a fracture of the orbital rim. This injury is typically the result of a high-impact blow to the lateral orbit
- Nasoethmoid fracture – Fracture of the maxillary bone in this portion of the orbital rim can result in disruption of the medial canthal ligament and the lacrimal duct system
- The medial rectus muscle may become trapped in fractures of the medial wall of the orbit
- Orbital roof fracture — Orbital roof fractures are more common in younger patients
Diagnosed with CT scan
Prompt ophthalmic referral
- Treatment with surgery
Question 1 |
You are called into the ER to see a patient that was hit by a motorcycle while crossing the street. Examination of her right eye reveals eyelid swelling, decreased visual acuity, enophthalmos (sunken eye). She denies headache or loss of consciousness but has significant pain in her eye and cheek. You order a CT of her head, what finding do you suspect?
a traumatic deformity of the orbital floor | |
Bleeding in the space between the brain and the tissue covering the brain. Hint: given the mechanism of this patient's injuries you must also r/o a subarachnoid hemorrhage. | |
a collection of blood inside the front part of the eye Hint: This describes a hyphema, which of course this patient may also have. You would be able to see this without a CT scan | |
Corneal abrasion Hint: A corneal abrasion is a scratch on the eye's cornea. This patient should also receive a fluorescein test before leaving the ER. This would not be seen on the CT. |
Question 1 Explanation:
An orbital blowout fracture is a traumatic deformity of the orbital floor or medial wall, typically resulting from impact of a blunt object larger than the orbital aperture, or eye socket.
Question 2 |
What neurological findings may occur with damage to the infraorbital nerve in a patient with a blowout fracture?
weakness in everyday activities like Brushing hair Hint: The hallmark of myasthenia gravis is fatigability and proximal to distal weakness. | |
inability to wrinkle the forehead. Hint: In Bell's Palsy the patient will not be able to wrinkle the forehead. | |
paresthesia in the gums, upper lips and cheeks | |
weakness of the legs, progressing to total paralysis of all four limbs, facial muscles and eyes. Loss of reflexes. Hint: This is a common presentation with Guillain-Barré syndrome. |
Question 2 Explanation:
Patients with a blowout fracture may experience paresthesia in the gums, upper lips and cheeks due to damage to the infraorbital nerve.
Question 3 |
During a baseball game, a 22 year-old college student is hit in the right eye by a baseball. He complains of blurry vision in that eye. On physical exam, the physician assistant notes proptosis of the right eye, and limitation of movement in all directions. On CT scan, which of the following is most likely to be seen?
Fracture of the medial orbital wall Hint: Fracture of the medial orbital wall is associated with diplopia from medial rectus impingement, orbital emphysema and epistaxis. | |
Prolapse of orbital soft tissue Hint: Prolapse of orbital soft tissue, including inferior rectus muscle, inferior oblique muscle, orbital fat, and connective tissue results in enophthalmos, ptosis, diplopia, anesthesia of the ipsilateral cheek and upper lip, and limitation of upward gaze and is seen with fractures of the orbital floor. | |
Hematoma of the orbit | |
Orbital emphysema Hint: Orbital emphysema is seen with fractures of the medial orbital wall or floor of the orbit into the maxillary and ethmoid sinuses respectively. It will not lead to proptosis. |
Question 3 Explanation:
Orbital hemorrhage into the space surrounding the globe following blunt trauma and rupture of the orbital vessels results in increased ocular pressure, proptosis, visual loss, and limitation of movement in all directions. CT reveals a hematoma.
Question 4 |
A 17 year-old male is accidentally struck in the right eye while playing football and is immediately transported to the hospital. In the emergency room, he complains of severe pain behind the eye as well as double vision. On examination, he has exophthalmos, cannot move his right eye upward and blood is noted in the anterior chamber. Which of the following is the most appropriate course of action at this time?
Apply ice packs and cold compresses Hint: See B for explanation. | |
Immediately refer the patient to an ophthalmologist | |
Attempt to keep the patient calm and order a skull x-ray Hint: See B for explanation. | |
Administer a dose of intramuscular broad-spectrum antibiotic Hint: See B for explanation. |
Question 4 Explanation:
This scenario describes a "blow-out" fracture of the orbit with hyphema and, because of the signs and symptoms presented, warrants an immediate consult by an ophthalmologist.
There are 4 questions to complete.
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References: Merck Manual · UpToDate
