Highlights & Basics
- Orbital fractures are traumatic injuries usually caused by assault, sports, or accidents.
- A careful evaluation of the orbit injury may include examination of the facial bones, eyelids, and surrounding soft tissue; inspection of the globe; and visual acuity.
- A definitive diagnosis is confirmed by computed tomography scan of the orbit.
- Urgent surgery is indicated in pediatric patients with signs of soft tissue (muscle) entrapment; namely upgaze limitation and the oculovagal response (presence of vagal stimulation by pressure to intraorbital structures, which results in bradycardia, hypotension, and nausea and/or vomiting). Surgery is delayed in most adult cases to allow edema and hemorrhage to resolve. In small, non-blowout fractures, conservative treatment may be considered.
- The use of goggles or safety glasses in contact sports is recommended to prevent orbital fractures and associated injuries.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
Images
Orbital bone anatomy
Pediatric blowout fracture: patient looking in central gaze. Mild right circumorbital ecchymosis is noted
Pediatric blowout fracture: patient looking in upward gaze. Right globe limitation by inferior soft tissue entrapment is noted
Right orbital blowout fracture; teardrop sign on occipitomental 15° x-ray
Right orbital blowout fracture on CT-scan; coronal reformat
Right orbital blowout fracture on CT-scan; sagittal reformat
No evidence of fracture on the left orbit as seen on CT-scan; sagittal reconstruction
Citations
al-Qurainy IA, Stassen LF, Dutton GN, et al. The characteristics of midfacial fractures and the association with ocular injury: a prospective study. Br J Oral Maxillofac Surg. 1991 Jan;29(1):291-301.[Abstract]
Markowitz BL, Manson PN, Sargent L, et al. Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment. Plast Reconst Surg. 1991 May;87(5):843-53.[Abstract]
Manolidis S, Weeks BH, Kirby M, et al. Classification and surgical management of orbital fractures: experience with 111 orbital reconstructions. J Craniofac Surg. 2002 Nov;13(6):726-37.[Abstract]
Cobb A, Murthy R, Manisali M, et al. Oculovagal reflex in paediatric orbital floor fractures mimicking head injury. Emerg Med J. 2009 May;26(5):351-3.[Abstract]
The College of Optometrists (UK). Trauma (blunt). April 2021 [internet publication].[Full Text]
1. al-Qurainy IA, Stassen LF, Dutton GN, et al. The characteristics of midfacial fractures and the association with ocular injury: a prospective study. Br J Oral Maxillofac Surg. 1991 Jan;29(1):291-301.[Abstract]
2. Markowitz BL, Manson PN, Sargent L, et al. Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment. Plast Reconst Surg. 1991 May;87(5):843-53.[Abstract]
3. Ayliffe P, Ward Booth P. Nasoethmoid fractures. In: Ward Booth P, Eppley BL, Schmelzeisen R, eds. Maxillofacial trauma and esthetic facial reconstruction. Edinburgh: Churchill Livingstone; 2003:215-28.
4. Gruss JS. Naso-ethmoid-orbital fractures: classification and role of primary bone grafting. Plast Reconstr Surg. 1985 Mar;75(3):303-17.[Abstract]
5. Chiang E, Saadat LV, Spitz JA, et al. Etiology of orbital fractures at a level I trauma center in a large metropolitan city. Taiwan J Ophthalmol. 2016 Feb 12;6(1):26-31.[Abstract][Full Text]
6. Manolidis S, Weeks BH, Kirby M, et al. Classification and surgical management of orbital fractures: experience with 111 orbital reconstructions. J Craniofac Surg. 2002 Nov;13(6):726-37.[Abstract]
7. Ko MJ, Morris CK, Kim JW, et al. Orbital fractures: national inpatient trends and complications. Ophthalmic Plast Reconstr Surg. 2013 Jul-Aug;29(4):298-303.[Abstract]
8. Cobb A, Murthy R, Manisali M, et al. Oculovagal reflex in paediatric orbital floor fractures mimicking head injury. Emerg Med J. 2009 May;26(5):351-3.[Abstract]
9. Clark TJ, Renner LM, Sobel RK, et al. Intimate partner violence: an underappreciated etiology of orbital floor fractures. Ophthalmic Plast Reconstr Surg. 2014 Nov-Dec;30(6):508-11.[Abstract]
10. Cohen AR, Renner LM, Shriver EM. Intimate partner violence in ophthalmology: a global call to action. Curr Opin Ophthalmol. 2017 Sep;28(5):534-538.[Abstract]
11. de Man K, Wijngaarde R, Hes J, et al. Influence of age on the management of blow-out fractures of the orbital floor. Int J Oral Maxillofac Surg. 1991 Dec;20(6):330-6.[Abstract]
12. Ethunandan M, Evans BT. Linear trapdoor or "white-eye" blowout fracture of the orbit: not restricted to children. Br J Oral Maxillofac Surg. 2011 Mar;49(2):142-7.[Abstract]
13. Egbert JE, May K, Kersten RC, et al. Pediatric orbital floor fracture: direct extraocular muscle involvement. Ophthalmology. 2000 Oct;107(10):1875-9.[Abstract]
14. Paton JF, Boscan P, Pickering AE, et al. The yin and yang of cardiac autonomic control: vago-sympathetic interactions revisited. Brain Res Rev. 2005 Nov;49(3):555-65.[Abstract]
15. Cohen SM, Garrett CG. Pediatric orbital floor fractures: nausea/vomiting as signs of entrapment. Otolaryngol Head Neck Surg. 2003 Jul;129(1):43-7.[Abstract]
16. Cope MR, Moos KF, Speculand B. Does diplopia persist after blow-out fractures of the orbital floor in children? Br J Oral Maxillofac Surg. 1999 Feb;37(1):46-51.[Abstract]
17. Magarakis M, Mundinger GS, Kelamis JA, et al. Ocular injury, visual impairment, and blindness associated with facial fractures: a systematic literature review. Plast Reconstr Surg. 2012 Jan;129(1):227-33.[Abstract]
18. Ilankovan V, Hadley D, Moos K, et al. A comparison of imaging techniques with surgical experience in orbital injuries. A prospective study. J Craniomaxillofac Surg. 1991 Nov;19(8):348-52.[Abstract]
19. Cobb AR, Murthy R, Saiet J, et al. The tear-drop sign: a trap door for the unwary? Br J Oral Maxillofac Surg. 2008 Oct;46(7):605-6.[Abstract]
20. The College of Optometrists (UK). Trauma (blunt). April 2021 [internet publication].[Full Text]
21. Shumruck KA, Campbell AC. Management of the orbital rim and floor in zygoma and midface fractures: criteria for selective exploration. Facial Plast Surg. 1998;14(1):77-81.[Abstract]
22. Newlands C, Baggs PR, Kendrick R. Orbital trauma. Antibiotic prophylaxis needs to be given only in certain circumstances. BMJ. 1999 Aug 21;319(7208):516.[Abstract]
23. US Food and Drug Administration. FDA drug safety communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. April 2017 [internet publication].[Full Text]
24. European Medicines Agency. Restrictions on use of codeine for pain relief in children - CMDh endorses PRAC recommendation. June 2013 [internet publication].[Full Text]
25. Medicines and Healthcare Products Regulatory Agency. Codeine: restricted use as analgesic in children and adolescents after European safety review. Drug Safety Update. 2013 Jun;6(11):S1.[Full Text]
26. Cobb AR. Oral and maxillofacial surgery. In: Fitzgerald O'Connor I, Urdang M, eds. Handbook for surgical cross-cover. Oxford and New York: Oxford University Press; 2008:364-5.
27. Ben Simon GJ, Bush S, Selva D, et al. Orbital cellulitis: a rare complication after orbital blowout fracture. Ophthalmology. 2005 Nov;112(11):2030-4.[Abstract]
