| An orbital fracture refers to breakage of any of seven facial bones in the eye socket (orbit), a cup-shaped arrangement of bones surrounding the eye, which normally protect the eye from injury. The six orbital bones include the superior orbital ridge and upper medial orbital ridge of the frontal bone (superior orbital rim), the lateral orbital rim of the cheekbone (zygoma), the inferior and lower medial rims of the orbit’s floor (maxilla), the lacrimal bone between the orbit and nose, the ethmoid bone (lamina papyracea) that forms the orbit’s medial wall and part of its posterior wall, and the sphenoid bone of the orbit’s posterior wall. The entire outer rim of bone is fairly thick compared to the bony floor (maxilla) of the eye socket and the ethmoid bone, which are paper-thin and delicate.
Orbital fractures are caused by blunt trauma and may result from motor vehicle accidents, sports injuries, industrial accidents, falls, dog bites, assault with a blunt object, and explosions.
Fractures in the orbital area are of several types. A blow-out fracture is an indirect fracture of the inferior or medial walls of the orbit occurring after a blow to the eye increases pressure within the orbit, literally blowing out, or fracturing, the weak floor of the orbit and roof of the maxilla sinus. This is the most common type of orbital fracture and may occur without other facial injury.
Some blow-out fractures can entrap extraocular muscles, causing problems with eye movement or double vision (diplopia). Trapdoor fractures occur in children and small-boned individuals whose bones are more flexible. In a trapdoor fracture, broken bones below the eye swing down at the instant of injury and then immediately swing back up, entrapping extraocular muscles that allow eye movement. The most frequently entrapped muscles are the inferior rectus (ocular depression) and the inferior oblique (ocular elevation). Fractures of this type can result in diplopia and, in acute cases, nausea and vomiting.
High-impact head injuries that cause multiple facial fractures with brain or spinal injury will often involve fracture of the frontal bone (superior orbital rim). High-impact injuries to the cheekbones (zygoma) can result in fracture of multiple orbital bones (tripod fracture, zygomaticomaxillary complex fractures) and may involve optic nerve entrapment or injury. Injury to the eye itself is the most serious consequence of orbital fractures.Risk: Orbital fracture is always the result of blunt trauma, placing males at greater risk because of their increased incidence of trauma (Widell); the risk among males is four times greater than among females (Harvard Medical School). Approximately 21.6% of injured riders of vehicles that provide no external protection (e.g., motorcycles and all-terrain vehicles) incur traumatic facial injury; similarly, 21% of sports injuries result in facial injury, primarily among individuals age 17 and younger (McKay). Among domestic violence victims, 81% suffer facial injuries, of which 30% are facial bone fractures (McKay). Incidence and Prevalence: About 2.5 million eye injuries, including orbital fractures, occur each year as the result of trauma (Harvard Medical School). Eye and orbital area injuries occur most frequently between ages 10 and 40 and in individuals older than age 70 (Widell). |
Source: Medical Disability Advisor
| History: Since orbital fractures result from blunt trauma, physicians and emergency personnel must first attempt to understand the circumstances of the traumatic event. The individual, if conscious, may report pain or headache; decreased vision or diplopia; and numbness or tingling in the face, upper lip, and gums. Individuals should be questioned about the presence and location of symptoms; visual problems such as double or blurred vision, flashes of light, or pain with eye movement; breathing difficulty, allergies, and current medications; and post-trauma events, including vomiting and whether or not consciousness was lost. Physical exam: Examination will evaluate the individual’s level of consciousness; vital signs and respiration; and the presence and location of injuries, bruises, swelling, and bleeding from lacerations. A complete examination of the face is performed, including evaluation of facial stability, observation of symmetry, and palpation of bony structures such as orbital ridge, frontal bone, and zygoma for mobility and possible fracture. The physician will perform a complete ocular examination of the eyes for a sunken appearance (enophthalmos), limitation of ocular movement, visual acuity, and lacerations to the eyelid or globe. The examination will check pupils for roundness, symmetry, and reactivity and may test ocular reflexes. Tests: Although plain x-rays are sometimes used, they can miss up to 20% of orbital fractures. CT is the preferred imaging modality for evaluating and diagnosing orbital fractures and visualizing the position of bones before and after surgery. Three-dimensional reconstruction CT scans are especially helpful for diagnosis and to evaluate postoperative positioning (McKay). The examiner will use a special microscope called a slit-lamp to look within the eye and may dilate the pupils with medication in order to view the integrity of the eye. |
Source: Medical Disability Advisor
| The goal of fracture repair is to prevent loss of vision, persistent diplopia, and malpositioning of the globe by removal of all displaced tissue from the fracture site and restoration of the architecture of the orbit. Examination by endoscope (endonasal endoscope), a lighted telescopic device that can visualize the orbit’s interior, helps surgeons determine the most appropriate surgical approach. Endoscopic surgical repair is a new surgical method (Mohadjer) and is usually performed under general anesthesia. The traditional surgical procedure is open reduction of the fracture using a transcutaneous or transconjunctival approach.
Not all fractures will require surgical repair; this is determined by the presence of enophthalmos, persistence of diplopia, or relative size and severity of the fracture. Surgical repair is the recommended treatment for orbital fractures involving extraocular muscle or nerve entrapment and in most cases of facial disfigurement. Trapdoor fracture may require surgery, based on the CT scan and the presence of diplopia. Repair of other orbital fractures frequently occurs within 3 to 14 days after trauma. Surgical repair may involve insertion of metal, synthetic, or bony implants to replace bone and restore stability, and it may use small metal plates, screws, or wires to stabilize bone fragments. Steroid drugs are sometimes prescribed to reduce swelling prior to surgery.
If the eye itself has been injured, it may require separate specific treatment. The physician may prescribe antibiotics for related sinus infections or to prevent sinus infections from spreading into the orbit. The physician may advise the individual to avoid blowing the nose and to elevate the head when lying down for several weeks after surgery. |
Source: Medical Disability Advisor
| Successful surgical intervention to restore the bones of the orbit and relieve entrapment of extraocular muscles and the optic nerve will usually preclude long-lasting effects from orbital fracture. Untreated eye socket fractures can result in permanent facial disfigurement, enophthalmos, and permanent diplopia. |
Source: Medical Disability Advisor
| Residual enophthalmos may persist after the initial correction, and a second surgery may be needed. A mass of blood (hematoma) may form within the orbit after surgery and cause bulging of the eye (exophthalmos), which will require further medical or surgical treatment. Infection, particularly sinus infection, may occur. Fractures of the orbit that involve the wall of the frontal sinus can result in spinal fluid leaks into the orbit or nasal cavity, occurring days, weeks, or many months after initial injury and surgery and possibly leading to meningitis or death if not discovered and treated. Stretching of the retinal artery with decreased blood flow to the retina or a lesion on the retinal nerve (neurapraxia) can result in markedly reduced visual acuity or even blindness. Facial injuries, especially those with associated disfigurement, can affect mental health and future functioning. |
Source: Medical Disability Advisor
| Activities requiring physical exertion or those that have a potential to cause further blunt orbital injury may be restricted. Protective facial devices may be required when facial trauma is a possible factor (athletes returning to sports shortly after fracture). Counseling and supportive therapy may be needed if the individual has been disfigured and suffers related self-esteem and performance issues.
In general, an individual may return to heavy work 3 weeks after the injury if surgery is not required. If there has been surgical repair, heavy work is usually contraindicated until at least 3 weeks after surgery. In some cases, numbness of the cheek can persist after surgery. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Did imaging studies reveal a single orbital fracture or multiple orbital fractures? Were other facial fractures present?
-
Was CT scan of the head ordered? Did findings reveal head injury?
-
Did individual lose consciousness? For how long?
-
Were concomitant injuries noted on physical examination?
-
Was the individual’s monocular and binocular best corrected vision altered as a result of orbital injury?
Regarding treatment:
- Was individual treated for an orbital fracture? Was surgery performed?
-
Have follow-up imaging studies verified fracture healing has occurred?
-
Are additional surgeries recommended or scheduled to correct disfigurement or vision problems?
-
Is individual under regular medical therapy?
-
Is individual taking pain medication?
Regarding prognosis:
- Does individual have comorbid conditions that may delay or complicate recovery?
-
Does individual have emotional or mental conditions (e.g., depression) that may delay or complicate recovery?
-
Has employer been able to accommodate any necessary restrictions?
|
Source: Medical Disability Advisor
| Barbar, Tariq Farooq. "Patterns of Ocular Trauma." Journal of the College of Physicians and Surgeons 17 3 (2007): 148-153.Cabaltica, Rex B. G. "Fractures about the Orbit in Professional American Football Players." American Journal of Sports Medicine 29 (2001): 55-57. Harvard Medical School. "Eye Socket Fracture (Fracture of the Orbit)." InteliHealth. 22 Sep. 2007. 29 Dec. 2008 <http://www.intelihealth.com/IH/ihtIH?t=9961&p=>. McKay, M. P. "Facial Trauma." Rosen's Emergency Medicine: Concepts and Clinical Practice. Ed. J. A. Marx. 6th ed. Philadelphia: Mosby Elsevier, 2006. Mohadjer, Y., and M. Hartstein. "Endoscopic Orbital Fracture Repair." Otolaryngologic Clinics of North America 39 5 (2006): Widell, T. "Fractures, Orbital." eMedicine. Eds. Michelle Ervin, et al. 6 May. 2008. Medscape. 29 Dec. 2008 <emedicine.com/emerg/topic202.htm>. |
Source: Medical Disability Advisor
| Feedback |
| Send us comments, suggestions, corrections, or anything you would like us to hear. If you are not logged in, you must
include your email address, in order for us to respond. We cannot, unfortunately, respond to every comment.
If you are seeking medical advice, please contact your physician. Thank you! |
Send this comment to:
Sales
Customer Support
Content Development
|
|
| |
|
|
|
|
|
This publication is designed to provide accurate and authoritative information in
regard to the subject matter covered. It is published with the understanding that
the author, editors, and publisher are not engaged in rendering medical, legal,
accounting or other professional service. If medical, legal, or other expert assistance
is required, the service of a competent professional should be sought. We are unable to respond to requests for advice.
Any Sales inquiries should include an email address or other means of
communication.
|