Orbital Floor Fracture

Four hours before he arrived at the emergency department, a 33-year-old man had been struck in the face by a rock. A laceration and periorbital hematoma were noted on the left side of the patient’s face. He complained of pain in this area. There was no history of intraocular disease. The left globe was intact, and no neurologic deficit was found. Carol A. Lundin, MD, and Joel M. Schwartz, MD, of Irvington, NY, report that a supine radiograph demonstrated interruption and widening of the floor of the left orbit (A). An upright radiograph revealed fluid in the left maxillary sinus (B, arrow), consistent with hemorrhage. Orbital floor fracture was diagnosed. An axial CT scan of the orbits demonstrated widening and increased density in the periorbital fat, which indicated soft tissue swelling (C). The scan was performed to evaluate the medial and lateral walls of the orbit, which were determined to be intact. A direct coronal CT scan showed the depressed fracture of the orbit floor, hemorrhagic debris in the left maxillary sinus (D, white arrow), and intraorbital emphysema (D, red arrow); air was noted passing through the fracture from the left maxillary sinus into the left orbit. Coronal imaging is best for visualizing the roof and floor of the orbit. If direct coronal imaging cannot be performed, thin-section axial images can be obtained with generation of coronal reformats. Orbital floor fractures may be caused by direct trauma to the inferior orbital rim, which results in buckling of the orbital floor. Fractures may also occur when rapidly increased intraorbital pressure is decompressed at the weakest point of the bony confines of the orbit. Suspect an orbital fracture when a patient has a history of trauma, ecchymosis with or without edema of the lids, diplopia, hypoesthesia of the cheek (related to injury to the infraorbital nerve), or emphysema of the orbit or lids. Enophthalmos and ptosis of the globe indicate a large fracture. Fractures of the orbit frequently involve the weakest part of the bony orbit-the lamina papyracea or medial wall. If the medial wall is involved, hemorrhagic debris is seen in the ethmoid complex, and air that emanates from the ethmoid results in intraorbital emphysema. Fractures of the orbit roof and lateral wall are much less common. They can be complicated by cerebrospinal fluid leak and herniation of intracranial contents into the orbit; entrapment of the superior rectus muscle is rare. Most orbital floor fractures heal without treatment, as in this case. Consider surgical repair in the event of complications, such as sensory disturbance as a result of injury of the infraorbital nerve, muscle entrapment when the inferior rectus herniates through the fracture defect, and enophthalmos from herniation of large portions of orbit contents into an adjacent sinus.