Orbital Fracture

Key Clinical Findings

• Reduced visual acuity

• Limited extraocular movements (possible muscle entrapment, often the inferior rectus)

• Hyphema (blood in anterior chamber)

• Infraorbital numbness (injury to infraorbital branch of trigeminal nerve)

• Palpable depression of the malar eminence (zygomaticomaxillary involvement)

• Subcutaneous emphysema in eyelids or conjunctiva (air leaking from sinus into orbit)

• Trismus (limited mouth opening if zygomatic arch or pterygoid involvement)

• Diplopia (particularly on upward gaze if inferior rectus muscle is entrapped)

• Enophthalmos (posterior displacement of the globe)

Immediate Concerns

• Red Flags for ED Review

  • Severe visual impairment or suspicion of globe rupture (irregular pupil, uveal prolapse)

  • Retrobulbar haematoma with increasing pain and proptosis (requires emergent decompression)

  • Significant hyphema or signs of raised intraocular pressure

Investigations

• Facial Bone CT (thin slices, including coronal views)

  • Identifies fractures of the orbital floor, medial wall, zygomaticomaxillary complex

  • Assesses for extraocular muscle entrapment or herniation of orbital contents

• Ophthalmological Assessment

  • Visual acuity, pupils (RAPD check), extraocular movements, slit-lamp exam if available

  • Forced duction test by ophthalmology if muscle entrapment is unclear

Management

• Initial Measures

  • Advise patient to avoid blowing nose for 2 weeks (prevent orbital emphysema)

  • Apply ice packs for up to 48 hours to reduce periorbital swelling

  • Provide analgesia (paracetamol, NSAIDs) as required

  • Consider prophylactic antibiotics (e.g., amoxicillin-clavulanate) if the fracture communicates with the sinus cavity

• Referral and Follow-up

  • Urgent maxillofacial (maxfax) or ENT referral within 1–3 days for orbital floor fractures or significant zygomatic involvement

  • Ophthalmology review if persistent diplopia, enophthalmos, or suspected eye injury

  • Surgical repair may be indicated for large orbital floor defects, significant enophthalmos (>2 mm), persistent diplopia, or muscle entrapment

• Aftercare

  • Observe for changes in vision or ocular alignment

  • Instruct patient to rest, avoid strenuous activity, and adhere to follow-up appointments

  • If diplopia persists or globe displacement remains beyond 2 weeks, specialist ophthalmological evaluation is crucial

Notes:

• Always evaluate visual acuity, ocular movements, and perform a thorough cranial nerve exam

• Infraorbital numbness suggests damage to infraorbital nerve, which can guide fracture location

• Early imaging and referral optimise outcomes and reduce risk of long-term complications (cosmetic deformity, chronic diplopia, chronic numbness)

• Watch for signs of infection (sinus involvement) or persistent swelling that could indicate a developing complication