Orbital fracture

5 Interesting Facts of Orbital fracture

1. Orbital fracture refers to a fracture of the bony orbit, including orbital walls, floor, rim, or roof 
2. Although orbital fracture can be suspected based on patient history and physical examination, CT imaging using coronal, sagittal, and axial views is the gold standard for diagnosis 
3. Whereas many cases of orbital fracture can be managed with supportive care and observation, certain cases require surgical repair 
   • Immediate surgical repair indicated for evidence of entrapment (in children, suspicion of entrapment) and significant enophthalmos 
   • Most cases are managed conservatively for a period of up to 14 days to allow periorbital swelling to subside 
     • Surgery is indicated if—after observation period—the patient exhibits enophthalmos greater than 2 mm, ocular motility dysfunction, persistent diplopia, facial hypesthesia in V2 distribution (maxillary nerve), globe malposition, or a fracture of greater than 50% of the orbital floor 
4. Associated ocular injuries occur in up to 29% of patients, the most common of which is commotio retinae; loss of vision occurs in up to 10% of cases 
5. Surgical repair (when indicated) typically leads to good outcome and resolution of symptoms

Pitfalls

• CT scans in coronal view are important for evaluating integrity of the orbital floor, but they can be difficult to obtain in patients with severe head and neck trauma; in these cases, use very thin axial cuts to reconstruct coronal views 
• Trapdoor fractures occur almost exclusively in children, but these fractures do occur in adults; do not discount possibility of trapdoor fracture in any age, as delayed diagnosis and treatment can result in permanent ocular motility disability 
• Trapdoor fractures may be difficult to diagnose owing to an absence of overt signs and symptoms; maintain high clinical suspicion for children with oculocardiac reflex signs and ocular motility with a history of trauma to the eye area 
• Do not rely on CT imaging to diagnose extraocular muscle entrapment 

Orbital fracture is fracture of the bony orbit, which may include the orbital walls (medial or lateral), floor (inferior wall), or less commonly, the roof (superior wall) 

May be isolated or occur in conjunction with other facial fractures and/or damage to facial bones and soft tissue 

Up to 29% of orbital fractures occur in the context of other ocular injuries 

Classification

• Although many terms exist to describe various orbital fractures, fractures should be clinically described by anatomic structures involved, mechanism of injury, and presence or absence of muscle or soft tissue entrapment 
  • Anatomic structures involved:
    • Orbital floor (inferior wall) and medial wall fractures
      • Comprise 81% of all orbital fractures that result from assault 
    • Lateral wall fractures
      • Less common because of wall thickness and protection by the associated temporalis muscle 
      • Often occur with zygomaticomaxillary complex fractures 
    • Orbital rim fractures 
      • Typically involve at least 2 distinct fractures, either on the same rim (eg, when the rim is struck focally) or on more than 1 rim 
        • Zygomatic complex fracture: occurs at 3 points including the inferior rim, the lateral rim, and the zygomatic arch 
        • Le Fort I fracture: horizontal fracture of the anterior maxilla that occurs above the palate and alveolus and extends through the lateral nasal wall and the pterygoid plates 
        • Le Fort II fracture: separation of the maxilla from the facial skeleton in a pyramidal shape; involves inferior orbital rim, orbital floor, medial orbital wall, and medial orbital rim 
        • Le Fort III fracture (craniofacial disjunction): involves lateral orbital rim, lateral orbital wall, orbital floor, medial orbital wall, and medial orbital rim 
    • Orbital roof (superior wall) fracture 
      • Accounts for 1% to 9% of all facial bone fractures 
      • Least common orbital fracture owing to thickness of the bone and proximity of the frontal sinus, which typically collapses first 
      • Typically associated with additional ocular and neurologic injuries, which may lead to late and serious complications such as encephalocele, growing skull fractures, and cerebrospinal fluid leakage 
  • Characterized by the mechanism of injury
    • Blowout fracture
      • Fractures in which bone fragments are displaced away from the orbit; typically increases volume of the orbit 
      • Fracture is confined to the orbital walls (floor and medial wall, less commonly the roof) and does not involve the rim 
    • Blow-in fracture 
      • Displacement of the orbital bones into the orbit, reducing the volume of the orbit
      • Typically caused by an orbital roof fracture resulting from an inferiorly directed supraorbital impact
    • Trapdoor fracture
      • Characterized by outward displacement of the fractured bone and immediate return of the bone to its original position 
      • Also known as linear nondisplaced or white-eyed blowout fractures 
      • Often results in entrapment of muscle or connective tissue; may lead to permanent damage of the neuromuscular complex 
        • Urgent release of entrapped tissue is important to prevent ischemia, scarring, and contraction, which may lead to permanent motility issues 
      • Most trapdoor fractures occur in the orbital floor, but some involve the medial wall 
      • More common in children and adolescents than in adults 
      • Clinically characterized by little ecchymosis or edema and marked extraocular muscle restriction
    • Comminuted fracture (most common isolated fracture) 
      • Characterized by displaced pieces of bone
      • Blowout and buckling fractures are possible
      • Not an indication for urgent care, as early and late treatment (up to several months after trauma) have been shown to produce similar results
• AOCMF classification (Arbeitsgemeinschaft für Osteosynthesefragen Craniomaxillofacial) 
  • Fractures defined by involved bones
    • Nasoorbitoethmoid fracture: trauma to the central upper midface
    • Internal orbital fracture or orbital wall fracture: trauma to the orbital walls and not the frame (includes blowout and blow-in fractures)
    • Combined orbital fractures: trauma involving the entire orbital skeleton
  • Fractures coded according to topography
    • Bony orbit component
      • R: rim
      • W: wall
      • A: apex
    • Bony orbit region
      • S: superior
      • M: medial
      • I: inferior
      • L: lateral
    • Bony orbit region formed by dividing the orbit along its anteroposterior extension
      • 1: anterior section of orbit
      • 2: midorbit

Clinical Presentation of Orbital fracture

History

• Typically, history of trauma to the face and/or associated facial injuries
• Patient may report double vision or vision loss 
• Eye pain, swelling of the surrounding area, bruising, or numbness of the cheek or upper teeth 
• Pain with eye movement, nausea, and vomiting can occur with trapdoor fractures (common in children) 
• Facial deformity (more common with lateral wall fractures) 
• Epiphora may occur with nasoorbitoethmoid fractures, owing to damage to the lacrimal system 

Physical examination

• General signs of orbital fracture
  • Periocular swelling 
  • Proptosis (during acute stages) 
  • Enophthalmos (related to later stages or large fractures)
    • Clinically visible at 3 to 4 mm of displacement; otherwise, may be observed during imaging 
    • Fractures at the medial wall and orbital floor junction (40% of medial wall fractures) may be more likely to result in enophthalmos 
    • May not be visible in acute stages owing to edema and/or hemorrhage 
  • Periorbital ecchymosis 
  • Crepitus may be audible if air from the sinuses has moved to the subcutaneous tissues as a result of nose blowing or sneezing 
  • Chemosis 
  • Facial hypesthesia in V2 distribution (maxillary nerve) 
  • Subconjunctival hemorrhage 
  • Entrapment of extraocular muscles can result in bradycardia, vomiting, syncope, asystole (eg, oculocardiac reflex), and restricted extraocular movements 
    • Oculocardiac reflex is more common with trapdoor fractures
• May differ depending on site or character of fracture
  • Orbital floor 
    • Periorbital edema and ecchymosis may be the only signs
    • Blood in the maxillary sinus
    • Hypoglobus or enophthalmos can result in cases of a large fracture and subsequent loss of support
    • Hypoesthesia, dysesthesia, or hyperalgesia suggests ipsilateral injury to the infraorbital nerve
    • Limited vertical movement, particularly restriction of upgaze, suggests entrapment of the inferior rectus or perimuscular fascia
  • Medial wall
    • May be asymptomatic (discovered incidentally on CT scan) or manifest as subcutaneous emphysema after the patient blows their nose 
    • Nonspecific findings include periorbital edema, ecchymosis, and subconjunctival hemorrhage 
    • Subcutaneous emphysema, epistaxis, and cerebrospinal fluid rhinorrhea are more specific findings 
    • Signs associated with entrapment of the medial rectus muscle include:
      • Globe retraction and palpebral fissure narrowing on attempted abduction (pathognomonic) 
      • Motility defects 
        • Motility restriction is manifested more by paresis of the entrapped muscle rather than limitation of excursions
        • Limitation of abduction, adduction (more common), or both may occur
        • Motility dysfunction associated with entrapped medial rectus muscle may be delayed by several days
      • Palpebral fissure retraction, in association with restricted lateral gaze, can occur with tightly entrapped muscle 
    • Enophthalmos is uncommon in patients with isolated medial wall fractures 
  • Lateral wall
    • Along with periorbital swelling and ecchymosis, patients may exhibit significant facial deformities due to the position of the lateral wall and the resulting changes in globe position if wall is fractured 
  • Point tenderness or bony “step-off” along the orbital rim suggests rim involvement 
  • Orbital roof 
    • Vertical or inward gaze limitation or diplopia suggests muscle involvement (superior oblique or rectus muscles)
    • Abnormal sensation along supraorbital or supratrochlear nerves
    • Displaced fractures are characterized by enophthalmos, hyperglobus, hypoglobus, or proptosis
  • Trapdoor fracture
    • Minimal periorbital edema, subconjunctival hemorrhage, and injection (white-eye blowout) 
    • Typically not associated with enophthalmos
    • Findings may differ depending on presence of entrapment 
      • Those without incarcerated tissue may have relatively normal physical examination findings
      • Those with incarcerated tissue will show ocular motility defects
• Suggested approach to physical examination 
  • For patients presenting with classical signs of orbital fracture, perform an external examination of the periocular tissue and determine globe integrity before performing ocular function testing 
    • If there is evidence of globe rupture, evaluate gross visual function, initiate vaulted eye protection, order orbital imaging, and consult ophthalmologist; evidence of globe rupture includes: 
      • 360° subconjunctival hemorrhage
      • Misshapen pupil (eg, peaked or corectopia)
      • Flat anterior chamber
    • If the globe is intact:
      • Assess extraocular movement 
        • Particularly important in children, owing to higher risk of entrapment
      • Further evaluate ocular motility via forced duction testing only if unable to determine whether entrapment exists based on extraocular movements and/or CT imaging 
        • It is recommended that this test be done only on a limited basis and only if the results will significantly change management of the patient
        • May be inaccurate in acute phase owing to hemorrhage and edema
      • Perform slit lamp examination to evaluate cornea and retina and identify associated injuries
      • Evaluate intraocular pressure with handheld tonometer  
        • Elevated intraocular pressure may result from orbital compartment syndrome

Causes

• Blunt trauma to the midface (most common) 
  • Superior or lateral wall fractures require substantial force, whereas medial wall and orbital floor fractures can occur with mild to moderate force 
    • In adults, the most common causes are motor vehicle accidents and assault 
    • In children, the most common causes are falls and sports injuries 
  • Blowout fractures are typically caused by trauma to the eye by an object larger than the orbital rim; there are 3 proposed mechanisms of fracture: 
    • Hydraulic mechanism: involves an increase in orbital pressure transmitted to the orbital walls, resulting in a blowout fracture 
    • Buckling mechanism: involves posterior movement of the orbital rim, creating pressure on the orbital floor bones 
    • Globe-to-wall contact mechanism: involves posterior displacement of the globe, which strikes the orbital wall, causing the fracture 
  • Blow-in fractures are thought to result from increased intracranial pressure or a shift in the cranium or intracranial contents 

Risk factors and/or associations

Age

• Most orbital fractures occur in patients aged 11 to 50 years, peaking at age 21 to 30 years; however, orbital fractures do occur in children and older adults 
  • Traumatic fracture of the frontal bone and superior orbital rim are more common in children, particularly those younger than 5 years 
  • Trapdoor fractures almost exclusively occur in children and very young adults owing to the greater bone elasticity found in this age range 

Sex

• Most orbital fractures occur in males (75% or more), which is associated more with individual behavior than with biological predisposition 

Ethnicity/race

• Black populations may be anatomically predisposed toward medial wall fractures

How is Orbital fracture diagnosed?

• Diagnosis of orbital fracture itself is based on thorough patient history, physical examination, and imaging 
  • All patients with facial trauma should have a complete primary and secondary survey completed in accordance with advanced trauma life support protocols to rule out any life-threatening trauma 
• Whenever possible, conduct complete eye examination; this is not necessary in emergent situations during acute stages of injury 
• CT scan is the gold standard for diagnosing orbital fractures 
  • Imaging of the entire face (coronal, sagittal, and axial views) is recommended to detect associated fractures, which are common 
    • Coronal view is best to show details of suspected orbital floor fractures 
      • May be difficult to obtain for patients with severe head and neck trauma; in this case, use very thin axial cuts to reconstruct coronal views 
    • Axial and sagittal views are useful for tracking extraocular muscles along orbital course 
    • Perform with thin 2- to 3-mm cuts 
  • Can evaluate fracture size and morphology, identify muscle entrapment into fracture site, and determine whether acute proptosis is secondary to hemorrhage or orbital emphysema 
• Plain radiographs of the face may be obtained when evaluating patients with facial trauma and associated injuries that may suggest an orbital fracture 
  • A Waters projection radiograph of the midface can detect blood (seen as opacity) in the sinuses that results from an orbital floor fracture 
  • Plain radiographs are generally not recommended for primary assessment of orbital fractures, unless CT is not available 

Imaging

• CT scan 
  • Gold standard for diagnosing orbital fractures 
    • Can be used to predict orbital volume change based on fracture size and displacement 
      • Displacement of more than 1 cm² or greater than 50% of the orbital floor predicts development of enophthalmos 
    • Elongated appearance of inferior rectus on cross-section may indicate inferior entrapment 
    • Orbital floor fracture findings include opacification of maxillary sinuses and globe displacement 
    • Trapdoor fractures may not be readily detectable on CT imaging, but subtle imaging changes may suggest presence of fracture 
      • Blood in adjacent sinus
      • Air in the orbit
      • Soft tissue outside of the orbit (teardrop sign) or within the sinus (representing entrapped tissue)
      • Abnormalities in size or shape of orbital muscles
    • Isolated blowout fractures of the medial wall (relatively rare) will typically appear as well-delineated prolapses of medial orbital contents into ethmoid sinus 
  • Do not rely on CT imaging to diagnose extraocular muscle entrapment
• Plain radiographs of face
  • May be ordered to evaluate facial trauma and associated injuries 
  • Certain radiographic findings should raise concern for an orbital fracture
    • On Waters projection, a “hanging teardrop” sign may indicate herniated globe structures (orbit, periorbital fat, and inferior rectus muscle) protruding from the floor of the orbit into the maxillary sinus 
    • Other findings on plain radiographs indicating orbital fracture include subcutaneous emphysema, air-fluid level in the maxillary sinus, and depression of bony fragments 

Differential Diagnosis

Most common

• Orbital hemorrhage
• Extraocular muscle damage
• Trochlear nerve injury

Treatment Goals

• Correct and restore bone fragments and reestablish normal orbital volume 
• Prevent further globe injury

Admission criteria

• Surgery for orbital fracture repair
  • Most surgeons keep patients for less than 24 hours of postoperative observation 
• Postoperative complication of retrobulbar hematoma (rare) 

Recommendations for specialist referral

• Evidence of globe rupture requires immediate ophthalmologist consultation 
• Consult a neurosurgeon early in cases of orbital roof fractures involving pneumocephalus, hematoma, or cerebrospinal fluid leaks 

Treatment Options

Treatment consists of supportive care, observation, and immediate or delayed surgical intervention; choice is based on clinical examination, orbital imaging, and risk-benefit assessment 

• Conservative treatment
  • Indicated for:
    • Fractures with minimal diplopia, no ocular motility dysfunction, and no significant enophthalmos or hypoglobus 
    • Nondisplaced fractures are typically managed conservatively with observation to exclude associated injuries or degeneration 
    • Most pediatric orbital fractures without entrapment can be managed without surgery 
  • Provide supportive care to prevent further globe injury 
  • Trauma surgeons recommend oral steroids to decrease orbital edema, regardless of need for surgery 
• Immediate surgery 
  • Indicated for:
    • Evidence of entrapment (eg, elicitation of oculocardiac reflex or persistent diplopia with positive forced duction test result and radiologic confirmation of orbital fracture); urgent surgery is necessary to release incarcerated tissue
    • Children with restricted eye movements and high clinical suspicion for entrapment (suggesting white-eyed blowout fracture)
    • Significant enophthalmos (larger than 2 mm)
• Observation followed by delayed surgery (within 14 days of fracture), if necessary
  • If there are no indications for immediate surgery, a waiting period of 2 weeks to determine the need for surgery is supported by most literature 
    • Initial observation period allows periorbital edema to decrease and facilitates examination
      • Allowing edema to reduce can provide greater exposure during surgery and lessen risk of compartment syndrome
      • Conversely, delayed surgery can increase risk of fibrosis of the impinged orbital tissues and subsequent diplopia
  • Decision to treat surgically after observation period is based on physical examination and CT findings; the following findings indicate need for surgery: 
    • Enophthalmos (greater than 2 mm)
    • Ocular motility dysfunction
    • Persistent diplopia in primary gaze or reading position
    • Progressive facial hypesthesia in V2 distribution (maxillary nerve)
    • Associated fractures causing facial pathologies 
    • Malposition of globe 
    • Fracture greater than 50% of orbital floor, particularly if associated with medial wall defect 

Drug therapy

• Corticosteroids
  • Methylprednisolone 
    • Methylprednisolone Sodium Succinate Solution for injection; Adults: 250 mg IV at induction of anesthesia followed by 250 mg IV every 6 hours for 3 additional doses postoperatively.

Nondrug and supportive care

Supportive care is indicated to prevent further globe injury 

• Instruct patient not to blow nose, as forcing air into the orbit can result in orbit compartment syndrome
  • Nasal decongestants may be used if necessary 
• Apply cold compresses and elevate head of bed to reduce periorbital edema

Procedures

Surgical repair of fracture

General explanation

• Exposure of fracture site, release of entrapped tissue (if necessary), and repair of orbital wall support, usually with an implant 
• Perform forced duction test to obtain baseline ocular motility before surgery, intraoperatively, and after placing implant to verify ocular motility 
• Intraoperative antibiotic use is well-established 
• Surgical approach depends on type of injury, surgeon experience, and equipment availability 
  • Orbital floor repair
    • Subciliary 
      • Associated with high complication rate
      • Ectropion occurs in 12.9% of cases
    • Subtarsal 
      • Associated with lower complication rate
    • Transconjunctival 
      • Very low complication rate (less than 1%) and no visible scar formation
    • Transcutaneous 
      • Infraorbital or lower eyelid incision
    • Transantral (maxillary sinus) 
    • Endoscopic (transmaxillary and transnasal) 
      • Minimizes globe manipulation and may be ideal for patients for whom traditional approaches are contraindicated
  • Medial wall repair 
    • Transcutaneous (Lynch incision)
      • Allows for good exposure, but can cause severe scarring or webbing
    • Transconjunctival inferior fornix
    • Transcaruncular
      • Does not leave a visible scar
    • Endoscopic transethmoidal
  • Lateral wall repair
    • Via existing lacerations 
  • Orbital roof repair 
    • Coronal
    • Superolateral orbital rim (supraorbital eyebrow or upper eyelid access)
    • Via existing lacerations
• Type of implant material is based on fracture type and location, patient age, and clinician preference 
  • Autogenous bone
    • Benefits: strong, lacks sharp edges, can be fixed to adjacent bone, radiopaque
    • Disadvantage: variable resorption rates, lacks pliability, potential for donor site morbidity
    • Donor sites include calvarium or iliac crest (most common) and nasal, maxillary, or mandibular bone
    • Indicated for fractures in children younger than 7 years
  • Autologous cartilage (septal or auricular cartilage)
    • Benefits: completely biocompatible, simple harvest technique, minimal donor site morbidity
    • Disadvantages: limited structural support, prone to resorption, poor structural support
    • Indicated for small fractures
  • Titanium mesh
    • Benefits: biocompatible, can fit simple and complex orbital defects, provides strong support, able to contour to defect, can be easily fixed to adjacent bone, osseointegration, easily sterilized, available
    • Disadvantages: high cost, allows tissue ingrowth that may make removal difficult, edges are prone to snagging tissue during placement
    • Indicated for large orbital floor defects
  • Porous polyethylene
    • Advantages: high biocompatibility, easily shaped, can be screw-fixated to bone, strong, long-term stability, easily removed
    • Disadvantages: may break into pieces (making removal difficult), expensive
    • Indicated for defects with edges that can support implant
  • Resorbable sheeting (eg, poly[L-lactide]/poly[D-lactide], polyglactin, polydioxanone)
    • Benefits: able to be contoured to the orbital defect, low infection rate
    • Disadvantages: high cost, concern for long-term stability
    • Indicated for small defects (smaller than 2.5 cm²) with stable medial and lateral borders
  • Patient-specific implants
    • Can be custom made from titanium, polyetheretherketone, and glass-bioceramic
    • Benefits: biocompatible, more accurate reconstruction
    • Disadvantages: requires intact contralateral orbit, expensive
    • Indicated for extensive complex orbital defects

Indication

• Immediate surgery is indicated for patients with identified muscle entrapment, children with suspected entrapment, or significant enophthalmos 
• Surgery is indicated if patient exhibits any of the following after an approximately 2-week observation period: 
  • Enophthalmos larger than 2 mm
  • Ocular motility dysfunction
  • Persistent diplopia
  • Facial hypesthesia in V2 distribution (maxillary nerve)
  • Malposition of the globe
  • Fracture of more than 50% of the orbital floor

Contraindications

• Relative
  • Ocular injuries (eg, hyphema, globe perforation, retinal tears) 

Complications

• Diplopia (most common) 
  • Typically only manifests during extreme gaze and does not require treatment
  • May be caused by rectus muscle weakness after releasing entrapped muscle; typically improves within weeks to months
  • Although surgically induced diplopia typically does not require treatment, adding prisms to the patient’s eyeglasses may improve this symptom; on rare occasions, patient may require surgery to reposition extraocular muscles
  • May be more likely in older patients and in those whose surgery was delayed 
• Vision loss (incidence, 0-0.4%); may be due to postoperative intraorbital hemorrhage 
• Traumatic optic neuropathy
• Impingement on orbital apex 
• Retrobulbar hematoma 
  • Necessitates immediate lateral canthotomy to lower intraocular pressure and surgical exploration of orbit
• Lower eyelid retraction 
• Extrusion of orbital implant 
• Orbital congestion 
• Epiphora 
• Late complications include: 
  • Ectropion 
    • Use of subciliary incision may increase risk 
  • Persistent diplopia (does not resolve within weeks to months); affects 8% to 42% of patients and may be due to implant impingement 
  • Infraorbital nerve damage
  • Postsurgical enophthalmos (7%-27%) 
    • Typically results from inadequate orbital volume restoration or fat atrophy
    • May require surgical positioning of implant or placement of additional material if clinically significant

Special populations

• Children
  • If surgery is indicated (eg, for entrapment or enophthalmos), split calvarial bone grafts are indicated for those younger than 7 years; resorbable alloplasts are an alternative 
    • Use of rigid implants may result in orbitomalar growth restriction and maxillary hypoplasia

Monitoring

• After surgical repair, monitor at 2 and 6 weeks for delayed complications; if patient is asymptomatic, continue monitoring at longer intervals for complications that may require further surgery 
  • Indications for repeated surgery (secondary orbital reconstruction): prolonged diplopia, enophthalmos and hypoglobus, telecanthus, contour abnormality or eyelid deformity, entrapped soft tissue 
  • Delay secondary reconstructions at least 6 months to allow adequate healing
• For children with orbital roof fractures, long-term follow-up with CT scans is recommended to evaluate for growing skull fracture (meningocele herniating into orbit) 

Complications

• Associated ocular injuries are common (29% of patients) 
  • Commotio retinae (most common; 22% of cases) 
  • Hyphema 
  • Corneal injury (eg, abrasions) 
  • Lens dislocation 
  • Retinal detachment or hemorrhage 
  • Subconjunctival hemorrhage 
  • Traumatic mydriasis 
  • Traumatic cataract 
  • Vitreous hemorrhage 
  • Traumatic iritis 
  • Acute glaucoma 
  • Traumatic optic neuropathy (3% of orbital fractures) 
    • Suggested by reduced visual acuity, color vision, and afferent papillary defect
  • Globe injury 
• Vision loss (0.7% to 10% of patients) 
• Growing skull fracture can occur in children with orbital roof fractures; as the child grows, so does the fracture 
  • May lead to meningocele that can herniate into the orbit, resulting in diplopia, pulsatile proptosis, and hypoglobus
• Orbital compartment syndrome 
  • Presents with orbital swelling and retrobulbar hemorrhage
  • May lead to optic neuropathy and loss of vision
  • Elevated eye pressure (greater than 40 mm Hg) suggests orbital compartment syndrome and is an indication for immediate canthotomy and cantholysis
• Delayed treatment may result in fibrosis, contracture, and unsatisfactory union 
  • Ischemia leading to Volkmann contracture of the extraocular muscles may occur with white-eyed blowout fractures, orbital compartment syndrome, older patients with hypotension, and patients with small-fracture diplopia 

Prognosis

• For most fractures requiring repair, surgery leads to good clinical outcomes
• For orbital fractures without significant enophthalmos or evidence of entrapment, outcomes may be improved by an observation period to allow edema to reduce and facilitate examination 
• Delaying surgery in cases of entrapment may lead to ischemia or muscle dysfunction due to fibrosis or neuropathic injury 
  • Early surgery for these cases produces a better outcome with a lower incidence of postoperative diplopia 

Prevention

• Methods taken to avoid facial trauma to the ocular area may decrease risk of orbital fractures 
  • Wearing protective goggles or helmets during sports
  • Avoiding aggressive play

Sources

Kunz C et al: The comprehensive AOCMF classification system: orbital fractures – level 3 tutorial. Craniomaxillofac Trauma Reconstr. 7(Suppl 1):S092-102, 2014 Reference