These injuries can be classified into three types: greenstick (partial break), simple and complex. There is some debate about the mechanism of blowout fracture. The sinuses surrounding the orbit include the ethmoidal air cells (anterior, middle and posterior), the sphenoidal sinuses, the maxillary sinuses and the frontal sinuses. 4 Unfortunately, these structures leave the superior, medial and inferior walls of the orbit less supported and vulnerable to catastrophic failure (blowout fracture, trap door fracture) from blunt force trauma. 12 Pneumatized ethmoid air cells, which maintain structural stability and resist fractures of the medial orbital wall, act as a safeguard for the eyeball during trauma. 12 Several sinuses surround the orbit help to lessen the weight of the skull and aid in the resonance of the voice. The other critical anatomical players are the surrounding paranasal air sinuses. 4,11 The orbital roof includes the orbital plate of the frontal bone and the lesser wing of the sphenoid the lateral wall is composed of the zygomatic bone and the greater wing of the sphenoid the floor of the orbit is composed of the orbital plate of the maxilla, the zygomatic and orbital process of the pterygopalentine bone the medial wall of the orbit is composed of the maxilla, the lacrimal, the ethmoid and body of the sphenoid. The seven bones of the orbit include the frontal, zygomatic, maxillary, ethmoid, sphenoid, lacrimal and pterygopalentine. If the eye settles inferiorly or medially into the exposed sinus, enophthalmos with restricted ocular motility will be present with or without loss of facial sensation. Other associated collateral injuries may include subconjunctival hemorrhage, ruptured globe, corneal abrasion, conjunctival laceration, hyphema, iridodialysis, lenticular subluxation, retinal detachment, vitreous hemorrhage, choroidal rupture, traumatic optic neuropathy and optic nerve evulsion. Pain, photophobia and lacrimation associated with post-traumatic uveal inflammation (iritis or iridocyclitis), variable facial swelling secondary to fluid or air (orbital emphysema), crepitus (a crackling noise when tissue infiltrated with air is palpated), gaze-evoked diplopia and pain upon movement of the eyes are all common. 1-4 Patients present with a history of blunt-force trauma, such as being struck with a projectile, like a ball, bat or fist, or being a participant in a collision injury, such as those caused by the impact of an air bag or contact with an object following a fall. The specific term “blowout fracture” is reserved to connote an isolated orbital floor or medial wall fracture in the setting of an intact orbital rim. 3,5-8 Traffic accident is the most common cause of unilateral or bilateral blowout fracture in males between the ages of 30-60 years with violent assault also seen commonly. 1-4 While there is no epidemiologic predilection for “blowout fracture,” there are clinical trends regarding those most likely to sustain these injuries: male, between the ages of 18–30, engaged in activities of poor judgment with most incidents occurring in or near the home. Goldmann applanation tonometry measured 17mm Hg OU.Īdditional testing included forced duction motilities to expose the limits of range of motion and magnetic resonance imaging of the face and head.īlunt trauma to the orbital rim is the typical cause of orbital floor and medial orbital wall fractures. The pertinent exam finding is demonstrated in the photograph. Biomicroscopic evaluation of the anterior segment showed mild ecchymosis adjacent to the area of impact and a small subconjunctival hemorrhage, OS. His external exam was unremarkable, with no evidence of afferent pupillary defect. His best-corrected entering visual acuity was 20/20 OU. The patient’s left eye demonstrated subconjunctival hemorrhage and he reported double vision. He denied having any allergies to medications or the environment. The patient was otherwise free of systemic disease, previous history of trauma or ocular surgery. He did explain that he saw double when he looked to his left. While there was pain to the touch, the eye didn’t ache and vision was not compromised. A 38-year-old Asian male presented emergently following blunt trauma from a fist.
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