What is Orbital Floor Fracture?
The bones that make up the eye socket, or the ‘orbit’, include the frontal, ethmoidal, sphenoid, zygomatic, and lacrimal bones. The construction of the socket includes the maxillary and lacrimal bones that create the inner side of the socket and the ethmoid bone’s thin sheet, the lamina papyracea. At the back of the socket, we find the sphenoid bone, containing a small channel, called the orbital canal, for nerves to pass through. The third, fourth, fifth, and sixth cranial nerves run close to this canal via a split known as the superior orbital fissure. The side wall of the socket is the job of the zygomatic bone. The brow and cheekbones, being the frontal and maxillary bones, respectively, frame the top and bottom of the eye socket.
Inside this socket, we find the six muscles responsible for eye movement. These are broken down into four ‘straight’, or rectus, muscles and two ‘slanting’, or oblique, ones. The eye, or ‘globe’, is also surrounded by fat and connective tissue, which help ease the pressure exerted by these muscles.
Because the bones in the eye socket are thin and fragile, they’re quite prone to breakage, even from minor injuries. Fractures can see a single or multiple bones in the socket affected, creating a variety of different break patterns. Furthermore, due to the close proximity of the eye socket to important structures within the skull, a thorough understanding of its layout is essential. Healthcare providers must be careful with their diagnosis tools and often need to collaborate with specialists to manage patients with eye socket fractures. Tailoring treatment options according to the exact fracture, its severity, and any related injuries helps minimize possible complications.
What Causes Orbital Floor Fracture?
A blowout fracture happens when the walls of the eye socket are broken, but the rim of the eye socket is not. This type of injury is often caused by things like falls, sports injuries from high-speed balls, car accidents, or physical violence. It usually happens when a force hits the eye directly but doesn’t push against the edge of the eye socket. Sometimes, after the fracture occurs, the pressure inside the eye socket can increase, sort of like a hydraulic effect. At other times, the fracture is caused when the force hits the edge of the eye socket, creating a buckling effect.
In children, a different kind of fracture might occur after an injury to the eye socket, known as a “trapdoor fracture”. This happens because the bone in children is still soft and flexible, so when a fracture happens, the bone pops back into place, but it might trap some soft tissues from the eye socket when it does so. Trapdoor fractures can be tricky because there might not be any obvious signs of injury, which is why it is sometimes referred to as a “white-eyed blowout.” In contrast, blowout fractures in adults usually come with visible changes to the soft tissue around the eye, like a sunken eye.
Risk Factors and Frequency for Orbital Floor Fracture
Orbital fractures, which are cracks or breaks in the bones around the eye, are more frequently seen in males and usually happen between the ages of 21 and 30. The most common places for these fractures are the orbital floor (the bone at the bottom of the eye socket) and the medial orbital wall (the inner side of the eye socket). The main causes for these types of fractures include falls, car accidents, and physical assaults.
Signs and Symptoms of Orbital Floor Fracture
When someone comes to the emergency room after head trauma, they could be conscious or unconscious. Those that are unconscious require immediate medical treatment and possibly resuscitation. Before assessing the full situation, it’s crucial to ensure that there aren’t any life-threatening injuries.
After emergencies have been ruled out, the healthcare provider can start to gather more information about the injury. They’ll ask about how and when the injury happened, and when symptoms appeared. Patients may report changes in vision, headaches, dizziness, pain or numbness around the eyes, swelling, and difficulty moving their eye or eyelid.
During a physical examination, the provider will check for signs of injury around the eye. This includes swelling, bruising, deformities,.. They will also check eye function by assessing vision, eye alignment, and eye muscle movement. Through a special examination called an ophthalmoscopy, they can check for any internal eye injury, like a detached retina. If a patient has eye pain and reduced vision, the doctor might suspect that the eyeball has ruptured.
Physical examination can reveal irregularities in the bones around the eye that can help locate the fracture. Also, the provider may need to check for a blood clot in the nose. It’s crucial to rule out large fractures that could lead to complications, such as the eye sinking backward into the orbital socket, misalignment of the structures below the eye, and disruption of the optic nerve.
Various symptoms might suggest an orbital floor (the bottom of the eye socket) fracture, including:
- Double vision when looking up
- Difficulty looking upwards
- Tenderness or step-offs at the lower edge of the eye socket
- No response of the pupil to light
- Poor vision
- Swellings and bleeding beneath the conjunctiva of the eye
- Bruising and swelling around the eye
Specific symptoms can indicate damage to certain structures:
- If sense of touch decreases over the lower edge of the eye socket and spreads to the side of the nose, this indicates damage to the trigeminal nerve.
- Crackling under the skin is a sign of a fracture in the maxillary sinus (a hollow space located beneath the cheekbone).
- If the muscle controlling downward eye movement (inferior rectus) is caught between broken pieces of the lower eye socket, this could be associated with damage to the eye muscle nerve.
- If the fractured eye socket bones push the eyeball backward, forward, or cause swelling behind the eyeball, a displacement of the fractured eye socket bones has occurred.
Early referral to an eye doctor or specialist for the eye socket might be required for further evaluation and decisions about treatment.
Testing for Orbital Floor Fracture
Imaging tests are commonly used to tell the difference between an orbital floor fracture and similar conditions such as medial or lateral wall fractures, orbito-zygomatic fractures, LeFort I, II, and III fractures, and nasoorbital ethmoidal fractures (also known as Markowitz fractures).
Plain x-rays can help determine if you have an orbital floor fracture. This could be the case if you have specific signs, such as subcutaneous emphysema (air trapped under your skin), a soft-tissue teardrop shape along the roof of your maxillary sinus (a hollow space within your cheekbone), or an air-fluid level in your maxillary sinus.
A type of imaging test called a computed tomography (CT) scan is the best method when looking for or assessing a blowout fracture. A CT scan might show orbital fat or the inferior rectus muscle (one of the muscles that move your eye) bulging into the maxillary sinus. This test can also detect hidden tears and any foreign bodies that might be present.
If surgery is being considered, preoperative blood work should be done. This might involve a complete blood count, testing for electrolytes (minerals in your blood and body fluids that carry an electric charge), a coagulation profile (tests that check how well your blood clots), and a pregnancy test for females.
Treatment Options for Orbital Floor Fracture
The main objective in treating orbital fractures, or broken bones around the eye, is to restore the look and function of the eye area. Depending on the situation, some cases can be handled without surgery, while others may require surgical intervention. People with orbital fractures should always be given antibiotics as a preventive measure against infections from mouth bacteria. Medicines like corticosteroids that reduce swelling may also be prescribed. It’s also important to avoid blowing the nose or doing anything that increases pressure in the chest, as this can worsen swelling in the eye area.
If surgery is necessary, it aims to put misplaced structures back into the eye cavity. Surgeons can access the area either through the lower eyelid or through the upper jaw. There are various types of implants that can be used in rebuilding the area, but if there is an ongoing infection, placement of an implant is not advisable. Using endoscopic methods, which involves inserting a scope through a small incision for viewing, is also an option in repairing orbital fractures.
Immediate surgery is necessary in specific situations such as children with a special type of fracture known as ‘trapdoor’, individuals with unstable vital signs, severe eye-related bleeding leading to progressive loss of sight, and significant sinking of the eyeball initially. Surgery may also be needed immediately if there’s trapping of structures in the eye socket, persistent double vision, sinking of the eyeball, abnormal lowering of the eyeball, or considerable damage to the floor of the eye socket, but most times, surgery for these conditions is delayed for a more thorough examination. An urgent repair is always needed for open injuries to the eye, however, repair of any orbital fractures should be delayed until the eye injury is stable.
Generally, surgery should ideally be performed within 2 weeks of getting the injury, to prevent scar formation. The typical practice is to wait a day or two to allow swelling to reduce. Sometimes, if a child has suffered an orbital fracture causing eye movement issues, results can be better if surgery is done within a week of the injury. However, if the patient’s only problem is related to the nerve infraorbital (a nerve near the eye) dysfunction, deciding on repair may require expertise and judgement. Some surgeons have reported good outcomes with early repair.
Before starting an orbital fracture repair procedure, it’s necessary to record the patient’s current sight, eye motor function, presence of double vision, degree of eyeball sinking, and any abnormal sensation. During the surgery, the function of the patient’s pupil must be repeatedly checked. The anesthesiologist should avoid giving any medications that may change the size of the pupil. The anesthesiologist also needs to be aware that slowing of the heart rate may occur due to the eye-heart reflex when there’s manipulation of the eye muscles.
For orbital fractures where the bone hasn’t moved, and there have been no immediate changes in the eye’s size, non-surgical treatment might be appropriate. Situations where surgery might not be recommended include the presence of blood in the anterior chamber of the eye, retinal tears, an injury perforating the eye, and overall medical instability.
What else can Orbital Floor Fracture be?
When a person experiences swelling around the eye, changes in vision, or issues with eye movement, it might be due to an injury to the orbit (eye socket). However, there are several other conditions that could cause similar symptoms and be confused with an orbital fracture. These are:
- Edema (swelling) in the soft tissues around the eye due to injury
- Abducens nerve palsy – a condition that affects the nerve responsible for eye movement
- Traumatic diplopia – double vision resulting from trauma
- Compressive optic neuropathy – damage to the optic nerve due to pressure
- Oculomotor nerve palsy – a condition that impacts the nerve controlling most of the eye’s movement
- Trochlear nerve palsy – affects a nerve that controls the movement of a specific eye muscle
A detailed medical assessment will aid in distinguishing an actual orbital fracture from these possible conditions.
What to expect with Orbital Floor Fracture
The outlook for healing broken bones in the eye socket, or orbital floor fractures, varies based on several factors. These include the complexity of the problem, the presence of other injuries or health issues, how quickly treatment is received, and differences in individual healing rates.
As a general rule, fractures that involve one bone and have little shifting of the broken bone, as well as trapdoor fractures, tend to heal better than those that involve multiple bones, or where the broken parts have moved a lot.
Whether there are other injuries or medical conditions can impact when surgery can happen. Quick treatment can prevent other issues and result in better healing. The bones around the eye usually mend well with the right treatment and physical therapy, unless the patient has a health issue that can slow down recovery, like uncontrolled diabetes. Whether a person’s vision completely recovers also depends on all these factors.
In the end, many patients with fractures in the bones around the eye get satisfying results with the right medical or surgical treatment. Being referred to an eye specialist or expert in eye socket injuries early on is crucial for getting personalized treatment and a better healing outlook.
Possible Complications When Diagnosed with Orbital Floor Fracture
There can be both immediate and later complications from eye surgery. These might include vision loss due to a large blood clot behind the eye or pressure on the back part of the eye socket. Some complications that may develop some time after the surgery are inward or outward turning of the eyelid, double vision, numbness beneath the eye, sunken eyes, and even blindness, and these can vary depending on the specific surgical method used. It’s important to quickly get specialist care and treatment to prevent these complications.
Possible Complications:
- Vision loss due to a large blood clot behind the eye
- Pressure on the back part of the eye socket
- Inward turning of the eyelid (Entropion)
- Outward turning of the eyelid (Ectropion)
- Double vision (Diplopia)
- Numbness beneath the eye (Infraorbital Paresthesia)
- Sunken eyes (Enophthalmos)
- Blindness
Recovery from Orbital Floor Fracture
Following surgery, it’s important for healthcare professionals to keep an eye out for possible complications such as infection or changes in vision or nervous system function. Visual clarity and pupil activity should be watched carefully, as any declines might mean another procedure is needed. To reduce swelling, patients should be advised to keep their head raised or sit upright. Applying a cool compress can also help lessen pain and swelling at the site of the surgery.
During the early stages of recovery, patients should be told to rest and avoid intense activities to support proper healing. Protecting the affected eye with a shield or patch could be suggested to prevent unexpected injury or additional damage. Patients should also have their pain managed properly before beginning any therapy sessions.
Guidelines for proper eye care, including how to clean the affected eye, how to administer eye medications, and how to maintain good overall eye health, should be provided. Patients suffering from blurred vision or double vision may be recommended vision therapy or exercises to help their eyes realign and coordinate.
As the healing progresses, patients might be allowed to slowly return to their normal activities. Regular check-ins with an eye doctor are essential to track healing, watch for complications, and manage any continuing symptoms.
Preventing Orbital Floor Fracture
To prevent fractures around the eye socket (also known as orbital fractures), a few safety measures can help lessen the risk of facial injuries. Here are a few steps you can take:
One way is by wearing safety gear, especially helmets, masks, safety goggles, and face shields, when doing high-risk activities. These could include playing sports, working on construction sites, or riding motorcycles.
Another is by making sure the areas where young children and older individuals spend a lot of time have non-slip floors. This can reduce the chances of slips and falls, which could lead to injuries.
Practicing safe driving habits, such as wearing seat belts and obeying traffic rules, can also significantly lower the risk of accidents leading to facial injuries.
It’s also important to keep up with regular eye check-ups. Spotting and treating vision problems early can help prevent falls. Lastly, good and healthy social relationships can prevent fights or arguments that could lead to physical harm and facial trauma.
Although it’s impossible to prevent all facial injuries, these precautions can greatly lessen the chances of sustaining an orbital fracture.
