Facial Trauma – Orbital Fractures

Overview

1. The clinical spectrum of facial trauma ranges from minimal soft tissue injuries to life threatening panfacial trauma.
2. This guide aims to outline basic assessment, management and referral pathways for the more common patterns of facial trauma namely:
   • Fractures of the mandible
   • Fractures of the zygomatic complex/arch
   • Orbital fractures
3. At presentation patients should be managed according to ATLS protocol so that life-threatening injuries/complications are prioritised.

Orbital Fractures

1. The most common isolated orbital fracture is a “blow-out” fracture involving the orbital floor +/- medial wall.

Clinical Features

1. An eye that is swollen shut still needs to be examined in order to exclude retrobulbar haemorrhage, globe injury or a paediatric orbital floor injury. This will ensure that sight threatening injuries are not missed. Common eye examination findings would include:
   • Subconjunctival haemorrhage
   • Restriction of eye movement
   • Diplopia
2. Numbness in the distribution of the infraorbital nerve

Imaging

1. Occipitomental views (“facial views”). Often at 10 and 30 degrees
2. CT orbits indicated if patient requires CT head or after discussion with OMFS

Must-Not-Miss Diagnoses

1. Retrobulbar haemorrhage: an unusual but significant complication where haemorrhage behind the globe of the eye causes compression of the optic nerve.
   • features include reduced visual acuity, a fixed and dilated pupil, a proptosed and tense globe, ophthalmoplegia and pain
   • management involves urgent discussion with local ophthalmology team and immediate lateral canthotomy and cantholysis with supplementary medical management including high-dose steroids
2. Paediatric orbital injuries: Children are particularly at risk of extra-ocular muscle entrapment with orbital floor injuries. A “trap-door” defect may occur which can result in early necrosis of the trapped soft tissue.
   • classically present as the “white eye blow out fracture” where there is reduced ocular motility +/- features of an exaggerated oculo-cardiac reflex. These patients are often misdiagnosed with a head injury as they feel sick when opening the affected eye.
   • confirm diagnosis with CT orbits
   • require admission and urgent transfer to the Royal Hospital for Children Glasgow under OMFS for surgical intervention to prevent muscle necrosis and permanent visual problems

Management

1. Any concerning eye signs (reduced visual acuity, globe injury, signs of retrobulbar haemorrhage, pain on upward eye movement, or signs of restricted eye movements in children) warrant urgent ophthalmology and OMFS referral
2. All patients with orbital fractures should be instructed not to blow their nose for 3 weeks due to the risk of surgical emphysema
3. In the absence of any concerning features these closed orbital fractures will be reviewed in an OMFS outpatient clinic in 7-14 days. If the patient is being discharged please send a referral to OMFS secretary [email protected] with a copy of the discharge letter. If the patient is remaining an inpatient please refer in-hours to OMFS on-call in DGRI.
4. Antibiotics are not routinely required

Content by Lee Mackie, Updated by Gary Bell