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Questions Answered: 300

Final Score 76%

229
71

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Maxillofacial & Dental

Question 42 of 300

A 23 year old woman presents to the Emergency Department after being involved in an altercation in a nightclub. She recalls being punched twice, once on the left side of her face and once directly to her nose. She did not lose consciousness and has full recollection of the events. You arrange for facial x-rays. Which of the following findings on facial x-ray is pathognomonic for an orbital blow-out fracture?

Answer:

The diagnosis of orbital blow-out fracture may be made on routine facial x rays (e.g. the pathognomonic "teardrop sign") but CT scan remains the gold standard if this injury is suspected or identified.

Orbital Blowout Fracture

Maxillofacial & Dental

Last Updated: 14th December 2023

In an orbital blowout fracture, the pressure from a direct blow involving the relatively tough globe is transmitted downwards, fracturing the floor of the orbit, and often results in herniation of intraocular contents into the maxillary sinus. This type of fracture typically occurs due to a direct blow to the central orbit e.g. from a fist, ball, elbow, dashboard or car seat.

Clinical anatomy

The bony orbit is composed of thickened orbital rims (margins) but relatively thin inner walls. The zygoma and maxilla form the greater part of the medial, inferior and lateral orbital margins as well as almost all of the orbital floor.

Bony Orbit. (Image by OpenStax College [CC BY 3.0 , via Wikimedia Commons)

Clinical features

  • Enophthalmos (due to increased orbital volume)
  • Diplopia/ophthalmoplegia, particularly upward gaze (due to trapping of the herniated inferior rectus muscle)
  • Orbital emphysema (fracture into adjacent paranasal sinus, usually the maxillary)
  • Malar region numbness (injury to infraorbital nerve)
  • Subconjunctival haemorrhage – if a clear posterior border cannot be seen , it is likely blood has tracked round the eye from a fracture of the orbital wall

Diagnosis

The diagnosis of an orbital blowout fracture may be made on routine facial x-rays (e.g. a 'teardrop' sign caused by soft tissue herniating through roof of maxillary sinus) but CT scan remains the gold standard if this injury is suspected or identified.

Relatively recently, focused ocular ultrasound (FOUS) has been evaluated in the ED and found to be highly accurate in both diagnosing and excluding both orbital and ocular trauma.

Management

Clinical suspicion of an orbital blowout fracture (e.g. diplopia or reduced eye movements) merits urgent referral to a maxillofacial surgeon and/or an ophthalmologist.

Although plain x-ray may reinforce suspicion, facial CT scan will be needed to visualise the fracture in detail and plan surgical repair.

There is no evidence to support routine antibiotic prophylaxis in orbital floor fracture (despite risk of orbital cellulitis) and local guidance should be followed.

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l
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