Case 9

30 year old female
Punched in the left eye after quarrel with boyfriend.
What is the diagnosis?
How would you manage this condition?

(P.S : ignore the radio-opaque artifact in the right orbit)

Answer : Blow-out Fracture


As shown above, a blow-out fracture results from a direct compressional force to the orbit, which results in increased intraorbiral pressure. The weakest part of the orbit is its inferomedial floor (lamina papyracea). The fracture may lead to the herniation of the orbital contents into the maxillary antrum.

Approach

1. As for all trauma cases, ensure ABCs are secure, esp. with respect to head injuries or cervical spine injuries that may require earlier attention than the orbital fracture.
2. Examine the affected eye to rule out urgent ocular injuries e.g. penetrating globe injury/ compressive orbital emphysema/ retrobulbar hemorrhage --> refer to Eye stat!
   
3. Test eye-movements to look for impingement on upward gaze (demonstrated in the clinical photograph above), which may suggest herniation and entrapment of extraocular muscle.
   
4. Test for infraorbital anesthesia - tap incisors on both sides to see if there's any difference in sensation.
   
5. Plain facial (OM view) X-rays to look for 'tear-drop' sign (suggestive of herniation into maxillary antrum and seen in X-ray above) and fluid-level/ opacification in affected maxillary antrum (likely to be bleeding in trauma setting).
6. Disposition - Refer to Plastics/ Eye. Consider antibiotics if there is evidence of blood in maxillary antrum.
7. Offer referral to counselling/ PSY in the setting of abuse. Document all findings carefully because this is a potential legal case and you may be asked to appear in court later.