Orbital floor fracture results from facial trauma. This type of fracture is mostly seen in young men and is often a result of motor vehicle accident or violence. Features include edema, decreased mobility of extraocular muscles, and visual disturbances.
Orbital floor fractures (OFFs) occur frequently, mainly in the context of trauma from physical altercations or road traffic accidents [1]. The main demographic characteristic that presents with this type of injury is the involvement of young men [2]. Orbital floor fracture can either be direct or indirect, where direct involves the orbital rim while indirect are exclusive to the orbital floor. On inspection, periorbital edema and bruising may be observed. In those who have sustained direct fractures, palpation may reveal a tender 'step-off' area on the orbital rim.
OFFs usually present with a combination of visual disturbances and eye movement dysfunction that include diplopia, proptosis, displacement of the eyeball in the orbit, either posteriorly (enophthalmos) or inferiorly (hypoglobus), and muscle or nerve entrapment. Hypesthesia, dysesthesia, and hyperalgesia are all signs of nerve injury. Extraocular muscle entrapment is evidenced by restricted ocular movements and the presence of an oculocardiac reflex, characterized by bradycardia, syncope, and nausea [3].
Children frequently have an atypical presentation, often described as 'white-eyed' orbital floor fracture, due to the absence of significant ecchymosis and erythema. Radiological signs are often minimal, and orbital emphysema may be present [4] [5].
Furthermore, "trapdoor" fractures are mostly seen in children. These involve muscle (inferior rectus) entrapment, however, they present with little sign of bone displacement or serious injury [6]. They usually exhibit a disturbance in ocular movements. This is important for physicians to note, as delayed treatment leads to permanent neuromuscular complications.
As OFFs are sustained via trauma, the initial workup should involve a primary survey and detailed physical examination. Subsequent examination of the globe is important, as patients may have sustained injuries to its structures which can be sight threatening and may need to be addressed urgently. The latter include retinal detachment, corneal abrasion, and neuropathy [7]. Patients may also have acute closed angle glaucoma, vitreous hemorrhage, and globe rupture. Patients may complain of loss of color vision and a deterioration in visual acuity. Presentations lacking visual symptoms do not rule out the possibility of globe injuries [8]. Elements that should be evaluated are the location and extent of damage, the presence of hemorrhage, globe injury, and soft tissue entrapment [9].
The principal imaging technique used is computed tomography (CT). This is a precise imaging modality in the assessment of the integrity of skeletal structures of the orbit. Furthermore, the use of CT scanning is useful in predicting the outcome of injury [10]. Entrapment of muscle can be evaluated by forced ocular supraduction or infraduction. However, this is only done if CT assessment does not yield clear results.
X-rays are no longer routinely requested, having been largely replaced by CT. The former may detect fat prolapse through what is known as the "tear drop" sign, in addition to the fluid collection in the maxillary sinus and orbital emphysema. Magnetic resonance imaging (MRI) has the advantage of being able to show multiple planes and is best in visualizing soft tissue injuries.