What is the diagnosis and treatment for a blowout fracture of the orbital floor?

From the Guidelines

The diagnosis of a blowout fracture of the orbital floor should be made using a CT scan, and treatment should be individualized based on the size and location of the fracture, as well as the presence of any functional problems, with surgical repair typically recommended within 2 weeks for symptomatic diplopia or large floor fractures 1. To assess for an orbital floor fracture:

• Perform a thorough eye exam, checking for diplopia, enophthalmos, and infraorbital numbness.
• Order a CT scan of the orbits with thin-slice axial and coronal views.
• Consult ophthalmology or maxillofacial surgery if a fracture is confirmed. The goals of treatment are to eliminate diplopia in the primary position and downgaze, and to enlarge the field of binocular single vision 1. Management typically involves:
• Conservative treatment for small, non-displaced fractures
• Surgical repair for large fractures or those causing functional problems, such as symptomatic diplopia or significant fat or periorbital tissue entrapment
• Pain management with NSAIDs or acetaminophen
• Antibiotics if there's evidence of infection or open fractures Patients should be advised to avoid nose-blowing and instructed on proper sinus precautions to prevent complications. In cases where surgical intervention is not immediately necessary, waiting 4 to 6 months after the injury may be advised to ensure stability of the misalignment prior to repair 1. Surgical repair within 2 weeks is recommended for patients with symptomatic diplopia, large floor fractures, or significant fat or periorbital tissue entrapment, as these conditions can result in permanent strabismus or other functional problems if left untreated 1.

From the Research

Diagnosis of Blowout Fracture of the Orbital Floor

• The diagnosis of a blowout fracture of the orbital floor is typically made based on a combination of clinical findings, including double vision, a sunken globe, and numbness in the distribution of the infraorbital nerve 2.
• Imaging studies, such as computed tomography (CT) scans, can be used to confirm the diagnosis and assess the extent of the fracture 2, 3.
• The CT variables that are most predictive of diplopia in patients with orbital blowout fractures include orbital floor fracture, extraocular muscle (EOM) displacement, and EOM entrapment 3.

Treatment of Blowout Fracture of the Orbital Floor

• The treatment of a blowout fracture of the orbital floor depends on the severity of the fracture and the presence of any complications, such as entrapment of the inferior rectus muscle 4.
• Prompt surgical intervention is often recommended in cases where there is entrapment of the inferior rectus muscle, as prolonged entrapment can lead to muscle ischemia and necrosis 4.
• The use of intraoperative CT scans has been shown to decrease the rate of postoperative complications, including diplopia, in patients undergoing orbital floor fracture repair 5.
• In some cases, delayed surgical treatment of blowout orbital floor fractures in children may lead to unsatisfactory functional results, and additional correction of strabismus may be necessary to obtain functional quality vision and satisfactory aesthetic appearance 6.

Surgical Techniques

• Various surgical techniques can be used to repair a blowout fracture of the orbital floor, including the transconjunctival approach, which is the most common approach used 5.
• The choice of implant material and the use of intraoperative CT scans can also impact the outcome of the surgery 5.
• Autogenous mandibular symphyseal grafts can be used for orbital floor reconstruction in children, and additional correction of strabismus may be necessary in some cases 6.