What is the best course of management for a 30-year-old male patient with a mildly displaced right orbital fracture, right nasal bone fracture, and facial soft tissue contusion following an altercation?

Management of Mildly Displaced Right Orbital and Nasal Bone Fractures

For a 30-year-old male with mildly displaced right orbital wall fracture, right nasal bone fracture, and facial soft tissue contusion following an altercation, observation with close follow-up is the recommended management approach, as surgical intervention is not immediately indicated for these mild fractures.

Initial Assessment and Imaging Evaluation

The patient has already undergone appropriate imaging studies:

• CT head (showing no acute intracranial abnormality)
• CT maxillofacial (revealing mildly displaced right medial orbital wall fracture and mildly displaced right nasal bone fracture)
• CT cervical spine and CT CAP (presumably normal)
• XR left shoulder

These imaging studies are appropriate for facial trauma evaluation, as CT maxillofacial is the gold standard for diagnosing facial fractures 1. The CT head was also appropriate to rule out intracranial injury, which is found in up to 68% of patients with facial fractures 1.

Clinical Evaluation

Key findings to assess in this patient:

• Visual acuity and ocular motility
• Presence of diplopia (especially in primary or downgaze)
• Forced duction testing to check for muscle entrapment
• Enophthalmos or hypoglobus
• Infraorbital nerve function (paresthesia)
• Nasal airway patency
• Presence of septal hematoma (requires immediate drainage if present)

The patient currently reports 5/10 pain around the right orbit but denies dizziness or nausea, which is reassuring.

Management Recommendations

For the Orbital Fracture:

Based on the American Academy of Ophthalmology guidelines 1, management should follow these principles:

1. Observation is appropriate since:

   • The fracture is described as "mildly displaced"
   • There is no mention of diplopia in primary or downgaze
   • No evidence of muscle entrapment
   • No mention of enophthalmos or hypoglobus

2. Follow-up evaluation should assess:

   • Development of diplopia
   • Restriction of ocular motility
   • Evidence of enophthalmos or hypoglobus
   • Infraorbital nerve function

3. Surgical intervention would be indicated if:

   • Symptomatic diplopia develops in primary or downgaze
   • Positive forced ductions or evidence of entrapment on CT
   • Development of significant enophthalmos or hypoglobus
   • Progressive infraorbital hypoesthesia

For the Nasal Bone Fracture:

According to the Praxis Medical Insights summary of clinical guidelines 2:

1. Referral to a specialist (otolaryngologist or plastic surgeon) is recommended for evaluation
2. Early intervention (within 1-2 weeks) is critical if surgical management is needed
3. Closed reduction would be appropriate for this mildly displaced fracture if cosmetic or functional concerns develop

Follow-up Plan

1. Short-term follow-up (within 1 week):

   • Assess for development of diplopia
   • Check for nasal airway obstruction
   • Evaluate for septal hematoma

2. Medium-term follow-up (2-3 weeks):

   • Reassess need for surgical intervention
   • Evaluate for persistent nasal deformity or breathing difficulties
   • Check for resolution of orbital pain

3. Long-term follow-up (if needed):

   • Address any persistent functional or cosmetic concerns

Important Caveats and Pitfalls

1. Delayed complications: Diplopia may be transient following trauma, but if it persists beyond 6 months, it is unlikely to resolve spontaneously 1.

2. Septal hematoma: Must be ruled out and drained immediately if present to prevent cartilage necrosis and saddle nose deformity 2.

3. Associated injuries: Nasal fractures may be part of more extensive facial trauma requiring comprehensive evaluation 2.

4. Timing considerations: If surgical intervention becomes necessary, early intervention (within 1-2 weeks) provides optimal outcomes for both orbital and nasal fractures 1, 2.

5. Pain management: Appropriate analgesia should be provided for the patient's 5/10 orbital pain.

The patient should be advised to return immediately if symptoms worsen, particularly if diplopia, visual changes, or increased pain develops.