What is the diagnosis and treatment for a blowout fracture?

From the Guidelines

The diagnosis and treatment of a blowout fracture should prioritize immediate repair for patients with CT or MR imaging evidence of an entrapped muscle or periorbital tissue associated with a nonresolving oculocardiac reflex, while observation may be considered in cases of minimal diplopia and good ocular motility without significant enophthalmos or hypoglobus. The diagnosis of a blowout fracture typically involves a combination of clinical evaluation and imaging studies, such as CT or MR scans, to assess the extent of the fracture and any associated complications, such as muscle entrapment or enophthalmos 1.

Key Considerations

• Symptoms of a blowout fracture may include diplopia, enophthalmos, restricted eye movement, numbness in the cheek or upper lip, and periorbital swelling or bruising.
• Treatment options depend on the severity and symptoms of the fracture, with conservative management or surgical repair being considered based on factors such as the size of the fracture, presence of muscle entrapment, and degree of enophthalmos.
• Surgical repair typically involves reconstructing the orbital floor using implants, such as titanium mesh or porous polyethylene, to restore orbital volume and free entrapped tissues 1.

Timing of Surgical Repair

• Immediate repair is indicated for patients with evidence of an entrapped muscle or periorbital tissue associated with a nonresolving oculocardiac reflex, as well as for cases of globe subluxation into the maxillary sinus 1.
• Repair within 1 to 2 weeks may be considered for patients with symptomatic diplopia, positive forced ductions, or entrapment on CT, as well as for large floor fractures, hypoglobus, and progressive infraorbital hypoesthesia 1.
• Delayed repair may be considered for patients with restrictive strabismus and unresolved enophthalmos, while observation may be considered in cases of minimal diplopia and good ocular motility without significant enophthalmos or hypoglobus 1.

Additional Recommendations

• Patients should avoid nose blowing for several weeks after injury to prevent orbital emphysema.
• Antibiotics may be prescribed if the fracture communicates with sinuses to prevent infection.
• Early ophthalmology and maxillofacial surgery consultation is essential for proper evaluation and management planning 1.

From the Research

Diagnosis of Blowout Fracture

• The diagnosis of a blowout fracture involves evaluating the patient for symptoms such as diplopia, enophthalmos, and infraorbital hypesthesia 2, 3, 4.
• Computed tomography (CT) scans with axial and coronal views are commonly used to assess the extent of the fracture and guide treatment decisions 5, 6, 4.
• The fracture can be classified into different types, such as trap-door, floor-fracture with incarcerated tissue, or depressed floor-fragment fractures, which can influence the treatment approach 5.

Treatment of Blowout Fracture

• Surgical intervention is often required for blowout fractures, particularly in cases of tissue entrapment, persistent diplopia, enophthalmos greater than 2 mm, or fractures involving more than 50% of the orbital floor 3, 4.
• The timing of surgical repair can vary, with some studies suggesting early repair for trap-door fractures and delayed repair for non-trap-door type fractures 5.
• Different surgical approaches can be used, including the endoscopic transmaxillary approach, which has been shown to be an effective alternative to traditional approaches 6.
• Implants, such as Medpor or titanium mesh, can be used to reconstruct the orbital floor and restore function and appearance 6, 4.
• Postoperative complications, such as infraorbital hypesthesia, diplopia, and ectropion, can occur, and revision surgery may be necessary in some cases 4.