What is the management of an orbital floor fracture without entrapment?

Management of Orbital Floor Fracture Without Entrapment

Observation is the recommended initial approach for orbital floor fractures without muscle or tissue entrapment, provided there is minimal diplopia (not in primary or downgaze), good ocular motility, and no significant enophthalmos or hypoglobus. 1

Initial Assessment and Exclusion of Urgent Indications

Before committing to conservative management, you must first exclude conditions requiring immediate or early surgical intervention:

• Rule out life-threatening and vision-threatening conditions first, as serious ocular injury occurs in 24% of blowout fractures 2
• Obtain CT imaging to confirm absence of muscle/tissue entrapment and assess fracture size 2
• Monitor for oculocardiac reflex (bradycardia, nausea, vomiting, syncope) which would indicate occult entrapment requiring urgent surgery 2
• Assess for forced duction restriction - positive findings suggest entrapment even without obvious CT evidence 1

Specific Criteria for Conservative Management

You can safely observe without surgery when ALL of the following are present:

• No muscle or periorbital tissue entrapment on CT 1
• Minimal or no diplopia, specifically excluding diplopia in primary position or downgaze 1
• Good ocular motility in all directions 1
• No significant enophthalmos (globe retraction) 1
• No hypoglobus (inferior globe displacement causing facial asymmetry) 1

Conservative Management Protocol During Observation

Wait 4-6 months after the injury before considering any surgical intervention, as strabismus and diplopia frequently resolve spontaneously during this period 1

During the observation period:

• Consider a short burst of oral corticosteroids to hasten recovery of edema and reveal any persistent strabismus that will remain after inflammation resolves 1
• Provide symptomatic diplopia management with occlusion, Fresnel prisms, or prism glasses for temporary or permanent relief 1
• Monitor for development of progressive symptoms that would trigger surgical intervention (worsening enophthalmos, persistent diplopia, progressive infraorbital hypoesthesia) 1

When to Abandon Conservative Management

Surgical repair becomes necessary if any of the following develop during observation:

• Large floor fractures with progressive enophthalmos or hypoglobus - repair within 2 weeks as these will not resolve spontaneously 1
• Symptomatic diplopia with positive forced ductions showing minimal improvement over time - repair within 1-2 weeks 1
• Progressive infraorbital hypoesthesia - repair within 2 weeks 1
• Persistent restrictive strabismus or unresolved enophthalmos after 4-6 months - consider delayed repair 1

Critical Pitfalls to Avoid

• Do not assume absence of entrapment based on good initial motility alone - significant fat or periorbital tissue entrapment can cause permanent strabismus without obvious muscle involvement 1
• Do not rush to surgery within the first 4-6 months unless specific indications exist - many cases resolve spontaneously, and premature intervention may be unnecessary 3
• Set realistic expectations - even with appropriate management, diplopia persists in 37% of patients who undergo surgical repair 2
• Perform forced duction testing to distinguish true restriction from paresis if any motility limitation is present 1

Delayed Surgical Considerations (If Conservative Management Fails)

If surgery becomes necessary after the observation period:

• Wait until alignment is stable (typically 4-6 months post-injury) before proceeding with strabismus surgery 1
• Use adjustable sutures when possible given the multifactorial nature of post-traumatic strabismus 1
• Counsel patients that complete elimination of diplopia may not be achievable, and multiple surgeries or long-term prism use may be required 1