Do blowout type facial fractures require immediate transfer if there is no ocular entrapment?

Blowout Fractures Without Ocular Entrapment Do NOT Require Immediate Transfer

Blowout fractures without ocular entrapment can be safely managed with observation and outpatient ophthalmology follow-up within 1-2 weeks, rather than immediate transfer. 1, 2

When Immediate Transfer IS Required

Before deciding on observation, you must first exclude these absolute indications for immediate surgical repair:

• CT or MRI evidence of entrapped muscle or periorbital tissue with nonresolving oculocardiac reflex (bradycardia, heart block, nausea, vomiting, loss of consciousness) 1, 3
• White-eyed blowout fracture (trapdoor fracture with muscle entrapment and oculocardiac reflex, primarily seen in children) 1, 4
• Globe subluxation into the maxillary sinus 1

When Observation Is Appropriate

The American Academy of Ophthalmology explicitly recommends observation for patients with:

• Minimal diplopia (not in primary or downgaze) 1, 2
• Good ocular motility without restricted eye movements 1, 2
• No significant enophthalmos or hypoglobus 1, 2
• Normal extraocular movements indicating no muscle entrapment 2
• No signs of oculocardiac reflex 2, 3

Critical Initial Assessment Before Discharge

You must rule out vision-threatening conditions, as 24% of blowout fractures have serious ocular injury and 5.5% result in complete vision loss in one eye 1, 3:

• Visual acuity testing in both eyes 2
• Pupillary examination for afferent defects 1
• Slit-lamp examination to exclude globe injury 2
• Extraocular movement testing in all directions 1, 2
• Forced duction testing if any restriction suspected 1
• Vital signs monitoring for bradycardia or vagal symptoms 1, 3
• CT imaging to assess fracture extent and rule out entrapment 1, 3

Outpatient Management Plan

Arrange ophthalmology follow-up within 1-2 weeks to monitor for delayed complications 2, 3:

• Diplopia develops in up to 86% of orbital fracture patients as edema resolves, and persists postoperatively in 37% even after surgical repair 1, 2
• Conservative measures during observation include occlusion for diplopia, Fresnel prisms for temporary relief, and a short burst of oral steroids to hasten recovery 1, 3
• Wait 4-6 months before considering strabismus surgery, as many cases resolve spontaneously unless substantial fat and orbital pulley entrapment is present 1, 3

Surgical Timing If Symptoms Progress

If the patient develops concerning features during follow-up, surgical repair should occur within 2 weeks for 1, 3:

• Symptomatic diplopia with positive forced ductions or CT evidence of entrapment with minimal improvement 1, 2
• Large floor fractures 1, 3
• Progressive infraorbital hypoesthesia 1, 2
• Early enophthalmos or hypoglobus causing facial asymmetry 1
• Significant fat or periorbital tissue entrapment (can cause permanent strabismus even without muscle entrapment) 1, 3

Common Pitfalls to Avoid

• Delaying ophthalmology referral can miss the 2-week window for optimal surgical intervention if symptoms develop 2, 3
• Assuming a normal initial exam means no future problems is dangerous, as diplopia and restriction can emerge as edema resolves 2
• Missing oculocardiac reflex signs (nausea, vomiting, bradycardia) which indicate urgent surgical need 1, 3
• Failing to obtain CT imaging when clinical suspicion exists, as some trapdoor fractures show minimal bone displacement but significant soft tissue entrapment 4, 5