What is the management approach for a left medial orbital fracture?

Management of Left Medial Orbital Fracture

The management of a left medial orbital fracture depends on clinical presentation: immediate surgery for muscle entrapment with oculocardiac reflex, repair within 2 weeks for symptomatic diplopia with positive forced ductions or significant tissue entrapment, and observation for asymptomatic or minimally symptomatic fractures without restriction. 1, 2

Initial Assessment

Perform these specific evaluations to determine management pathway:

• Check vital signs for bradycardia, heart block, nausea, vomiting, or loss of consciousness indicating oculocardiac reflex from entrapped muscle requiring urgent intervention 2, 3
• Test visual acuity in both eyes, as 24% of blowout fractures have serious ocular injury and 5.5% result in complete vision loss 2, 3
• Perform forced duction testing if any restriction is suspected to distinguish mechanical restriction from paresis 1, 2
• Assess for diplopia specifically in primary position and downgaze, as location matters more than severity for surgical decision-making 1, 3
• Measure enophthalmos with Hertel exophthalmometry, as >2mm indicates need for earlier intervention 4, 5
• Obtain CT imaging to assess fracture extent and confirm entrapment (use CT rather than MRI if any concern for metallic foreign body) 2, 3

Surgical Timing Algorithm

Immediate Repair (Same Day)

Proceed directly to surgery for:

• CT or MRI evidence of entrapped muscle or periorbital tissue with nonresolving oculocardiac reflex 1, 2, 3
• White-eyed blowout fracture (trapdoor fracture with muscle entrapment, primarily in children) 1, 3
• Globe subluxation into the maxillary sinus 1, 3

Repair Within 2 Weeks

Schedule surgery for:

• Symptomatic diplopia with positive forced ductions or CT evidence of entrapment showing minimal improvement over initial observation period 1, 2, 3
• Significant fat or periorbital tissue entrapment, which can cause permanent strabismus even without muscle entrapment 1, 2
• Large floor fractures with hypoglobus 1, 2
• Progressive infraorbital hypoesthesia 1, 2, 3
• Early enophthalmos or hypoglobus causing facial asymmetry, as these will not resolve spontaneously 1, 2, 3

The 2-week window permits edema to subside while preventing permanent fibrotic changes 1, 2

Observation (No Surgery)

Observe without surgical intervention for:

• Minimal diplopia not in primary position or downgaze 1, 2, 3
• Good ocular motility without restricted eye movements 2, 3
• No significant enophthalmos (<2mm) or hypoglobus 1, 2, 3, 4
• Fracture defects <3cm² without tissue entrapment 4
• Asymptomatic fractures, which heal without consequences in the majority of cases 6

Research shows 85% of isolated medial wall fractures are asymptomatic at presentation, and conservative management is adequate for these patients 6

Conservative Management During Observation

For patients managed non-operatively, implement:

• Short burst of oral steroids to hasten recovery and reveal persistent strabismus after edema resolution 1, 2
• Occlusion for diplopia management 1, 2, 3
• Fresnel prisms for temporary relief 1, 2, 3
• Prism glasses for temporary or permanent diplopia relief 1, 2
• Botulinum toxin injection in select cases 1, 2
• Ophthalmology follow-up within 1-2 weeks to monitor for delayed complications, as diplopia develops in up to 86% of patients as edema resolves 3

Delayed Strabismus Surgery (After 4-6 Months)

If diplopia persists beyond the observation period:

• Wait 4-6 months after orbital trauma before considering strabismus surgery, as many cases resolve spontaneously unless substantial fat and orbital pulley entrapment is present 1, 2, 3
• Ensure alignment stability before proceeding 1, 2
• Use adjustable sutures when possible 1, 2
• Perform preoperative forced generation testing and intraoperative forced duction testing 1

Critical Pitfalls to Avoid

• Fat entrapment is nearly as challenging as muscle entrapment, causing fibrotic and adhesion syndromes not easily relieved by dissection, so don't underestimate its significance on CT 1, 2
• Even with proper surgical repair, diplopia persists postoperatively in 37% of patients, so set realistic expectations that complete elimination may not be achievable 1, 2, 3
• Fractures in the anterior third of the medial wall (zone 1) cause more severe diplopia than posterior fractures, even if the defect is smaller, so location matters more than size 4
• Do not rely solely on fracture size for surgical decision-making—clinical signs of entrapment and functional impairment are more important than defect dimensions 4
• The degree of enophthalmos correlates with fracture size, but diplopia and motility restrictions do not, requiring independent assessment 4