What is the management of an orbital wall fracture?

Management of Orbital Wall Fractures

The management of orbital wall fractures is determined by a time-sensitive algorithm based on the presence of muscle entrapment, oculocardiac reflex, and functional impairment—with immediate repair required for entrapped tissue with nonresolving oculocardiac reflex, repair within 2 weeks for symptomatic diplopia with positive forced ductions or large floor fractures, and observation for minimal symptoms without significant enophthalmos. 1

Initial Assessment: Rule Out Life-Threatening Conditions

Before addressing the fracture itself, all life-threatening and vision-threatening conditions must be treated first, as 24% of blowout fractures have serious ocular injury, 5.5% result in complete vision loss in one eye, and 0.8% cause bilateral vision loss. 1, 2

Monitor for signs of oculocardiac reflex including bradycardia, heart block, dizziness, nausea, vomiting, or loss of consciousness—these indicate entrapped muscle requiring urgent intervention. 2

Obtain CT imaging to assess fracture presence and tissue entrapment; use CT rather than MRI if any concern exists about metallic foreign bodies. 2

Ensure ophthalmology evaluation for patients with eyelid laceration, extraocular motion abnormalities, or pupillary defects, as 27% of these patients require changes in ocular management. 3

Surgical Timing Algorithm

Immediate Repair (Within 24 Hours)

Proceed to immediate surgical repair for:

• CT or MRI evidence of entrapped muscle or periorbital tissue with nonresolving oculocardiac reflex 1, 2
• White-eyed blowout fracture (trap-door fracture with muscle entrapment and oculocardiac reflex, particularly in children) 1
• Globe subluxation into the maxillary sinus (rare but demands immediate repair) 1

Repair Within 2 Weeks

Schedule surgical repair within 1-2 weeks for:

• Symptomatic diplopia with positive forced ductions or CT evidence of entrapment with minimal improvement over time, allowing edema to subside before re-evaluation 1, 2
• Significant fat or periorbital tissue entrapment, which can cause permanent strabismus even without muscle entrapment 1
• Large floor fractures, hypoglobus, and progressive infraorbital hypoesthesia 1, 2
• Early enophthalmos or hypoglobus causing facial asymmetry, as these will not resolve spontaneously 1

Delayed Repair (After 2 Weeks to 6 Months)

Consider delayed repair for:

• Restrictive strabismus and unresolved enophthalmos that persist beyond the observation period 1, 2
• Wait 4-6 months after orbital trauma before strabismus surgery to ensure alignment stability, as many cases resolve spontaneously 1, 2

Observation Without Surgery

Observe conservatively for:

• Minimal diplopia (not in primary or downgaze position) with good ocular motility 1, 2
• No significant enophthalmos or hypoglobus 1, 2
• Fracture defects less than 3 cm² with enophthalmos less than 2mm and no soft tissue or muscle entrapment 4

Conservative Management During Observation Period

Implement conservative measures while monitoring:

• Short burst of oral steroids can hasten recovery and reveal persistent strabismus after edema resolution 1, 2
• Occlusion therapy for diplopia management 1, 2
• Fresnel prisms for temporary diplopia relief 1, 2
• Prism glasses for temporary or permanent diplopia relief 1, 2
• Botulinum toxin injection in select cases 1, 2

Surgical Planning Considerations

When surgery is indicated, perform:

• Preoperative and intraoperative forced duction testing to distinguish restriction from paresis, which is critical for surgical planning 1
• Forced generation testing preoperatively 1
• Use adjustable sutures when possible, particularly in complex cases 1

Set realistic expectations: Even with proper surgical repair, diplopia persists in 37% of patients postoperatively, and complete elimination of diplopia may not be achievable due to multifactorial etiology. 1, 2 Multiple strabismus surgeries and long-term prism glasses may be required. 1

Critical Pitfalls to Avoid

Fat entrapment is nearly as challenging as muscle entrapment, causing fibrotic and adhesion syndromes not easily relieved by dissection around the involved muscle—adhesions may extend deep into the orbit beyond surgical reach. 1, 2

Fractures of the anterior orbit (anterior third of medial wall) cause more severe diplopia than posterior fractures, even when the posterior defect is larger, so location matters more than size alone. 4

Lateral wall fractures indicate severe facial trauma and may be associated with intracranial injury or visual loss requiring emergent management before addressing the fracture. 5

Delayed complications can occur: Minimally displaced orbital roof fractures can develop delayed pulsatile exophthalmos and orbital encephalocele, necessitating close interdisciplinary observation involving plastic surgery, neurosurgery, and ophthalmology. 6