What diagnostic work‑up is indicated for a patient with head trauma and a small left periorbital laceration to rule out intracranial injury, orbital fracture, and globe damage?

Diagnostic Work-Up for Head Trauma with Periorbital Laceration

Obtain a non-contrast orbital CT with thin slices and multiplanar reconstructions immediately, and if the mechanism suggests significant head trauma or if superior orbital wall fracture is present, extend the scan to include the head. 1, 2

Initial Clinical Assessment

Before imaging, perform a rapid focused examination to identify vision-threatening injuries:

• Measure visual acuity in both eyes—any reduction suggests globe or optic nerve damage 1, 2
• Perform pupillary examination looking specifically for an afferent pupillary defect (indicates optic nerve or severe retinal injury) and irregular pupil shape (suggests globe rupture) 1, 2
• Test extraocular movements in all directions to detect muscle entrapment or restriction 2
• Inspect for hard signs of open globe injury: active bleeding from the eye, inability to move the eye, severe ocular pain, or visible scleral/corneal laceration 3

Critical pitfall: If you suspect an open globe injury based on these hard signs, immediately place a rigid eye shield without applying any pressure, do NOT manipulate the globe or perform forced duction testing, and obtain urgent ophthalmology consultation—do not delay for imaging if the diagnosis is clinically obvious 3, 2

Imaging Protocol

Orbital CT (Primary Study)

Non-contrast thin-section orbital CT with multiplanar reconstructions is the study of choice for evaluating:

• Globe integrity and rupture (most commonly at the limbus/corneoscleral junction) 2
• Orbital fractures (floor fractures are most common, roof fractures least common) 2, 4
• Intraorbital foreign bodies with 94.9% sensitivity, especially metallic objects 3, 1, 2
• Retrobulbar hemorrhage, lens dislocation, and vitreous hemorrhage 4

Head CT (When to Add)

Extend imaging to include the head in these specific scenarios:

• Superior orbital wall (roof) fracture present—this carries a 4.15-fold increased risk of intracranial injury 5
• Associated frontal bone fracture—this carries a 4.38-fold increased risk of intracranial injury 5
• Any symptoms suggesting traumatic brain injury: loss of consciousness, altered mental status, vomiting, or amnesia 5
• High-energy mechanism of injury 5

The incidence of concomitant intracranial injury in orbital wall fracture patients is 9% overall, but rises to 13% in those with TBI symptoms and remains 6% even in asymptomatic patients 5. Maxillary hemosinus on head CT has a 99.7% negative predictive value for excluding orbital floor fractures 6.

MRI Contraindication

Never order MRI when a metallic intraorbital foreign body is possible—the magnetic field can cause movement of ferromagnetic objects and devastating injury 3, 1, 2

Wood foreign bodies appear hypoattenuating on CT and may be mistaken for air; MRI can be considered as a supplementary study only after metallic foreign body has been definitively excluded 3, 1

Immediate Ophthalmology Referral Indications

Obtain same-day ophthalmology consultation for:

• Any hard signs of open globe injury (active bleeding, severe pain, inability to move eye) 3, 2
• Reduced visual acuity in the affected eye 1
• Irregular pupil or afferent pupillary defect 1, 2
• Restricted extraocular movements or diplopia 2
• Signs of retinal pathology (vitreous hemorrhage, vitreous pigment) 2
• Hyphema or shallow anterior chamber 1

Prognostic Red Flags on Imaging

Poor visual outcomes are associated with:

• Lacerations ≥5 mm 3, 2
• Lens injury or vitreous hemorrhage 3, 2
• Intraocular foreign bodies 2
• Ciliary body detachment 2