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Blow-Out Fracture

Blow-Out Fracture is a topic covered in the 5-Minute Emergency Consult.

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Basics

Description

  • Defined as an orbital floor fracture without orbital rim involvement
  • Results from sudden blunt trauma to the globe:
    • Typically caused by the force of a projectile > half the size of the fist
  • Force transmitted through the noncompressible structures of the globe to the weakest structural point: The orbital floor
  • Transmitted force “blows out” or fractures the orbital floor.
  • Orbital floor serves as roof to air-filled maxillary and ethmoid sinuses:
    • Communication between the spaces results in orbital emphysema.
  • Orbit contains fat, which holds the globe in place:
    • Orbital floor fracture may result in herniation of the fat on the inferior orbital surface into the maxillary or ethmoid sinuses.
    • Leads to enophthalmos owing to orbital volume loss and sinus congestion; fluid collection may occur secondary to edema and bleeding.
  • Infraorbital nerve runs through the bony canal 3 mm below the orbital floor:
    • Injury may result in hypoesthesia of the ipsilateral cheek and upper lip.
    • To distinguish facial hypoesthesia related to local swelling from nerve injury: Test for sensation on the ipsilateral gingiva, which is within the infraorbital nerve distribution.
  • Inferior rectus and the inferior oblique muscle run along the orbital floor:
    • Restriction of these extraocular muscles may occur because of entrapment within the fracture, contusion, or cranial nerve dysfunction.
    • Typically manifests as diplopia on upward gaze
    • Inability to elevate the affected eye normally on exam
  • Medial rectus located above the ethmoid sinus:
    • Less commonly entrapped
    • Diplopia on ipsilateral lateral gaze

Etiology

Caused by a projectile which strikes the globe. The force is transmitted through the noncompressible structures of the globe to the weakest structural point: the orbital floor resulting in a blow out fracture.
Pediatric Considerations
  • Orbital roof fractures with associated CNS injuries more common in children
  • Orbital floor fractures: Unlikely before 7 yr of age:
    • Orbital floor is not as weak a point in the orbit due to lack of pneumatization of the paranasal sinuses.
  • Unfortunately fractures can occur in children and may result in unrecognized entrapment of the rectus muscle labeled the “white-eyed” fracture:
    • These children may present with marked nausea, vomiting, headache, and irritability suggestive of a head injury that commonly distracts from the true diagnosis.

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Citation

Rosen, Peter, et al., editors. "Blow-Out Fracture." 5-Minute Emergency Consult, 5th ed., Lippincott Williams & Wilkins, 2016. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307014/all/Blow_Out_Fracture.
Blow-Out Fracture. In: Rosen P, Shayne P, Barkin AZ, et al, eds. 5-Minute Emergency Consult. 5th ed. Lippincott Williams & Wilkins; 2016. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307014/all/Blow_Out_Fracture. Accessed April 23, 2019.
Blow-Out Fracture. (2016). In Rosen, P., Shayne, P., Barkin, A. Z., Wolfe, R. E., Hayden, S. R., Barkin, R. M., & Schaider, J. J. (Eds.), 5-Minute Emergency Consult. Available from https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307014/all/Blow_Out_Fracture
Blow-Out Fracture [Internet]. In: Rosen P, Shayne P, Barkin AZ, Wolfe RE, Hayden SR, Barkin RM, Schaider JJ, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2016. [cited 2019 April 23]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307014/all/Blow_Out_Fracture.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Blow-Out Fracture ID - 307014 ED - Rosen,Peter, ED - Shayne,Philip, ED - Barkin,Adam Z, ED - Wolfe,Richard E, ED - Hayden,Stephen R, ED - Barkin,Roger M, ED - Schaider,Jeffrey J, BT - 5-Minute Emergency Consult UR - https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307014/all/Blow_Out_Fracture PB - Lippincott Williams & Wilkins ET - 5 DB - Emergency Central DP - Unbound Medicine ER -