The orbital fracture

Definition – What is an orbital fracture?

An orbital fracture is also called an orbital fracture. An orbital fracture is therefore a fracture of the bony parts of the skull bones that form the orbit. The orbit is formed by parts of several bones.

These include: The frontal bone (the frontal bone), the lacrimal bone (the lacrimal bone), the upper jaw (the maxilla), the zygomatic bone (the zygomatic bone), the ethmoid bone (the ethmoid bone), the palatal bone (the palatine bone) and the sphenoid bone (the sphenoid bone). An orbital fracture is almost always caused by an external force. This is usually blunt force, such as a punch or the kick of a football.

The broken bones pinch the eyeball as well as the eye muscles and optic nerve connected to it. As a result, in addition to bleeding and pain, double vision, limited mobility of the eyeball and significant visual disturbances are usually experienced. If the nerves are also damaged, this can lead to sensory disturbances and paralysis in the corresponding muscle groups.

As the size of the haematoma increases, the discomfort also increases, as the space in the eye socket becomes smaller and smaller. In the case of a classical orbital fracture, some typical symptoms occur. In detail, however, these can vary greatly from patient to patient.

Often there is an increased intraocular pressure, which if left untreated can lead to damage to the optic nerve of the affected eye. The increased intraocular pressure is caused on the one hand by the bruising and the possibly pushed together eye socket, and on the other hand by bleeding into the surrounding tissue (i.e. a haematoma), which increases in size and competes with the eyeball for a place in the eye socket. This effect can possibly be intensified if the patient tries to move the eye in a certain direction.

However, the haematoma (bruise) does not only spread inside the eye socket, but is also clearly visible to the outside and is often very painful. Because of its characteristic appearance, which is caused by the bone structures and blood vessels involved, it is also called a “monocular hematoma“. This spreads over the entire upper and lower eyelid and can swell so much that it is no longer possible to open the eye without the help of the fingers.

First of all, the treating ophthalmologist will ask the patient to describe the course of the accident as precisely as possible, as this will already provide initial, important indications of any injuries and possible complications. Also the condition of the patient must be asked exactly in order to localize jokes and to be able to classify the symptoms. Typical questions from the ophthalmologist would be, for example, “What was the cause of the accident?

“, “Do you have pain? “, “Do you have the feeling that your face feels different than before? “, “Do you see double images?

Once these introductory questions have been answered, the doctor will begin examining the head and the eye socket. He will pay particular attention to the formation of a bruise (i.e. a haematoma), a sunken or protruding eyeball (also known as enophthalmos or exophthalmos) and swelling in and around the orbit. A careful palpation of the bone will give an initial indication of how many bones are involved and whether it is a simple or complicated orbital fracture.

If it is a complete breakthrough of the orbit, in which the floor of the orbit is also no longer intact, the orbit fracture is also called a “blow-out fracture”. In addition to the symptoms already described, the eyeball can sink into the now deepened orbit, which is also known as an enophthalmos. Another important part of the examination is the functional test.

This includes testing the eye function itself (the double images already mentioned), the function of the nerves in and around the eye (do some areas feel different from others? Can all muscles be moved? Do paralyses exist?).

It is also important to pay attention to accompanying symptoms such as a runny nose (there could be a leakage of blood or cerebrospinal fluid if the orbital fracture is correspondingly severe. Depending on the extent of the injury, doctors from other disciplines may need to be called in to help assess the fracture more accurately. After the patient has been thoroughly questioned and examined, imaging techniques are applied.

The most significant ones in this case are: an X-ray, a computer tomography (CT), and a magnetic resonance imaging (MRT). Here the course of the fracture edge, the bones and structures involved are assessed and any bone splinters are searched for. It is also possible to assess whether tissue parts are trapped in the fracture gap.

If the orbital fracture is a simple fracture without bone splinters, trapped structures or complications, surgery is not necessarily required. On the contrary, according to current knowledge, the operation is even controversially discussed. The risks and the effort of such an operation should not be underestimated and the question must be asked by the doctors whether it is worth the potential benefits and success.

In some cases there is a spontaneous improvement of the orbital fracture even within the first four weeks. For this reason, a physician never makes the decision alone in the case of an existing orbital fracture, but always consults colleagues from other disciplines, such as ophthalmology, ENT, trauma surgery, maxillofacial surgery and radiology. Surgery should be performed if at least one of the following criteria is met: If surgery is then decided upon, it must be determined how the orbit is to be reconstructed.

A choice can be made between plastic or metallic material to reattach the bones of the orbit. Surgery must be performed immediately, in some cases it is advisable to wait a few days and even up to two weeks until the swelling has subsided before surgery. If the doctors decide against surgery because there are no complications and it is a simple orbital fracture, the orbital fracture is treated conservatively.

This means that the patient will be prescribed decongestant medication, which is usually a cortisone preparation. Antibiotics are administered to prevent infection. Painkillers are prescribed as required by the patient.

Regular check-ups should be carried out by the treating physician to assess the healing process and possibly to arrange for a change in therapy if the success does not occur as desired. – Enophthalmus (i.e. a sunken eyeball) of more than 2mm

  • Double pictures
  • Trapped eye muscles
  • If more than 50 percent of the orbital floor is broken
  • If a patient complains of severe sensory disturbances or paralysis

Surgical treatment of an orbital fracture is indicated if it is not a simple fracture of the orbit, which will heal spontaneously and promptly even without surgical intervention. If the patient complains of double vision, the eyeball has sunk more than 2mm into the orbit, the eye muscles are jammed (i.e. the eye is no longer fully mobile in all directions), if more than 50 percent of the orbit is fractured, or if the patient describes pronounced paralysis and loss of sensation on the affected half of the face, surgery should be performed.

Also, if it is a complicated orbital fracture, i.e. if the bones are splintered or other structures in addition to the orbit are injured, such as the upper jaw, zygomatic bone, tear ducts or paranasal sinuses. In some cases it may be advisable not to decide for or against surgery immediately, but to wait a few days (up to two weeks). During this time the bleeding may heal and the swelling may go down, so that the extent of the orbital fracture and possible complications can be better assessed.

The operation itself is also easier to perform and more promising in a swollen state. If the orbital fracture is to be treated surgically, the operation is performed in several steps. First, the course of the fracture edge must be assessed and any displacement of the individual parts must be detected.

Particular attention must be paid to the very thin walls of the orbit, as these can break very quickly in the course of an orbital injury and then lead to complications. In a second step, the trapped tissue is then removed from the fracture gap and moved back to its original location. Here, the surgeon must pay particular attention to fine structures such as smaller muscles, blood vessels and nerves so that they are not damaged or, in the case of existing damage, can be repaired.

In the next step, smaller bone fragments are removed from the wound and the larger bone fragments are rejoined and joined together. Whether plastic or metal is used here is at the surgeon’s discretion. Depending on the extent of the orbital fracture and the accompanying injuries, different numbers and sizes of connecting pieces may be required.

As a rule, these remain attached to the bone after the operation, since subsequent removal is associated with considerable effort and risks. The aim of the operation is always to remove the tissue damage, to reconstruct all structures as far as possible and to ensure a stable orbit and surrounding bone. In the majority of cases, an orbital fracture is caused by a direct external force.

Most dangerous is a punctual occurrence of blunt or even pointed force on the orbit itself, its edge or the surrounding areas. This can be, for example, a fist punch, a shot with a football or with a smaller tennis ball or golf ball. Eye socket fractures can also occur in car accidents or other accidents in which the head area is also injured.

Statistically, one third of orbital fractures are caused by traffic accidents and another third by punches. Another fifteen percent are caused by accidents at work and the remaining ten percent by sports accidents. Here, the acutely increased pressure in the orbit caused by the crushing of the eyeball from the outside leads to either partial or complete rupture of the orbital bones.

In particular, the bone of the orbital floor is only a few millimeters thick and therefore susceptible to fracture. Furthermore, orbital fractures can be classified according to where the fracture lies exactly and which bones have all been injured. A rough distinction is made between orbital roof and orbital floor fractures.

It is important where the violence hit the head, since different structures are involved depending on the location. Furthermore, a distinction is made between simple and complicated fractures. – In a simple fracture, a clear fracture edge runs through the affected bone or bones.

  • In a complicated fracture, the edge is not straight, but there are chipped parts in the fracture area, which lead to an additional risk for the eye. The healing of an orbital fracture is highly dependent on its severity and extent, the concomitant injuries and the type and timing of the chosen therapy. If the fracture is a simple and complication-free orbital fracture, surgery is not required and the chances are good that the fracture will heal on its own within the next four weeks.

However, the symptoms do not disappear suddenly, but it is a long and gradual healing process, so patients must be very patient and careful during this time. However, if the fracture is moderate to severe, surgery is necessary. If the bone parts can be rejoined well and little damage has been caused in the surrounding tissue, healing will occur within the coming weeks and months.

In many cases, little or no consequential damage remains. If major measures have become necessary during the operation, such as the application of a splint, it must then be decided whether and when it is to be removed again. These measures are taken to prevent a relapse and to achieve the best possible result for the patient.

If structures such as cranial nerves or the optic nerve have been damaged by the orbital fracture, unfortunately in most cases the damage is irreparable and cannot be repaired. This results in various consequences with which the affected person must learn to live. In most cases, these are sensory disturbances or paralysis in the injured half of the face.

Visual disturbances caused by damage to the optic nerve are also no longer curable and sometimes lead to serious impairments. An orbital fracture rarely occurs alone. This means that usually not only the eye socket itself is affected, but also the surrounding structures such as nerves, blood vessels etc.

have been damaged. In most cases a combined fracture is present. In this case, either the zygomatic bone, the nose or the upper jaw is broken in addition to the orbit.

The fracture of the zygomatic bone is the most common combination. All structures located in this area can be damaged by the orbital fracture. These include the lacrimal duct system, cranial nerves running through it (such as the facial nerve) as well as the eye and its nerves, muscles and vessels.

The resulting monocular hematoma can also lead to additional impairments. There is a wide range of injuries that occur within the eyeball:

  • For example, the cornea can be injured
  • Foreign bodies can get into the eye

The risks of an orbital hernia operation are largely identical to the usual risks associated with any operation. Bleeding and infection may occur.

There may be pain and swelling in the affected area after the operation. The result may not correspond to the desired condition, so a second operation may be necessary. Complications may occur during the operation, for example due to the anaesthetic or if the orbital fracture is more severe than initially expected by the imaging procedures.

During surgery in the area of the orbit, the most severe possible complication is damage to the optic nerve, the so-called optic nerve. This would lead to an impairment of vision up to its complete loss, which would also be irreparable. If damage to the optic nerve is already present due to the accident itself, the chances of recovery are difficult to estimate in advance of the operation.

Sometimes small bone splinters have drilled into the nerve and thus permanently damaged it. The eye muscles can also be affected in this way. Bleeding complications are another source of risk during this operation.

Either caused by the orbital fracture itself or following the operation, bleeding into the tissue can cause severe swelling. This is so dangerous because the space in the eye socket is very limited and even a moderate swelling can be enough to push aside other structures such as the eyeball or the optic nerve and thus damage them. It is therefore important to administer sufficient decongestant medication and to monitor the healing process regularly.

If the orbital fracture is present in combination with a fracture of the zygomatic bone, it is usually a complicated orbital fracture with concomitant injuries, which must be treated surgically. Especially if bone splinters have come loose from the zygomatic bone or the edges of the bones have shifted against each other, surgery is necessary. The aim of the operation is then to rejoin the zygomatic bone as seamlessly as possible and to remove bone splinters, as these could otherwise lead to complications and inflammation.

For this purpose, the surgeon has a variety of different bone plates and screws at his disposal to achieve an optimal result. In some cases, autologous cartilage tissue is also removed from a different site to be re-inserted in the area of the zygomatic arch fracture, thus avoiding the use of foreign material. The operation itself is of course carried out under general anaesthesia and is performed during the procedure on the orbit to avoid additional surgery.

In case of very severe fractures of the zygomatic bone with serious damage to the surrounding structures, a tamponade may be inserted. This is a type of cotton swab that ensures that leaking blood is collected and that the tissue structures and bone cavities such as the nose and paranasal sinuses are kept free. Tamponades have to be removed after an appropriate period of time, but this does not require another operation. Whether the bone plates and screws used are removed after the healing process is complete depends on the type of procedure and the material used and is decided by the treating surgeon. Here you will find more information on the topic: Zygomatic fracture – symptoms, therapy and prognosis