A 75 yo M presents to the ED after a mechanical fall w/ L facial pain and swelling. He fell forward, hitting his face on the ground. He denies LOC and is not on anticoagulation. On exam, there is noted L eyelid swelling. PERRLA, and EOM and vision are intact. A CT of the facial bones is done and shown below. What's the diagnosis? (scroll down for answer)

Answer: Orbital Floor Fracture

• Medial aspect of the orbital floor is one of thinnest portions of orbit (along w/ medial wall/lamina papyracea of ethmoid bone)
• Evaluate visual acuity, pupils and EOM
• Entrapment of inferior oblique and rectus muscles --> restricted upward gaze and diplopia
• Possible signs/symptoms:
• Decreased sensation in infraorbital nerve distribution
• Enophthalmos- globe displaced posteriorly
• Afferent pupillary defect
• Oculocardiac reflex: pressure on globe or entrapment causes bradycardia or nausea/vomiting
• Requires immediate (within 48 hours) vs. delayed (within 2 weeks) surgical repair
• Indications for immediate repair: enophthalmos > 2cm, defect > 2cm, symptomatic entrapment, unresolving oculocardiac reflex

References:

Gart MS. Gosain AK. Evidence-based Medicine: Orbital Floor Fractures. Plast Reconstr Surg. 2014 Dec; 134(6):1345-55.