Blow-out fracture
 

Left blow out fracture. The scar in the upper lid provides clue to  left ocular trauma. Left blow-out fracture causing up-gaze and  down-gaze problems.

The affected side has enophthalmos (this may be mild). There is restriction of upgaze of the affected eye.  In the examination: look for any abnormal head posture such as chin elevation mention that you like to palpate the inferior orbital rim for any step or gap due to fracture (this may not be present) test the sensation over the infra-orbtial region for any infra-orbital nerve entrapment.

Questions:

1. The following is an X-ray of a patient who sustained an orbital injury and had problem with upgaze. Which side is the abnormality located?
 

answer The left orbit is affected. Note the present of tear drop sign at the  inferior orbital rim.

2. A patient with blow out fracture may not experience problem with binocular vision except on upgaze. Can you think of any profession in which he may experience problem and what treatment may be available?

answer
Professional photographer or snooker player.
Base down prism may be useful if surgery is not advisable.

3. How do you manage a blow-out fracture?

answer
Work-up: the diagnosis should be suspected in any blunt trauma to the orbit. Fracture is suggested by diplopia on upgaze, increased intraocular pressure on upgaze, enophthalmos and paraesthesia in the distribution of infra-orbital nerve. Surgical emphysema suggests communication with the para-nasal sinus
Investigation:
X-ray: Waters' view shows opacification with a fluid level in the maxillary sinus or tear drop sign in the presence of floor fracture
CT delineate the fracture and identify any prolapsed orbital content
Indications for surgery:
diplopia in primary position
large fracture
enophthalmos greater than 3 mm
Surgery
orbital floor approached via incision along inferior orbital margin, alternatively via the inferior conjunctiva or through the roof of the mouth. The periosteum is identified and elevated, a prosthesis is placed over fracture to prevent further prolapse. This may be bone grafts, silastic or Teflon.
 

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