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CLINICAL PEARLS AND PITFALLS
A blowout fracture is a displaced fracture of the bones of the orbit.
Hallmark physical findings include impaired extraocular movements,
pain with extraocular movements, or periorbital swelling or ecchymosis.
Palpation of the bony rim of the orbit may not exhibit severe point
tenderness even in the presence of fracture, depending on the bone(s)
involved.
Blowout fracture requires emergent evaluation by ophthalmology.
Smaller fractures can tether extraocular muscles, especially the inferior
rectus muscle, causing bradycardia.

Current Evidence
There are two proposed mechanisms for blowout fractures. The first is that force
is transmitted from the orbital rim to the medial wall or floor. The second is that
force applied to the globe is transmitted to the orbital walls. The medial wall is
the most common site of fractures. CT is the diagnostic modality of choice.
Indications for operative management include rectus muscle entrapment,
enophthalmos, central-gaze diplopia, restriction of extraocular movements, or
loss of orbital support.

Goals of Treatment
The primary goal of therapy in the ED is prompt recognition of blowout fractures
and any associated intraocular injuries, including entrapment and commonly
associated globe injuries. Approximately 20% of displaced orbital fractures are
associated with globe injury; therefore, emergent ophthalmology consultation is
indicated in all cases. Pain control is the primary goal of treatment of
nondisplaced orbital fractures.

Clinical Considerations
Clinical Recognition
Blowout fracture is suggested if any of the following are present: restriction of

eye movements following trauma, enophthalmos, infraorbital anesthesia,
diplopia, step-off deformity, or subcutaneous emphysema. The pathophysiology
and diagnosis of blowout fractures are discussed in Chapter 28 Eye: Strabismus .
Fractures to the inferior and/or medial orbital wall are the most common as
they are the thinnest bone. The lateral wall is the least commonly fractured. The