An 18-year-old man was brought to the ER by his mother. He reported being punched in the face the night before at a party. His left eye was swollen shut, and he was complaining of pain and problems with vision.
On exam, he had significant periorbital swelling and was barely able to open his left eye on his own. Crepitus (a crack, snap, or pop sensation palpable under the skin) could be felt on palpation due to an air leak from the maxillary sinus.
Remember the maxillary sinus is open to air via the nose, so a fracture of the floor of the orbit communicates with the sinus and is therefore an open fracture with risk of infection.
His pupils were PERL. His extraocular movements were tested by having him follow my finger in all four directions and showed limited movement of the left eye, causing him to experience diplopia (double vision) on superior gaze.
CT scan showed a depressed fracture of his orbital floor with entrapment of extraocular muscle. He would need surgery. The patient indicated surprise. I explained to the patient and his mother that this wasn’t just a black eye. A blow to the eye does not usually rupture the globe (eyeball).
Rather, the very fragile bones that form the socket of the eye are more likely to fracture, especially the medial and inferior bones. Sometimes these fractures can be displaced, and one of the extraocular muscles responsible for eye movement can become entrapped, as in this case.
He underwent a surgical procedure where the inferior orbital floor was accessed by making a conjunctival incision under his eye, then freeing the entrapped muscle and placing an implant on the fractured area. Following surgery, the patient fortunately regained his extraocular range of motion.
The lesson for this young man was: don’t get into fights. A punch to the face can result in serious injury.
The lesson for EMTs: don’t assume a shiner is just a bruise.
References:
Grob S, Yonkers M, Tao J. Orbital Fracture Repair. Semin Plast Surg. 2017 Feb;31(1):31-39. Access at https://pmc.ncbi.nlm.nih.gov/articles/PMC5330799/ .
