One Punch

An ER visit with the reasons why one punch is really all it takes.

In Hollywood movies, during fight scenes, the characters often take multiple blows to the face and yet continue fighting with minimal apparent injury. This is not true in real life. 

I recall the first time I took care of someone brought to the ED unconscious after sustaining a beating to the face. The amount of swelling and disfigurement of this man's face was truly horrifying. 

Just one punch to the jaw can break it. Just one punch to the eye can result in an orbital bone fracture requiring surgery. In fact, one punch can result in death.

A 19-year-old man came to the ED one Sunday morning. He had been punched in the eye the previous night while celebrating his birthday at a bar. He was complaining of pain and swelling in the left eye area and nausea. He was unable to open his left eye. The eyelids and periorbital area were significantly swollen with reddish-purple ecchymosis. 

On examination, he was alert and oriented with normal vitals except for a pulse of 54. It was difficult to visualize his left globe but it was apparent that his left eye was not moving in sync with his right eye. The globe also appeared to be lower than his right eye and bulging. His upward gaze was limited. A CT scan confirmed the presence of an orbital floor fracture with retro-orbital hematoma with a downward and outward displacement of the globe.

The orbit, the pocket where the globe sits, is made up of 5 bones. These orbital bones are quite delicate and are prone to fracture when a force strikes the globe or orbital rim. Other structures in the orbital area that may be injured include the extraocular muscles, sinuses, medial and lateral palpebral ligaments, lacrimal or tearing system, and nerves. Injury to the orbit is not life-threatening as an isolated injury but may be associated with other life-threatening injuries. Of course, life-threatening injuries take precedence in treatment. 

Orbital bone fractures are more common than open injuries to the globe after blunt trauma. Sometimes periorbital muscles, the muscles that control eye movement, can become entrapped in the fracture resulting in decreased range of motion of the eye. Retro-orbital hematoma with globe displacement may also occur. 

Entrapment can also result in severe vagal symptoms, caused by the oculocardiac reflex associated with extraocular muscle entrapment resulting in bradycardia, nausea, and vomiting. Decreased visual acuity and double vision can occur. Loss of sensation above or below the eye can result from supraorbital or infraorbital nerve damage. Crepitus, that feeling of crackling beneath the skin on palpation, can also occur if the fracture extends into the sinus and air has traveled under the skin.

Surgical repair is not always indicated but will be if there is displacement of the globe, increased distance between the medial canthi of the eyes, or overflowing of tears.

This patient went on to have a surgical repair of his injury. In real life, fist fights can have serious consequences. All it takes is one punch.

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