Orbital fractures
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
urgent eye morbidity
advanced trauma life support + ophthalmology/maxillofacial consult
Advanced trauma life support (ATLS) is the initial approach in the assessment and management of any patient who may have orbital fractures and systemic injuries. Once the patient has been stabilised, urgent referral for ophthalmological assessment of eye and associated structures (generally by an ophthalmologist or maxillofacial surgeon) is required.
surgery
Treatment recommended for ALL patients in selected patient group
Orbital floor blow-out fractures causing soft-tissue entrapment can exacerbate the oculovagal response and require urgent surgical intervention. The oculovagal reflex refers to the presence of vagal stimulation by pressure to intraorbital structures, which results in bradycardia, hypotension, and nausea and/or vomiting. It is generally caused by blow-out fractures in children.[11]Cobb A, Murthy R, Manisali M, et al. Oculovagal reflex in paediatric orbital floor fractures mimicking head injury. Emerg Med J. 2009 May;26(5):351-3. https://www.doi.org/10.1136/emj.2008.059857 http://www.ncbi.nlm.nih.gov/pubmed/19386870?tool=bestpractice.com However, it has been described in other causes of pressure on the orbital contents, such as ophthalmic surgery, adult orbital fractures, zygomatic fracture management, and even cosmetic face-lifts.
antibiotic prophylaxis
Additional treatment recommended for SOME patients in selected patient group
Routine use of antibiotic prophylaxis is not recommended in the treatment of orbital fractures. However, a recommended approach is to administer broad-spectrum antibiotics for cases of open fracture, surgical emphysema, orbital grafting, or when open reduction and internal fixation is performed.[26]Newlands C, Baggs PR, Kendrick R. Orbital trauma. Antibiotic prophylaxis needs to be given only in certain circumstances. BMJ. 1999 Aug 21;319(7208):516. http://www.ncbi.nlm.nih.gov/pubmed/10454413?tool=bestpractice.com
The treatment course is 1 week.
Antibiotics are not indicated if there is evidence of a fracture communicating with a sinus.
Primary options
amoxicillin: 500 mg orally three times daily
OR
erythromycin base: 250 mg orally four times daily
intravenous atropine
Additional treatment recommended for SOME patients in selected patient group
The oculovagal reflex refers to the presence of vagal stimulation by pressure to intraorbital structures, which results in bradycardia, hypotension, nausea, and/or vomiting. Children are more sensitive.[11]Cobb A, Murthy R, Manisali M, et al. Oculovagal reflex in paediatric orbital floor fractures mimicking head injury. Emerg Med J. 2009 May;26(5):351-3. https://www.doi.org/10.1136/emj.2008.059857 http://www.ncbi.nlm.nih.gov/pubmed/19386870?tool=bestpractice.com In extreme cases, patients may require to be treated intravenously with an antimuscarinic acetylcholine antagonist such as atropine.
Primary options
atropine: children: 0.01 mg/kg intravenously as a single dose, may repeat every 4-6 hours if required, maximum 0.4 mg/total dose; adults: 0.5 mg intravenously as a single dose, may repeat every 3-5 minutes if required, maximum 2 mg/total dose
no urgent eye morbidity
ophthalmology referral, conservative treatment and follow-up
Conservative treatment is initially considered in all cases where urgent surgery is not indicated.
Patients should be reviewed 1 week later, following resolution of oedema that may overlie residual local injury. Orthoptic testing may reveal that, although a fracture is present, there is no derangement of function or cosmesis, and therefore no delayed surgery is indicated.
Non-steroidal anti-inflammatory drugs (NSAIDs) can be used to treat mild to moderately severe pain. Ibuprofen is usually considered for the initial therapy. Paracetamol alone, or in combination with codeine, can be used in patients with hypersensitivity to aspirin or NSAIDs, with upper gastrointesitnal (GI) disease, or taking oral anticoagulants.
Codeine is contraindicated in children younger than 12 years of age, and it is not recommended in adolescents 12 to 18 years of age who are obese or have conditions such as obstructive sleep apnoea or severe lung disease as it may increase the risk of breathing problems.[27]US Food and Drug Administration. FDA drug safety communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. April 2017 [internet publication]. https://www.fda.gov/Drugs/DrugSafety/ucm549679.htm It is generally recommended only for the treatment of acute moderate pain, which cannot be successfully managed with other analgesics, in children 12 years of age and older. It should be used at the lowest effective dose for the shortest period and treatment limited to 3 days.[28]European Medicines Agency. Restrictions on use of codeine for pain relief in children - CMDh endorses PRAC recommendation. June 2013 [internet publication]. http://www.ema.europa.eu/docs/en_GB/document_library/Press_release/2013/06/WC500144851.pdf [29]Medicines and Healthcare Products Regulatory Agency. Codeine: restricted use as analgesic in children and adolescents after European safety review. Drug Safety Update. 2013 Jun;6(11):S1. https://www.gov.uk/drug-safety-update/codeine-restricted-use-as-analgesic-in-children-and-adolescents-after-european-safety-review
Primary options
ibuprofen: children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day
Secondary options
paracetamol: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg every 4-6 hours when required, maximum 4000 mg/day
OR
paracetamol/codeine: children ≥12 years of age: consult specialist for guidance on dose; adults: 15-60 mg orally every 4-6 hours when required
More paracetamol/codeineDose refers to codeine component.
Maximum dose is 4000 mg/day of the paracetamol component (adults).
delayed surgery
Additional treatment recommended for SOME patients in selected patient group
Surgery is delayed in most adult cases to allow oedema and haemorrhage to resolve.
Delayed surgical intervention is undertaken in patients with persistent or worsening functional or cosmetic derangement. In complex facial trauma, surgery is typically delayed at least 1 week for swelling to resolve.
The decision to perform surgery depends on the position of the defect, the age of the patient, and the existence of concomitant injuries.
For orbital floor fractures: the surgical approach is transconjunctival or through the lower eyelid at various levels.
Orbital roof/complex cranio-maxillofacial fractures: coronal approach through the hair-bearing skin of the scalp is standard to avoid facial scarring and maximise exposure.
Other incisions through facial/lid skin: repair may involve alloplastic or synthetic material.
Cranial and facial bone fractures are usually fixed with titanium or steel miniplates.
antibiotic prophylaxis
Additional treatment recommended for SOME patients in selected patient group
Routine use of antibiotic prophylaxis is not recommended in the treatment of orbital fractures. However, a recommended approach is to administer broad-spectrum antibiotics in the following cases:[26]Newlands C, Baggs PR, Kendrick R. Orbital trauma. Antibiotic prophylaxis needs to be given only in certain circumstances. BMJ. 1999 Aug 21;319(7208):516. http://www.ncbi.nlm.nih.gov/pubmed/10454413?tool=bestpractice.com
For open fractures
When surgical emphysema is present
When open reduction and internal fixation is performed
In orbital grafting.
Treatment course: 1 week.
Antibiotics are not indicated if there is evidence of a fracture communicating with a sinus.
Primary options
amoxicillin: 500 mg orally three times daily
OR
erythromycin base: 250 mg orally four times daily
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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