Orbital Fractures: Symptoms, Types, Causes and Treatment

Orbital fractures are among the most frequent and complex injuries affecting the bones surrounding the eye. They can lead to significant pain, vision changes, and even permanent facial deformity if not diagnosed and managed appropriately. Understanding the symptoms, types, causes, and treatment options is crucial for both clinicians and patients. This article provides a comprehensive, evidence-based overview, synthesizing findings from leading studies and clinical reviews.

Symptoms of Orbital Fractures

Orbital fractures can present with a variety of symptoms, ranging from subtle discomfort to dramatic changes in vision and facial structure. Recognizing these symptoms early is vital, as timely diagnosis can prevent long-term complications and guide appropriate treatment.

Symptom	Description	Frequency/Significance	Source(s)
Swelling	Edema around the orbit	Very common, early sign	1, 5
Ecchymosis	Bruising (black eye)	Frequent, but may be absent	1, 5, 4
Subconjunctival Hemorrhage	Blood under eye surface	Most frequent ocular finding	5
Diplopia	Double vision	Suggests muscle entrapment	2, 3, 7, 6
Nausea/Vomiting	Especially with movement	Red flag for muscle entrapment	1, 4, 6
Restricted Motility	Limited eye movement	Indicates muscle/fat entrapment	2, 6, 4
Pain (esp. movement)	Pain with eye movement	May signal severe injury	2
Visual Changes	Blurred or reduced vision	Can indicate severe trauma	2, 5
Enophthalmos	Sunken eye appearance	Seen in some fracture types	3, 8, 15

Table 1: Key Symptoms of Orbital Fractures

Recognizing the Signs

Orbital fractures often produce visible and sometimes alarming signs. Swelling and bruising (ecchymosis) around the eye are among the most common initial findings and can alert both patients and clinicians to the possibility of a fracture 1, 5. Subconjunctival hemorrhage—bleeding beneath the clear surface of the eye—is actually the most frequent ocular finding in these injuries 5.

However, not all orbital fractures present with obvious external symptoms. In so-called "white-eyed" blowout fractures, especially in children, the classic signs of bruising or swelling may be absent. Instead, these cases can present with nausea, vomiting, dizziness, and even faintness, due to the oculocardiac reflex triggered by muscle entrapment 4, 6. This can result in the injury being missed or mistaken for a neurological problem.

Eye Movement and Vision

One of the most clinically significant symptoms is diplopia, or double vision. This typically results from restriction of eye movement, which may be caused by entrapment of the muscles or orbital fat in the fracture 2, 6, 7. Pain on eye movement, especially when accompanied by blurred vision or markedly reduced visual acuity, is a red flag for severe ocular trauma and requires urgent attention 2.

When to Worry

Certain symptom clusters are highly predictive of more serious injury. For example, the presence of two or more of the following—blurred vision, pain with eye movement, visual acuity worse than 20/40, and restricted motility—predicts severe ocular trauma with high sensitivity and specificity 2. Early recognition of these signs can be life- and vision-saving.

Types of Orbital Fractures

Orbital fractures aren't all the same. The type of fracture influences both the symptoms experienced and the approach to treatment. Classification is based on the location and pattern of the fracture, as well as the mechanism of injury.

Type	Key Features	Prevalence/Notes	Source(s)
Blowout	Floor or medial wall, rim intact	Most common (floor > medial)	9, 12, 14
Orbital Rim	Involves orbital rim	Often with other facial fx	9, 11
Combined	Rim + wall(s)	More complex, severe	9, 11, 7
Roof Fracture	Superior orbital wall	Less common, can be severe	3, 12
Trapdoor	Hinge-like, soft tissue entrap.	Common in children	4, 6, 15
Medial Wall	Medial orbital wall involved	Second most common wall fx	7, 14, 12

Table 2: Main Types of Orbital Fractures

Blowout Fractures

Blowout fractures are the most frequently encountered type, especially involving the orbital floor and, to a lesser extent, the medial wall. These occur when a blunt force increases intraorbital pressure, causing the thin walls to "blow out" while the rim remains intact 9, 12, 14. The floor is most commonly involved, followed by the medial wall 12, 14. Blowout fractures can lead to herniation of orbital contents and entrapment of muscles, causing diplopia and restricted eye movement.

Orbital Rim and Combined Fractures

Fractures involving the bony rim of the orbit usually result from higher-energy trauma and may involve adjacent facial bones (zygoma, maxilla, frontal bone) 9, 11. Combined fractures—those involving both the rim and orbital walls—are more complex and often associated with additional facial injuries and more severe complications 9, 7.

Roof and Medial Wall Fractures

Although less common, orbital roof fractures can be particularly serious, especially if associated with intracranial injury or dura exposure 3. Medial wall fractures are the second most common location for blowout injuries 14, 12. Medial wall fractures may occur in isolation or as part of more extensive patterns and can be classified by severity and anatomical involvement 7.

Trapdoor Fractures and Pediatric Patterns

Children are more likely to experience "trapdoor" fractures, where the elastic bone snaps back after breaking, trapping muscles or soft tissue. These may present with minimal external signs ("white-eyed" fractures) but significant functional impairment, such as restricted movement and nausea/vomiting due to the oculocardiac reflex 4, 6, 15. Early surgical intervention is crucial in these cases to prevent permanent muscle damage.

Classification Systems

Several systems exist to further classify fractures based on their anatomical distribution and severity. For example, medial orbital wall fractures can be grouped into four types, ranging from isolated medial wall involvement to complex midfacial trauma 7. Pediatric orbital fractures can also be categorized by extent: pure orbital, craniofacial, or common fracture patterns, each with different implications for management 8.

Causes of Orbital Fractures

Understanding what causes orbital fractures can help with prevention and improve awareness of risk factors. While trauma is the universal culprit, the specific sources and patterns vary by age, gender, and geography.

Cause	Demographic Trends	Prevalence/Notes	Source(s)
Road Traffic Accidents	All ages, esp. young males	Leading cause globally	5, 14, 12
Assault	Young males, women (DV)	Second most common/varies by age	2, 12, 13
Falls	Elderly, women, children	Common in older age groups	2, 12, 14
Sports Injuries	Children, young adults	Not uncommon	5, 12
Domestic/Sexual Violence	Women	Frequent in female patients	13
Animal Attacks	Rare	Occasional	5

Table 3: Main Causes of Orbital Fractures

Trauma: The Universal Factor

Orbital fractures almost always result from direct trauma to the face. The most common causes worldwide are road traffic accidents (RTAs), assaults, and falls 5, 14, 12. RTAs are especially prevalent in younger and middle-aged adults, while falls are more common in older adults and children 12, 14.

Assault and Violence

Assault is a significant cause, particularly among young men. In women, a notable proportion of orbital fractures result from domestic or sexual violence—up to one third in some studies—making it essential for healthcare providers to consider and sensitively inquire about this possibility when evaluating female patients 13.

Age and Gender Differences

• Children: More likely to sustain fractures from sports, play, or falls. Pediatric bones are more elastic, resulting in unique patterns like trapdoor fractures 6, 8.
• Adults: RTAs and assaults predominate.
• Elderly: Falls become a leading cause, especially in women 12.
• Gender: Males are more frequently affected overall, but domestic violence is a significant cause in women 5, 13.

Uncommon Causes

Sports injuries and animal attacks are less common but can still result in orbital fractures, especially in children and young adults 5.

Treatment of Orbital Fractures

Management of orbital fractures is highly individualized, depending on the type and severity of the fracture, patient age, and associated injuries. The primary goals are to restore function, prevent permanent vision loss, and achieve the best possible cosmetic outcome.

Treatment Type	Main Indications	Common Approaches	Source(s)
Observation	Minor, non-displaced, no entrapment	Serial exams, imaging	8, 3, 15
Surgical Repair	Entrapment, diplopia, enophthalmos, oculocardiac reflex	Release, reconstruction	3, 4, 6, 15
Urgent Surgery	Nonresolving oculocardiac reflex, white-eyed fracture, muscle entrapment	Immediate intervention	4, 6, 15, 16
Delayed Surgery	Persistent diplopia, large defects	Within 2 weeks preferred	15, 16, 18
Implants	Reconstruction of wall/floor defects	Titanium, polyethylene	3, 11, 18
Conservative in Children	Most non-severe pediatric fractures	Observation, minimal surgery	3, 8, 4

Table 4: Main Treatment Approaches for Orbital Fractures

Observation vs. Surgery

Not all orbital fractures require surgery. Many small, non-displaced fractures without muscle or fat entrapment are managed conservatively, with observation and follow-up imaging 8, 3. In pediatric cases, unless there is acute enophthalmos, vertical dystopia, or muscle entrapment, nonoperative management is often preferred 8.

Indications for Surgical Intervention

Surgery is indicated when there is:

• Entrapment of extraocular muscles or orbital fat, leading to restricted eye movement and/or persistent diplopia 6, 4
• Nonresolving oculocardiac reflex (nausea, vomiting, bradycardia with eye movement), particularly in "white-eyed" blowout fractures 4, 15, 16
• Early enophthalmos (sunken eye), hypoglobus (eye displaced downward), or large floor defects (>1 cm²) 15, 18
• Persistent or severe visual changes indicating globe or optic nerve injury 2, 18

Timing of Surgery

• Immediate (within days): For muscle entrapment with oculocardiac reflex or white-eyed fractures 4, 6, 15
• Within 2 weeks: For symptomatic diplopia with positive forced duction (mechanical restriction) and radiographic evidence of entrapment or large fractures at risk for latent enophthalmos 15, 16, 18
• Delayed: When initial swelling must subside or for complex reconstructions

Surgical Techniques and Materials

Surgical approaches depend on fracture location and complexity:

• Orbital floor and medial wall: Transconjunctival, subciliary, or transcaruncular approaches 3, 7, 10
• Roof fractures: Bicoronal approach is most common in adults 3
• Implant materials: Titanium miniplates, porous polyethylene, bone grafts, or silastic implants are used to reconstruct the orbital walls and restore normal anatomy 3, 11, 18

Special Considerations in Children

Children often require less extensive reconstruction due to elastic bone and unique healing. However, early surgery is critical in trapdoor fractures to prevent permanent muscle damage and persistent diplopia 4, 6, 8.

Multidisciplinary Management

Optimal care often involves collaboration between ophthalmology, plastic surgery, otolaryngology, and maxillofacial surgery, to address both the bony and soft tissue components of the injury and to monitor for complications affecting vision 11, 17.

Conclusion

Orbital fractures are multifaceted injuries with potential for significant functional and cosmetic consequences. Understanding the spectrum of symptoms, fracture types, causes, and treatment options is vital for effective management.

Key takeaways:

• Symptoms include swelling, bruising, subconjunctival hemorrhage, diplopia, pain with movement, and, in children, nausea/vomiting due to oculocardiac reflex 1, 2, 4, 5, 6.
• Types range from common blowout (floor/medial wall) fractures to more complex combined, roof, and pediatric trapdoor patterns 9, 12, 14, 3, 4, 6.
• Causes are dominated by trauma—especially road traffic accidents, assaults, and falls—with variations by age and gender; domestic violence is a significant cause in women 5, 12, 13, 14.
• Treatment is tailored to the individual—most minor fractures are observed, but surgery is needed for muscle entrapment, severe symptoms, or large defects; urgent intervention is critical in selected cases, especially in children 3, 4, 6, 8, 15, 16, 18.

Prompt recognition and multidisciplinary management are essential to optimize patient outcomes and prevent long-term complications.