Orbital Trauma

Michael Rothman
The globe and orbit constitute a very small portion of the body; however, trauma to this region assumes critical
importance due to the high value we place on vision. The evaluation of orbital trauma has progressed rapidly with
the development and wide distribution of computer-assisted imaging. Plain radiography, angiography, computed
tomography (CT}, and magnetic resonance imaging (MRI), may all be used in the evaluation of orbital trauma and
the search for foreign bodies.
Copyright 1997 by W,B. Saunders Company

HE ORBIT MAY be injured directly or indirectly, with both blunt and penetrating trauma
occurring with equal frequency. Soft tissue swelling
often obscures direct clinical evaluation of the globe,
limits ocular motion, and may limit clinical assessment of vision. Plain film evaluation of the orbit
may accurately depict the presence of bony injury,
as well as the presence of radiopaque and radiolucent foreign bodies. However, the lack of soft tissue
detail limits its utility for treatment planning. CT
shows both soft tissue and bony injury, and more
clearly defines the location and orientation of
displaced bony fragments, foreign bodies and air.
MRI may be complementary to CT scanning in
certain patients, particularly with injuries involving
the globe or optic nerve, but is contraindicated in
the presence of a metallic foreign body.
The presence of orbital emphysema or penetrating trauma, enophthalmos/exophthalmos, palpable
bony step-off, visual loss or extra-ocular muscle
deficit on physical examination indicates the need
for cross-sectional imaging evaluation. 1,2

TECHNIQUE

In many emergency rooms, plain film evaluation

of the orbit remains the standard initial imaging
modality. Standard plain film examination of the
orbit includes anteroposterior or Caldwell, lateral,
and Water's views of the face. Although supplementary views may be obtained (eg, Rhese view of the
optic foramen), subtle and complex fractures are
best evaluated by CT scanning. The ability to
obtain an adequate plain film examination of the
orbit may be limited in the presence of concurrent
trauma elsewhere, particularly cervical injuries.
Standard CT examination should include both
axial and direct coronal imaging at slice thicknesses of 3 mm or less, with images presented in
both soft tissue and bone windows (preferably
using bone algorithm reconstruction). Imaging may
be obtained with either conventional axial or spiral/
helical modes. Helically acquired data may be
retrospectively reconstructed in thinner sections (1

to 1.5 ram), allowing for improved coronal reconstructions when direct coronal imaging is not possible,
or is limited by streak artifact from dental materials.
Obfique sagittal reconstructions along the course of the
optic nerve may also be useful in selected circumstances. Three-dimensional presentation of data sets
can be performed, allowing interactive review and
display, although the effort and time required to do so
may be prohibitive in an acute setting. Contrast administration is not necessary.
The use of MRI in acute trauma has not been
studied prospectively in large series. Injuries to the
orbit may be well demonstrated on MR1, and it is
useful in selected cases, once metal foreign bodies
have been excluded. 3,4 Standard evaluation of the
orbit may be performed with a standard head coil or
with a dedicated surface coil, and should include
both axial and coronal Tl-weighted sequences (see
the article by Belden, same issue). Oblique sagittal
sequences may be useful for evaluation of the optic
nerve injuries, while T2-weighted sequences and
post-contrast infusion fat-suppressed images delineate globe injuries well (see the article by Kubal,
same issue). Dynamic evaluation of extra-ocular
muscle function may be obtained in patients with
entrapment syndrome with or without diplopia.
FOREIGN BODIES

Foreign bodies may be deposited into the orbital

soft tissues as a consequence of penetrating injury,
and must be localized prior to surgical debridement. X-rays in orthogonal planes may provide
sufficient information, but CT shows smaller fragments and their relationship to the globe and optic
nerve5,6 (Fig 1). Wood is generally appreciated
From the Department of Radiology, University of Maryland
Medical Systems, Baltimore, MD.
Address reprint requests to Michael Rothman, MD, Anna
Gudelsky Magnetic Resonance Imaging Facility, University of
Maryland Medical Systems 22 S Greene St, Baltimore, MD
21201.
Copyright 1997 by W.B. Saunders Company
0887-2171/97/1806-000455. 00/0

Seminars in Ultrasound, CT, andMRI, Vo118, No 6 (December), 1997: pp 437-447

437

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MICHAEL ROTHMAN

Fig 1. Metal foreign bodies sip shotgun injury and repair.

(A) Lateral CT Scout film. Multiple metal projectiles overlie the
face and orbits. Metal mesh fixes orbit floor (arrow). (B) Axial CT,
bone window: 2 metal BBs in right orbit, mesh plate is elevated
above orbit floor (arrow). C) Axial CT above level of (B), soft tissue
window. Displacement of optic nerve by elevated mesh plate
(arrow) (subsequently re-operated and repaired).

emergently as linear air density, whereas glass is

usually hyperdense (Fig 2). Plastics vary in their
composition and thus, in their CT appearance. 7
Metals are hyperdense, and may cause streak
artifact. Plain films or CT may be used with
confidence to exclude the presence of ocular metallic foreign bodies before MRI. MRI may also be
used to localize non-metallic foreign bodies, s Retained foreign bodies may lead to infection and
abscess formation.
ISOLATED ORBITAL FRACTURES
Blow-out Fractures

"Blow-out" fractures occur when direct blunt

force is applied to the globe and orbit, with disruption of an orbital wall and resultant decompression
of orbital contents. 9 The inferior or medial wall is

most often damaged, with the superior and lateral

walls less commonly involved, l By definition, the
orbital rim is intact ("pure" blow-out fracture) il
(Fig 3, 4). Herniation of orbital fat and periorbita
into the adjacent maxillary or ethmoid sinuses may
occur, and is easily observed on both CT and MRI.
These injuries may be associated with displacement
of the rectus muscles or their connective tissue
attachments and limitation of range of motion of
the globe (entrapment syndrome). 1 Children have
an increased incidence of "trap-door" fractures and
resultant limitation of range of motion as compared
with adults) 2 Contusion and laceration of the
extraocular muscles may also produce a restriction
of motion. Fractures may allow communication of
air into the orbit, often with air-fluid levels demonstrated within adjacent paranasal sinuses (Fig 5).

ORBITAL TRAUMA

439

tion of gaze more frequently than with blow-out

fractures, and surgical intervention is necessary is
all cases.15 As with blow-out fractures, involvement
of the orbital rim separates pure and impure
blow-in fractures. Superior fractures are associated
with more severe cranial injuries, especially epidural hematomas and frontal lobe contusions ~6(Fig 6).
COMPLEX ORBITAL FRACTURES

Complex fractures of the midface/orbit are welldefined by CT, including zygomaticomaxillary complex fracture (ZMC) or "tripod" fractures (the
zygomatic arch, orbit, maxillary sinus, and zygomaticofrontal process), " N O E " (naso-orbitalethmoid), Le Fort type 2 and 3 fractures (involvement of the pterygoid plates, nasal cavity, and orbit
walls), and skull base fractures extending through
the optic canal, MRI may be helpful acutely in
directly evaluating the intracanalicular portion of
the optic nerve. CT and MRI may also be helpful in
the evaluation of chronic sequelae of orbital injuries, such as entrapment syndromes (Fig 7), exophthalmos/increased orbital volume (Fig 6), enophthalmos/decreased orbital volume, visual disturbances/
diplopia, and post-surgical complications (Fig 1).

Zygomaticomaxillary Complex Fracture

Fig 2. Wood foreign body. (A) Axial CT. Linear air density
(arrow heads) represents wooden FB. (B) Axial CT, delayed
f011ow-up. Linear increased density (arrow heads) represents
fluid accumulating in interstices of wooden FB. Surrounding
soft tissue indicates hematoma and inflammatory reaction.
Note additional FB (arrow) poorly observed on (A).

Extension of the fracture plane to involve the rim

("impure" blow-out fracture) generally indicates a
more severe traumatic injury. 1t Involvement of the
superior rim is particularly significant, and is
associated with a greater likelihood of associated
cranial injuries, especially in children. 13 As children age and the paranasal sinuses pneumatize, the
incidence of orbital floor fractures increases. 14

Blow-in Fractures
"Blow-in" fractures are a result of the application of blunt force near the orbit, with decompression and displacement of fracture fragments into
the orbit. Patients present with proptosis and restric-

ZMC fractures are usually the result of direct

trauma to the malar eminence, resulting in depression of the cheek, dental malocclusion, or trismus.
Facial anesthesia due to trauma of the infraorbital
nerve is common. The complex includes fractures
of the zygomatic arch, orbit floor and rim, anterior,
lateral and posterior walls of the maxillary sinus,
and zygomaticofrontal process (Figs 8, 9). Nondisplaced fractures are termed "simple." "Complex"
fractures are associated with more significant vascular or airway injuries due to the medially displaced
and rotated fracture fragments. ~7 Although plain
films may delineate the fracture lines well, CT is

Fig 3. Concurrent inferior and medial blow-out fractures.

(A, B, C, D) Plain film, Caldwell view; coronal CT, bone and soft
tissue windows; coronal Tl-weighted MRI. Left orbit floor and
medial wall are disrupted, with dependent soft tissue density
representing herniated orbital contents (*), bone fragment
(arrow), and partial opacification of maxillary sinus. Medial
rectus muscle (arrow head) is tented toward the opacified left
ethmoid air cells and medial blow-out fracture. Soft tissue
streaky density within intraconal space represents hematoma. (E,F) Axial CT and Tl-weighted MRI. Medial blow-out
fracture and medial rectus tenting (arrow head) are better
seen. Intraconal hematoma and left globe hemorrhage with
choroidal detachment (large arrowhead) are also noted.

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MICHAEL ROTHMAN

Fig 3 (on previous page).

ORBITAL TRAUMA

441

Fig 6. Superior blow-in fracture. Coronal T1-weighted MRI.

Right superior orbit encephalocele (arrow), old, due to prior
superior blow-in fracture.

Fig 4. Superior blow-out fracture. (A) Coronal CT, bone window. Comminuted fracture of the orbital roof (arrow). CT of the
brain shows a subfrontal hematoma and cortical contusion.

preferred for its ability to accurately define the

degree of displacement of the fracture fragments.

Naso-Orbital-Ethmoid Complex Fracture

The NOE fracture occurs due to direct trauma to
the midface and nasal bones. Concurrent complex
bilateral facial trauma and multisystem injuries are
commonly observed when the trauma is due to

high-speed motor vehicle accidents, but simple

fractures are more frequent when the injury is due
to a direct blow as from a fist.18 Fractures may
include avulsion of the fossa, comminution of the
fossa or canal, and linear fractures of the canaP 9
(Fig 10). Transection of the nasolacrimal apparatus
may occur, but is infrequent. Telecanthus, or widening of the interorbital distance, may be observed
acutely and is due to avulsion of the medial canthal
ligament. Epiphora or lacrimal mucocele due to
blockage of the duct, and rhinorrhea secondary to
cerebrospinal fluid leak from a concurrent cribi-

Fig 5. Medial blow-out fracture. (A,B) Axial and coronal CT, bone window. Extensive intra- and extra-conal orbital air from lamina
papyrcea disruption/ethmoid sinus outlines intraorbital structures.

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MICHAEL ROTHMAN

Fig 8. Zygomaticomaxillary complex fracture (ZMC). (A) Plain

film, Water's view. Left ZMC fracture, including zygomatic arch (a),
orbit floor and rim (b), anterior, lateral (c) and posterior walls of the
maxillary sinus, and zygomaticofrontal process (d).

form plate or frontal sinus fracture, may occur in

delayed presentation.
Le Fort Fractures

These midface fractures occur along lines of

structural weakness, as defined by Le Fort in 1901.
Three types are classically described (in order of
increasing severity): (1) transverse fracture through
the maxilla above the level of the hard palate
including the pterygoid plates, resulting in dissociation of the maxilla from the midface; (2) pyramidal
fracture crossing the nasal bridge and septum,
medial orbital walls and floors, maxillary antra, and
pterygoid plates, resulting in dissociation of the
midface from the cranium; (3) transverse fracture
through the nasal bridge, and orbits, then diverging
through the zygomaticofrontal processes and arches,
and the maxilla and pterygoid plates, resulting in
craniofacial dissociation (Fig 11). Although originally described as bilaterally symmetrical, pure
c

Fig 7. Medial blow-out fracture, chronic. (A, B, C) Axial and

coronal CT soft tissue window, coronal CT bone window.
Tented and clinically entrapped left medial rectus muscle
(arrow head), with herniation of medial rectus muscle, fat, and
periorbita into ethmoid air cells, Lack of sinus fluid, and
clinical history, confirm chronicity. Note persistent intraorbital
air on coronal CT, indicating continuing communication of
sinus cavity and orbit.

ORBITAL TRAUMA

443

Fig 9. Zygomaticomaxillary complex fracture. (A, B, C, D)

Axial, coronal anterior, coronal posterior and 3D CT, bone window. Right ZMC fracture, including zygomatic arch(a), orbit floor
and rim (b), anterior, lateral and posterior walls of the maxillary
sinus (c), and zygomaticofrontal process (d). This patient also has
a right naso-orbital-ethmoid fracture (arrow).

fracture patterns are rare, and combinations of

complex midface fractures are usually observed:
the "facial smash" 17 (Figs 10, 12).
Complications due to this severe facial trauma
are extremely common. Soft tissue hematomas
resulting in airway compromise must be excluded
during the evaluation process. Immediate and delayed cerebrospinal fluid leaks occur more often
with these injuries than with other orbitofacial
fractures. Coexistent remote trauma is also frequent
due to the high-velocity impact that produces these
injuries) 7

TRAUMATIC CRANIAL NEUROPATHIES

Diplopia occurring in the setting of orbital

trauma is common and may be due to either injury
or restriction of the extraocular muscles or cranial
nerves. Cranial nerve injury may occur at the
brainstem, in the cisterns, at the skull base or
cavernous sinus, or at the orbital apex. CT scanning
in axial and coronal planes evaluates the extracranial and skull base segments effectively, but MRI,
with high-resolution thin section sequences, best
visualizes the intracranial extent of the cranial

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MICHAEL ROTHMAN

Fig 10. Naso-orbital-ethmoid fracture/facial smash. (A, B) Axial

CT inferior and superior levels. Comminuted, impacted bilateral
facial fractures with displacement and rotation of nasolacrimal
sac/lacrimal bone and duct (arrow). (C) Anteroposterior dacrocystogram transecting and obstructing the nasolacrimal duct (arrow).

nerves. Cranial nerves 2, 3, 4, 5, and 6 (optic,

ophthalmic, trochlear, trigeminal, and abducens)
may all be injured following trauma.
Optic nerve injury may result from direct penetrating trauma, or may be due to compression or
transection in association with fractures of the
orbital apex/optic canal? Loss of visual acuity or
visual field deficits are noted by the patient or
discovered on physical examination. The presence
of post-septal soft tissue density in and around the
optic nerve sheath is indicative of perineural hematoma (Fig 13). Bony fragments may also displace
or contuse the nerve (Fig 14).
Isolated ophthalmic nerve (CN 111) palsy due to

trauma is less common than CN III palsy from other

causes? ~Patients present with a combination of diplopia, ptosis, and pupillary dilation. The presence of neck
pain, Homer's syndrome, or bruit on physical examination should prompt further evaluation of the vascular
tree for the possibility of internal carotid dissection.
Trochlear (CN IV) nerve palsy occurs secondary
to trauma more often than from any other cause.
CN IV innervates the superior oblique muscle, and
its deficit results in unopposed action of the inferior
oblique muscle. Identification of a trochlear deficit
clinically is difficult as a palsy results in hypertropea, mimicking a blow-out fracture on physical
examination. 2a

ORBITAL TRAUMA

445

Fig 11. Le Fort fracture. (A, B, C, D) Axial CT from inferior to

superior, 3D reconstruction. Bilateral Le Fort fractures: right Le
Fort I, II, Left Le Fort I, II, II1. Pterygoid plates fractures (large arrow
head) define this complex.

Fig 12. Facial smash. (A, B) Axial CT bone and soft tissue windows. Bilateral facial smash-highly comminuted and impacted
crush facial injury. Left globe is ruptured and filled with hemorrhage.

446

M CHAEL ROTHMAN

Trigeminal (CN VI) nerve palsy results in facial

anesthesia and absent corneal reflex. It is commonly injured in fractures of the orbit floor or roof,
especially if the rim is involved. Fractures through
the orbital apex/fissures may also produce Clinical
symptoms. ~7
Abducens palsy (CN V1) is the most frequently
encountered cranial neuropathy and results in lat-

Fig 14. Optic canal fracture and optic nerve compression.

(A, B) Axial and coronal CT, bone window, Complex skull base
fracture-extending through right optic canal; with inferior
displacement and clockwise rotation of the fracture fragment
(arrow). Right sphenoid sinus Iocule is opacified, right pterygold plates are fractured (open arrows); right superior Orbit
rim is fractured (arrowhead). ,

Fig 13. Penetrating trauma, (A, B, C) Axial and coronal CT,

sagittal reconstruction along the course of the optic nerve.
Perineural hematoma (h) along optic nerve following stab
injury to inferiomedial orbit with a pencil.

eral rectus palsy and limitation of lateral gaze. The

ner+e's long intracranial course is thought to be
responsible for its increased susceptibility to traumatic injury.23
Acute or delayed onset of post-traumatic dipl0pia associated ~ith proptosi s and chemosis, sugge;ts a diagfiosis Of direct carotid cavernous fistula
(CCF! (Fig. 15)'. Direct CCF results from a tear of
the cavernous internal carotid artery that allows
arterial blood [0 enter the cavernous sinus, reversing tl~e flo~v in the venous tributaries. Prominent
anterior .venous drainage resultS in the Orbital
presgntatidn. 24

ORBITAL TRAUMA

447

Fig 15. Traumatic direct carotid cavernous fistula. (A) Axial CT bone windows demonstrate fractures of the superior orbital fissure,
lateral sphenoid wall, and carotid canal (arrows). Note the bilateral comminuted temporal bone fractures. (B) Lateral internal carotid
arter!ogram demonstrates a direct carotid cavernous fistula with anterior venous drainage into the superior (SOV) and inferior (IOV)
ophthalmic veins a s well as posterior drainage into the inferior (IPS) and superior (SPS) petrosal sinuses.

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