Blowout Fractures of the Orbit

  • David R. JordanEmail author
  • Louise Mawn


An orbital floor fracture or “blowout fracture” is most often associated with midfacial trauma ranging from mild, and almost insignificant, to severe, and debilitating. When called upon to assess the patient with a blowout fracture, the first step in treatment is to take a careful history and ask about the mechanism of injury. It is useful to know the size of the object, the force, and velocity at which the object approached the eye, as well as any other associated head or body injuries. With an accelerating object such as a bungee cord or hockey puck, there is often much more globe trauma than a fist or a soccer ball. Although it is essential in all traumas that a complete ophthalmic examination be performed to detect direct and indirect injury to the eyelids, globe, optic nerve, and surrounding periocular structures, knowing the mechanism of injury gives you an idea of how serious the associated injuries may be.


Maxillary Sinus Soft Tissue Injury Orbital Floor Inferior Rectus Floor Fracture 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Lee HJ, Jiliani M, Frohman L, Baker S. CT of orbital trauma. Emerg Radiol. 2004;10:168–72.PubMedCrossRefGoogle Scholar
  2. 2.
    Wachler BSB, Holds JB. The missing muscle syndrome in blowout fractures: an indication for urgent surgery. Ophthal Plast Reconstr Surg. 1998;14:17–8.PubMedCrossRefGoogle Scholar
  3. 3.
    Freund M, Hahnel S, Sartor K. The value of magnetic resonance imaging in the diagnosis of orbital floor fractures. Eur Radiol. 2003;12:1127–33.CrossRefGoogle Scholar
  4. 4.
    Parbhu KC, Galler KE, Li C, Mawn LA. Underestimation of soft tissue entrapment by computed tomography in orbital floor fractures in pediatric population. Ophthalmology. 2008;115:1620–5.PubMedCrossRefGoogle Scholar
  5. 5.
    Soll DB, Poley BJ. Trapdoor variety of blowout fracture of the orbital floor. Am J Ophthalmol. 1965;60:269–72.PubMedGoogle Scholar
  6. 6.
    Soll SM. Trapdoor orbital fractures (letter to editor). Ophthal Plast Reconstr Surg. 2000;16(4):306–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Jordan DR, Allen LH, White J, et al. Intervention within days for some orbital floor fractures: the white-eyed blowout. Ophthal Plast Reconstr Surg. 1998;14:379–90.PubMedCrossRefGoogle Scholar
  8. 8.
    Hatton MP, Watkins LM, Rubin PA. Orbital fractures in children. Ophthal Plast Reconstr Surg. 2002;109:482–9.CrossRefGoogle Scholar
  9. 9.
    Grant III JH, Patrinely JR, Weiss AH, et al. Trapdoor fracture of the orbit in a pediatric population. Plast Reconstr Surg. 2002;109:482–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Lane K, Penne RB, Bilyk JR. Evaluation and management of pediatric orbital fractures in a primary care setting. Orbit. 2007;26:183–91.PubMedCrossRefGoogle Scholar
  11. 11.
    Kwon JH, Moon JH, Kwon MS, et al. The differences of blowout fracture of the inferior orbital wall between children and adults. Arch Otolaryngol Head Neck Surg. 2005;131:723–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Warwar RE, Bullock JD, Ballal DR, Ballal RD. Mechanisms of orbital floor fractures: a clinical, experimental and theoretical study. Ophthal Plast Reconstr Surg. 2000;16:188–200.PubMedCrossRefGoogle Scholar
  13. 13.
    Waterhouse N, Lyne J, Urdng M, Garey L. An investigation into the mechanism of orbital blowout fractures. Br J Plast Surg. 1999;52:607–12.PubMedCrossRefGoogle Scholar
  14. 14.
    Burnstine MA. Clinical recommendations for repair of isolated orbital fractures: an evidence-based analysis. Ophthalmology. 2002;109:1207–10.PubMedCrossRefGoogle Scholar
  15. 15.
    Dutton JJ. Management of blow-out fractures of the orbital floor. Surv Ophthalmol. 1991;35:279–80.PubMedCrossRefGoogle Scholar
  16. 16.
    Matteini C, Renzi G, Becelli R, et al. Surgical timing in orbital fracture treatment: experience with 108 consecutive cases. J Craniofac Surg. 2004;15:145–50.PubMedCrossRefGoogle Scholar
  17. 17.
    Chang EW, Manolidis S. Orbital floor fracture management. Facial Plast Surg. 2005;21:207–13.PubMedCrossRefGoogle Scholar
  18. 18.
    Harris GJ. Orbital blow-out fractures: surgical timing and technique. Eye. 2006;20:1207–12.PubMedCrossRefGoogle Scholar
  19. 19.
    Hartstein ME, Roper-all G. Update on orbital floor fractures: indications and timing for repair. Facial Plast Surg. 2000;16:95–106.PubMedCrossRefGoogle Scholar
  20. 20.
    Cole P, Boyd V, Banerji S, et al. Comprehensive management of orbital fractures. Plast Reconstr Surg. 2007;120:57S–63S.PubMedCrossRefGoogle Scholar
  21. 21.
    Putterman AM, Stevens T, Urist MJ. Non surgical management of blow-out fractures of the orbital floor. Am J Ophthalmol. 1974;767:232–9.Google Scholar
  22. 22.
    Smith B, Converse JM. Early treatment of orbital floor fractures. Trans Am Acad Ophthalmol Otolaryngol. 1957;61:602–9.PubMedGoogle Scholar
  23. 23.
    Emory JM, Van Noorden GK, Sclernitzauer DA. Orbital floor fractures; long term follow-up of cases without surgical repair. Trans Am Acad Ophthalmol Otolaryngol. 1971;75:802–12.Google Scholar
  24. 24.
    Putterman A. Interview: “Dr Allen M. Putterman on the subject of blow-out fractures of the orbital floor”. Ophthal Plast Reconstr Surg. 1985;1:73–4.PubMedCrossRefGoogle Scholar
  25. 25.
    Converse JM. Two plastic operations for repair of the orbit following severe trauma and extensive comminuted fracture. Arch Ophthalmol. 1944;31:323–9.CrossRefGoogle Scholar
  26. 26.
    Tajima S, Sugimoto C, Taniro R, et al. Surgical treatment of mal-united fractures of zygoma with diplopia and with comments on blow-out fractures. J Maxillofac Surg. 1974;2:201–10.PubMedCrossRefGoogle Scholar
  27. 27.
    Wilkins R, Havins W. Current treatment of blow-out fracture. Ophthalmology. 1982;89:464–6.PubMedCrossRefGoogle Scholar
  28. 28.
    Manson PN, Iliff N. Management of blow-out fractures of the orbital floor. II: early repair of selected injuries. Surv Ophthalmol. 1991;35:279–98.CrossRefGoogle Scholar
  29. 29.
    Putterman AM. Management of blow-out fractures of the orbital floor. III: a conservative approach. Surv Ophthalmol. 1991;35:279–98.CrossRefGoogle Scholar
  30. 30.
    Berkowitz RA, Putterman AM, Patel DB. Prolapse of the globe into the maxillary sinus after orbital floor fracture. Am J Ophthalmol. 1981;91:253–7.PubMedGoogle Scholar
  31. 31.
    Stasior OG, Roen JL. Traumatic enophthalmos. Ophthalmology. 1982;89:1267–73.PubMedCrossRefGoogle Scholar
  32. 32.
    Sires BS, Stanley Jr RB, Levine LM. Oculocardiac reflex caused by orbital floor trapdoor fracture: an indication for urgent repair. Arch Ophthalmol. 1998;16:955–6.Google Scholar
  33. 33.
    Cohen SM, Garrett CG. Pediatric orbital floor fractures: nausea/vomiting as signs of entrapment. Otolaryngol Head Neck Surg. 2003;129:43–7.PubMedCrossRefGoogle Scholar
  34. 34.
    Smith B, Lisman RD, Simontan J, et al. Volkman’s contracture of the extraocular muscles following blow-out fracture. Plast Reconstr Surg. 1984;74:200–5.PubMedCrossRefGoogle Scholar
  35. 35.
    Volkman R. Die ischemischen Muskella hmongen und fractuturen. Centralbl Chir. 1881;8:801–5.Google Scholar
  36. 36.
    Koorneef L. Current concepts on the management of orbital blow-out fractures. Ann Plast Surg. 1982;9:185–200.CrossRefGoogle Scholar
  37. 37.
    Kum C, McCulley TJ, Yoon MK, Hwang TN. Adult orbital trapdoor fracture. Ophthal Plast Reconstr Surg. 2009;25(6):486–7.PubMedCrossRefGoogle Scholar
  38. 38.
    McInnes AW, Burnstine MA. White-eyed medial wall orbital blowout fracture. Ophthal Plast Reconstr Surg. 2010;26(1):44–6.PubMedCrossRefGoogle Scholar
  39. 39.
    Brannan PA, Kersten RC, Kulwin DR. Isolated medial wall fractures with medial rectus incarceration. Ophthal Plast Reconstr Surg. 2006;22:178–83.PubMedCrossRefGoogle Scholar
  40. 40.
    Yenice O, Ogut MS, Onal S, Ozcan E. Conservative treatment of isolated medial wall fractures. Ophthal Surg Laser Imaging. 2006;37:497–501.Google Scholar
  41. 41.
    Joseph JM, Rosenberg C, Zoulman CI, Zoulman RA, White M, Lisman RD. Oculocardiac reflex associated with a large orbital floor fracture. Ophthal Plast Reconstr Surg. 2009;25(6):496–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Mendelblatt FI, Firsch RE, Lemberg L. A study comparing methods of preventing the oculocardiac reflex. Am J Ophthalmol. 1962;53:506–12.PubMedGoogle Scholar
  43. 43.
    Carroll SC, Ng SG. Outcomes of orbital blowout fracture surgery in children and adolescents. Br J Ophthalmol. 2010;94:736–9.PubMedCrossRefGoogle Scholar
  44. 44.
    Hawes MJ, Dortzbach RK. Surgery on orbital floor fractures. Influence of time or repair and fracture size. Ophthalmology. 2002;109:1207–10.CrossRefGoogle Scholar
  45. 45.
    Converse JM, Smith B, Obear MF, Wood-Smith D. Orbital blowout fractures: a ten year survey. Plast Reconstr Surg. 1967;39:20–36.PubMedCrossRefGoogle Scholar
  46. 46.
    Dal Canto AJ, Linberg JV. Comparison of orbital fracture repair performed within 14 days versus 15 to 29 days after trauma. Ophthal Plast Reconstr Surg. 2008;24(6):437–43.PubMedCrossRefGoogle Scholar
  47. 47.
    Rinna C, Ungari C, Salteral A, et al. Orbital floor restoration. J Craniofac Surg. 2005;16:968–72.PubMedCrossRefGoogle Scholar
  48. 48.
    Nunery WR, Tao JP, Johl S. Nylon foil “wraparound” repair of combined orbital floor and medial wall fractures. Ophthal Plast Reconstr Surg. 2008;24:271–5.PubMedCrossRefGoogle Scholar
  49. 49.
    Smith BC, Putterman AM. Fixation of orbital floor implants. Description of a simple technique. Arch Ophthalmol. 1970;83:598.PubMedCrossRefGoogle Scholar
  50. 50.
    Tse DT. Cyanoacrylate tissue in securing orbital implants. Ophthalmic Surg. 1986;17:577–80.PubMedGoogle Scholar
  51. 51.
    Chang SH, Custer PL, Mohadjer Y, Scot E. Use of Lorenz titanium implants in orbital fracture repair. Ophthal Plast Reconstr Surg. 2009;25:119–22.PubMedCrossRefGoogle Scholar
  52. 52.
    Lane KA, Bilyk JR, Taub D, Pribitkin EA. Sutureless repair of orbital floor and rim fractures. Ophthalmology. 2009;116:135–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Greenwald HS, Keeney AH, Shannon GM. A review of 128 patients with orbital fractures. Am J Ophthalmol. 1974;78:655–64.PubMedGoogle Scholar
  54. 54.
    Liu D. Blindness after blow-out fracture repair. Ophthal Plast Reconstr Surg. 1994;10:206–10.PubMedCrossRefGoogle Scholar
  55. 55.
    Girotto JA, Gamble WB, Robertson B, et al. Blindness after reduction of facial fractures. Plast Reconstr Surg. 1998;102:1821–34.PubMedCrossRefGoogle Scholar
  56. 56.
    Bodker FS, Cytryn AS, Putterman AM, Marschall MA. Postoperative mydriasis after repair of orbital floor fracture repair. Am J Ophthalmol. 1993;115:372–5.PubMedGoogle Scholar
  57. 57.
    Okinaka Y, Hara J, Takahashi M. Orbital blow-out fracture with persistent mobility deficit due to fibrosis of the inferior rectus muscle and perimuscular tissue. Ann Otol Rhinol Laryngol. 1999;108:1174–6.PubMedGoogle Scholar
  58. 58.
    Jordan DR, St Onge P, Anderson RL, et al. Complications associated with alloplastic implants used in orbital fracture repair. Ophthalmology. 1992;99:160–8.CrossRefGoogle Scholar
  59. 59.
    Folketad L, Westin T. Long-term sequelae after surgery for orbital floor fractures. Otolaryngol Head Neck Surg. 1999;120:914–21.CrossRefGoogle Scholar
  60. 60.
    Lee HBH, Nunery WR. Orbital adherence syndrome secondary to titanium implant material. Ophthal Plast Reconstr Surg. 2009;25:33–6.PubMedCrossRefGoogle Scholar
  61. 61.
    Custer PL, Lind A, Trinkaus KM. Complications of supramid orbital implants. Ophthal Plast Reconstr Surg. 2003;19:62–7.PubMedCrossRefGoogle Scholar
  62. 62.
    Morrison AD, Sanderson RC, Moos KF. The use of silastic as an orbital implant for reconstruction of orbital wall defects: review of 311 cases treated over 20 years. J Oral Maxillofac Surg. 1995;53:412–7.PubMedCrossRefGoogle Scholar
  63. 63.
    Polley JW, Ringer SL. The use of Teflon in orbital floor reconstruction following blunt facial trauma: a 20-year experience. Plast Reconstr Surg. 1987;79:39–43.PubMedCrossRefGoogle Scholar
  64. 64.
    Oxturk S, Sengezer M, Isik S, et al. Long-term outcomes of ultrathin porous polyethylene implants used for reconstruction of orbital floor defects. J Craniofac Surg. 2005;16:973–7.CrossRefGoogle Scholar
  65. 65.
    Taban M, Nakra T, Mancini R, Douglas RS, Goldberg RA. Orbital wall fracture repair using seprafilm. Ophthal Plast Reconstr Surg. 2009;25:211–4.PubMedCrossRefGoogle Scholar
  66. 66.
    Buchel P, Raahal A, Seto I, Iizuka T. Reconstruction of orbital floor fracture with polyglactin 910/polydioxanon patch (Ethisorb): a retrospective study. J Oral Maxillofac Surg. 2002;31:367–73.CrossRefGoogle Scholar
  67. 67.
    Bauman A, Burggasser G, Gauss N, Ewers R. Orbital floor reconstruction with an alloplastic resorbable polydioxane sheet. Int J Oral Maxillofac Surg. 2002;31:367–73.CrossRefGoogle Scholar
  68. 68.
    Loftfield K, Jordan DR, Fowler J, Anderson RL. Orbital cyst formation associated with gelfilm use. Ophthal Plast Reconstr Surg. 1988;3:187–91.CrossRefGoogle Scholar
  69. 69.
    Browning CW. Alloplastic material in orbital repair. Am J Ophthalmol. 1967;63:955–62.PubMedGoogle Scholar
  70. 70.
    Weintraub B, Cucin RL, Jacobs M. Extrusion of an infected orbital-floor prosthesis after 15 years. Plast Reconstr Surg. 1981;68:586–7.PubMedCrossRefGoogle Scholar
  71. 71.
    Mauriello Jr JA, Fiore PM, Kotch M. Dacryocystitis: late complication of orbital floor fracture repair with implant. Ophthalmology. 1987;94:248–50.PubMedCrossRefGoogle Scholar
  72. 72.
    Goldman RJ, Hessburg PC. Appraisal of surgical correction in 130 cases of orbital floor fracture. Am J Ophthalmol. 1973;76:152–5.PubMedGoogle Scholar
  73. 73.
    Alpar JJ. Unusual complication of orbital floor blowout fracture repair. Ann Ophthalmol. 1977;9:1173–6.PubMedGoogle Scholar
  74. 74.
    Aronwitz JA, Freeman BS, Spira M. Long-term stability of Teflon orbital implants. Plast Reconstr Surg. 1896;78:166–73.CrossRefGoogle Scholar
  75. 75.
    Wolfe SA. Correction of lower eyelid deformity caused by multiple extrusions of alloplastic orbital floor implants. Plast Reconstr Surg. 1981;68:429–32.PubMedCrossRefGoogle Scholar
  76. 76.
    Mauriello Jr JA. Inferior rectus muscle entrapped by Teflon implant after orbital floor fracture repair. Ophthal Plast Reconstr Surg. 1990;6:218–20.PubMedCrossRefGoogle Scholar
  77. 77.
    Kohn R, Romano PE, Puklin JE. Lacrimal obstruction after migration of orbital floor implant. Am J Ophthalmol. 1976;82(6):934–6.PubMedGoogle Scholar
  78. 78.
    Mauriello Jr JA, Flanagan JC, Peyster RG. An unusual late complication of orbital fracture repair. Ophthalmology. 1984;91:102–6.PubMedCrossRefGoogle Scholar
  79. 79.
    Nicholson DH, Guzak Jr S. Visual loss complicating repair of floor fractures. Arch Ophthalmol. 1971;86:369–75.PubMedCrossRefGoogle Scholar
  80. 80.
    Lederman IR. Loss of vision associated with surgical treatment of zygomatic-orbital floor fracture. Plast Reconstr Surg. 1981;68:94–8.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.University of Ottawa Eye InstituteOttawaCanada
  2. 2.Vanderbilt University Medical CenterNashvilleUSA

Personalised recommendations