WIDI - N10) Double vision after facial trauma

N10) Double vision after facial trauma

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with orbital wall fracture.
Review the DDx considerations in orbital wall fracture.
Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with orbital wall fractures.

History

A 35-year-old male presents to the emergency department with facial swelling and pain following an assault. He endorses left-sided periorbital pain and double vision.

Physical Exam

BP: 115/81, HR: 76, RR: 18, Temp 37C, O2 saturation: 99%. HEENT: left periorbital tenderness, edema, and ecchymosis. Neuro: PERRLA. Limited downward eye movement on the left side. No focal neurologic deficits.

Labs

Unremarkable.

Provisional Diagnosis

Select the Dx you believe is most appropriate

Epidural hematoma

Open globe injury

Zygomatic arch fracture

Orbital blowout fracture

Concussion

The patient’s facial ecchymosis and tenderness with diplopia following trauma is concerning for an orbital blowout fracture with consequent entrapment of the inferior rectus muscle.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

This patient requires an urgent workup for his condition.

First Imaging Study

What is the first imaging study you will order?

Head CT

Head MRI

CT is the modality of choice to assess and characterize facial fractures.

Well done. You were correct

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Second Imaging Study

What is the next imaging study you will order?

MRI

None

No further imaging is needed as the diagnosis of orbital wall fracture was confirmed with CT.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Orbital wall fracture without rectus muscle impingement

Orbital wall fracture with rectus muscle impingement

Based on the clinical history of trauma and CT findings, the patient has a left orbital wall fracture with impingement of the left rectus muscle.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

The patient will require urgent management.

Assessment and Plan

Please provide your assessment and plan for this patient

This patient is a 35-year-old male who presents with facial swelling and pain following an assault. Based on the patient’s history of trauma, diplopia, and CT findings, the patient has a left orbital wall fracture with left inferior rectus muscle impingement. The patient also has a left anterior superior nasal septum fracture. We will consult ophthalmology and plastic surgery or OMFS for evaluation for surgical intervention.

Lessons Learned:
- Orbital wall blowout fractures often result from high-velocity blunt trauma to the eye causing herniation of the orbital contents into the maxillary sinus. CT is the modality of choice for making this diagnosis.
- Clinical features of orbital wall fractures include unilateral periorbital pain, edema, ecchymosis, and restricted ocular movement with or without diplopia if the rectus muscle is entrapped.

Socioeconomic Factors: Males between the ages of 16 and 35 are more likely to suffer from orbital wall fractures from trauma.

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Contributors:
Sean Kwak, MS2 - Content Contributor
Haoyu Wang - Content Contributor
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator