This gentlemen fell asleep on the toilet and fell off bumping his head. There was no LOC. There should be enough information in the first x-ray to guess at least one diagnosis which in this context should lead to the second.
A few days ago I posted this:
And the answer is of course:
What’s the deal with blow-out fractures then?
- Typically from a blow to orbit and in particular the globe itself
- Classically this is from a squash ball (which I’ve seen twice now) or in this case a fist
Why is the inferior orbital wall affected?
- the orbit is pyrmidal in shape with the base of the pyramid facing you and the apex post in the skull. As the globe is forced backwards the walls of the orbit come under pressure
- Technically the thinnest walled part of the orbit is the medial wall and the ethmoid bone but the force in a blow to the globe tends to get redirected inferiorly rather than medially
What kind of problems can it cause?
- First look at this guys CT and take a guess [UPDATE – I suspect the muscle labelled inf oblique is actually inf rectus but don’t worry too much about it]
- yes you’ve got it – opthalmoplegia
- specifically difficulty in movements in the vertical plane. Even though sup rectus brings about superior gaze, the fact the inf rectus is trapped means that the eye is unable to be directed superiorly
Any other problems?
- direct globe injury – this is a whole topic in itself but in brief think fixed or irregular pupil, severe pain, and reduced acuity.
- orbital compartment syndrome – this is fairly interesting and worth a point or two
- pressure can rapidly develop in the orbit either from oedema from the injury or a haematoma or build up of air in the orbital cavity from the opened maxillary sinus
- the orbit it a fairly fixed compartment bounded by the bony walls and the globe and orbital septum
- the pressure eventually will lead to an ischaemic and dead eye if not treated
- treatment is surgical release, typically by a lateral canthotomy (that’s a fairly eye watering link by the way so be warned) – one of those procedures that Cliff Reid and Simon Carley suggested we should be thinking about in extreme situations.
- big time vagal reactions
- sometimes these people can brady and faint on you. They can vomit lots and look terrible too and that’s all thought to be down to vagal stimulation. Which brings me to my next point…
- remember these patients have head injuries and ? brain injuries so that vomiting nd brady might not be down to vagal response but cushings reflex!
- and remember too that if they have a head injury then they might have a neck injury. Not from a squash ball though…
And now that you’ve read all that can I strongly suggest that you go and read a similar and much better post on the same topic over on LITFL.