Recognition and Management of an Orbital

Blowout Fracture in an Amateur Boxer

CASE
Page A. Karsteter, MAJ, MPT 1

REPORT
Craig Yunker, MS, ATC 2

Study Design: Case report. Vision and life-threatening com-

Objectives: To identify key elements in the recognition and management of a patient with an plications make this an important
orbital blowout fracture and make recommendations on diagnosis, treatment, referral, imaging, injury to identify quickly. Post-
and return to sports. traumatic orbital emphysema can
Background: Orbital blowout fractures are uncommon but important injuries for physical damage ocular ner ves and
therapists to recognize. Immediate management is essential in preventing complications. The
muscles, and is easily relieved with
mechanism of injury is a direct blow to the orbital rim or orbit.
Case Description: The patient reported to the athletic training room 15 minutes after completing a
decompression.3 Although rare, or-
boxing match and reported that his left eye had suddenly inflated after blowing his nose. We bital cellulitis can quickly develop
suspected an orbital blowout fracture and referred him immediately to the emergency department into an abscess that can lead to
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where conventional radiographs were ordered. On follow-up the next day, after determining that meningitis, septicemia, cavernous
the radiographs were normal, but still having a high index of suspicion for an orbital blowout sinus thrombosis, and death.33 Dif-
fracture, we referred him to his primary care manager. The primary care manager ordered a ferential diagnoses include
computed tomography scan that revealed the fracture and referred the patient to ophthalmology. trochlear nerve injury, bruised
Outcomes: The patient was restricted from the remaining 4 weeks of the boxing season. He extraocular muscles, orbital hem-
completed a rigorous Army physical fitness test 7 days postinjury and the Marine Corps Marathon orrhage, retinal tear, and edema
Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

47 days postinjury. without blowout.4,30 Initial diag-

Discussion: Orbital blowout fractures without double vision, extraocular muscle entrapment, or
nostic workup should include a
persistent numbness can be treated with time and protection. The patient can continue with
normal fitness activities except contact or collision sports. J Orthop Sports Phys Ther
thorough history and physical ex-
2006;36(8):611-618. doi:10.2519/jospt.2006.2207 amination, orbital radiographs
and/or computed tomography
Key Words: boxing, direct access, eye, facial fractures, physical therapy (CT) scan, and referral to the
emergency department, primary

T
he recognizing of injuries that need referral to other care manager, or ophthalmology
specialists or have the potential for complications is an as the case warrants.
Journal of Orthopaedic & Sports Physical Therapy®

essential skill for the physical therapist. The orbital blowout The purpose of this case report
fracture is one of these injuries. This injury should not be is to identify key elements in the
directly managed by the physical therapist, but must be recognition and management of a
recognized and referred to the appropriate specialist for immediate patient with an orbital blowout
management and treatment. fracture and discuss diagnosis,
An orbital blowout fracture is a fracture of any wall of the orbit, treatment, referral, imaging, and
including the medial wall, lateral wall, posterior wall, the floor, or the return to sports.
roof. The most common injury site is the floor or medial wall (Figure
1).4 Any blow to the face or eye, especially the orbital rim, can cause CASE DESCRIPTION
this injury.
After losing in a midseason bout
1
Student, US Military-Baylor University Post-Professional Sports Medicine-Physical Therapy Doctoral by split decision, a 20-year-old ca-
Program, West Point, NY. det in his junior year at the
2
Instructor, Department of Physical Education, West Point, NY.
This manuscript was approved by the Keller Army Community Hospital Institutional Review Board, West United States Military Academy,
Point, NY. The boxer provided informed consent for publication of this case report. The views expressed reported to ringside medical per-
in this article are those of the authors and do not reflect the official policy of the Department of Defense sonnel for standard postbout
or the US Government.
Address correspondence and requests for reprints to Major Page Karsteter, 3081B Webb Place, West screening. He was screened and
Point, NY 10996. E-mail: page.karsteter@us.army.mil cleared for mild traumatic brain

Journal of Orthopaedic & Sports Physical Therapy 611

Downloaded from www.jospt.org at on October 10, 2022. For personal use only. No other uses without permission.
FIGURE 1. Orbital Anatomy, frontal view. Reprinted from Dutton JJ, Atlas of Clinical and Surgical Orbital Anatomy (1994), with permission
from Elsevier.
injury and obvious facial injury by a physical therapist
enrolled in a sports medicine residency.
Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
According to the Department of Physical Education
(DPE) at West Point, all boxers are screened immedi-
ately for mild traumatic brain injury and obvious
facial injury after each bout, using the Department of
Physical Education Head Injury Evaluation Sheet
(Appendix). This is similar to, but more formalized
than, the United States Amateur Boxing postbout
examination.29 In the presence of 1 or more signs or
symptoms of mild traumatic brain injury, we conduct
Journal of Orthopaedic & Sports Physical Therapy®
serial exams every 5 minutes for a 20-minute period,
in accordance with the protocol in the appendix.7
The physical therapist conducted both subjective
and objective postbout examinations. The subjective
examination covered questions on dizziness, head-
ache, nausea, tinnitus, amnesia, and blurred or
double vision. The objective examination included
observation of gait, testing of double leg balance with
eyes open and closed, and testing information pro-
cessing by asking simple memory and daily-activity
questions. Because the boxer had neither subjective
complaints nor objective findings in his postbout
examination, he was released without need for
follow-up or further evaluation.
Training Room Initial Visit
About 15 minutes after the bout, the boxer came
to the DPE athletic training room complaining that
612
he felt a pop and his left eye ‘‘inflated’’ after blowing
his nose. The head DPE athletic trainer and the same
physical therapist evaluated the boxer in the training
room and suspected an orbital blowout fracture. The
athletic trainer had previous experience with similar
injuries that included a description by the athlete of
the eye ’’inflating’’ after nose blowing. With this
presentation, we performed a subjective and objective
facial examination.
The subjective examination revealed numbness to
the boxer’s lower eyelid and under his eye, but no
blurred or double vision. However, he admitted to
having double vision during the bout after receiving a
blow to the eye in the first round of the 3-round
bout. The double vision resolved before the bout was
over so he did not report it during the postbout
screening, even though he was specifically asked if he
had blurred or double vision. The objective examina-
tion, including palpation of the orbital rim, observa-
tion of ocular movement, and observation of ocular
position was unremarkable except for obvious swell-
ing around the left eye.
After his evaluation in the athletic training room,
we transported him to the emergency department,
with a copy of our clinical findings, by routine shuttle
for further evaluation. We instructed him to avoid
blowing his nose for the next 48 hours and to follow
up in the training room the next day. The emergency
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006
 department physician ordered orbital and facial ra-
diographs, which were unremarkable per the radiolo-
gist’s report.
Follow-up Care
When the boxer reported to the training room the
next day, he had new complaints of pain with
combined ocular adduction and infraduction (look-
ing down and in), as well as periorbital numbness
extending to the tip of his nose. His physical exami-
nation was unchanged, except he now had periorbital
ecchymosis with the swelling. Because of our high
index of suspicion for an orbital blowout fracture, the
athletic trainer instructed the boxer to go to routine
sick call at the Cadet Health Clinic the next day and
to inform the healthcare provider he saw that the
athletic training room personnel recommended a CT
scan. In our facility, physical therapists are authorized
to order CT scans, but the physical therapist in this
case was not available in the athletic training room at
the time of the follow-up.
The CT scan was completed 3 days postinjury and,
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according to the radiologist, demonstrated ‘‘. . . frac-
ture of the right orbital floor as well as lamina
papyracea. A small amount of orbital fat herniates
into the maxillary sinus. There is associated preseptal
and postseptal orbital emphysema, as well as small
amount of fluid in the maxillary sinus, likely repre-
Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
senting blood. The right ethmoid sinuses are nearly
completely opacified secondar y to the lamina
papyracea fracture. The ocular muscles do not appear
involved, showing no signs of entrapment’’ (Figure
2).
Once the CT scan confirmed an orbital blowout
fracture in this boxer, our role in his care became
observational. We continued to have the subject
check in with us in the athletic training room to
Journal of Orthopaedic & Sports Physical Therapy®
monitor his progress.
FIGURE 2. Computed Tomography Scan showing an orbital blow-
out fracture.
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006
Based on these findings, the boxer’s primary care
provider gave him an excusal, exempting him from
contact activities for 30 days, terminated the remain-
ing 4 weeks in his boxing season, and referred him to
ophthalmology.
An ophthalmologist evaluated the boxer 10 days
CASE
postinjury and found nothing significant on examina-
tion. The ophthalmologist diagnosed an asympto-
matic left orbital floor/medial wall blowout fracture
with neither extraocular muscle entrapment nor
REPORT
enophthalmosis. The ophthalmologist did not require
the boxer to make a follow-up visit and did not make
specific return-to-sport recommendations.
OUTCOMES
The orbital swelling persisted for about 24 hours
and the numbness essentially resolved in about 72
hours, but persisted mildly for just over 1 week. The
boxer also reported that he noticed periorbital bruis-
ing after about 4 to 6 hours, which resolved gradually
over time. Seven days postinjury, acting on his own
initiative, he completed the Army Physical Fitness
Test, which includes a 2-minute push-up event, a
2-minute sit-up event, and a timed 2-mile run. He
scored a 262/300 possible points on the test. Eight
days postinjury he presented to the DPE athletic
training room and reported that his symptoms were
resolving. He complained of residual numbness un-
der the eye and mild pain at end range of eye
movements. Two months postinjury he reported that
he was asymptomatic and that he had recently com-
pleted the Marine Corps Marathon 47 days
postinjury. Fourteen months postinjury, he reported
no problems with his eye and that he had returned
to all activity, including diverse activities such as
paintball, soccer, swimming, bicycling, and military
field training.
DISCUSSION
Epidemiology
Any blow to the orbital rim or eye can cause a
blowout fracture and most blowout fractures are the
result of falling, aggression, or sporting events.4,31
Shere et al31 found that 14.1% of blowout fractures
were the result of sports in a military population.
This was the third most common source in a study of
1141 blowout fractures in United States Army Sol-
diers over a 20-year period. The most common cause
was violent assault (37.8%), followed by motor vehicle
crashes (17.6%). Any sport that intentionally or
unintentionally involves contact to the face may result
in a blow to the periorbital region, causing a blowout
fracture. Sports commonly associated with potential
facial contact include soccer, boxing, wrestling, bas-
ketball, and rugby. Other sports that are less com-
613

FIGURE 3. Buckling Mechanism for orbital blowout fracture. Force
is conducted from the thicker orbital rim to the thinner orbital floor
and walls from a blow to the orbital rim resulting in fracture. Used
with permission from Mark Brown and www.EyePlastics.com.
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Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
FIGURE 4. Hydraulic Mechanism for orbital blowout fracture. Force
is transmitted to the orbital walls by increased intraorbital hydraulic
pressure caused by pressure to the eyeball resulting in fracture.
Used with permission from Mark Brown and www.EyePlastics.com.
Journal of Orthopaedic & Sports Physical Therapy®
monly thought of as involving facial contact but can
result in a blowout fracture include diving, gymnas-
tics, cheerleading, and snowboarding.4,5,13,36 We
could find no reports in the literature about the
incidence of this injury in specific sports.
Mechanism of Injury
The injury producing event for an orbital blowout
fracture is typically blunt trauma to the periorbital
region.6 There are 2 theories that attempt to explain
this injury: buckling and hydraulic. In the buckling
theory, force is conducted from the thicker orbital
rim to the thinner orbital floor and walls from a blow
to the orbital rim (Figure 3). This causes the weakest
segment, typically the medial wall and floor, to blow
out.9,42 In the hydraulic theory, force is transmitted
614
to the walls by increased intraorbital hydraulic pres-
sure caused by pressure to the eyeball (Figure
4).6,27,42
Support for the buckling theory includes a case
report on a 69-year-old man who suffered an orbital
blowout fracture after a blow to the orbital rim 5 days
after a cataract extraction and implantation of an
intraocular lens in that eye. The mechanism was
observed by a technician in the office immediately
after the subject’s 5-day follow-up examination. The
technician observed the subject falling and hitting his
face on the door with the force going through the
subject’s thick-rimmed glasses. The surgeon immedi-
ately re-examined the subject and found his ocular
sutures to be intact. Because the surgical procedure
remained undisturbed by the trauma, the author
reasonably concluded that forces were not transmit-
ted through the globe.16
Supporting the hydraulic theory is a case report of
a diver suffering an orbital blowout fracture due to
high-diving.28 Although it is possible that the cumula-
tive force of the water striking the orbital rim may
have transmitted enough pressure to cause a blowout
fracture, it is more likely that the force was transmit-
ted hydraulically through the globe.
Many authors suspect that both mechanisms cause
this injury.1,16,38,41 The importance of understanding
the 2 theories is to stimulate creativity in developing
ways of preventing blowout fractures in all sports
through equipment or rule changes.
Examination Findings: History and Physical
Examination
Initial signs and symptoms of an orbital blowout
fracture include immediate swelling of the eye, a
feeling of fullness in the eye, pain around the orbital
rim, pain or difficulty with eye movements, double
vision, enopthalmosis (recession of the eyeball in the
socket), and numbness or tingling in the lower
eyelid, nose, and upper lip.22 Swelling occurs as
blood and/or air enters the orbit through the
ethmoid or maxillary sinuses. Double vision and pain
with eye movement, especially with adduction and
infraduction (looking down and in), may occur if the
inferior rectus muscle becomes entrapped at the
fracture site. An increase in the volume of the orbit
after injury contributes to enopthalmosis. Any change
of 2 mm or more may present a cosmetically poor
outcome. The V2 branch of the maxillary nerve
(cranial nerve V) exits through the inferior orbital
fissure (Figure 1).22 This is a pure sensory nerve that
supplies sensation to the lower eyelid, nose, and
upper lip and can be compressed by increased
pressure.3
In a descriptive report of 82 orbital blowout
fractures, 25% of patients had double vision, 12.5%
had limited ocular motility, and 40% had enopthal-
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006
 mosis.6 In a case report of a diver who experienced
an orbital blowout fracture after striking the water,
initial symptoms included double vision and limita-
tion of left ocular rotation on upward right gaze,
suggesting entrapment of the inferior rectus or infe-
rior oblique muscles.28 There may be a delay in the
onset of these symptoms as swelling in the orbit
gradually increases. In another case report, the sub-
ject received blunt trauma to the orbital rim after a
fall that was witnessed by staff members in an
ophthalmology clinic. The subject was examined im-
mediately but had no symptoms and no subjective
complaints. That evening he developed double vision
with upward gaze and the following day in clinic
examination demonstrated limited upward gaze.16
An anecdotal cardinal sign is sudden swelling or
‘‘inflating’’ around the eye immediately after nose
blowing. This is caused by air rushing from the
maxillary sinus into the orbital cavity and may occur
24 to 48 hours after the injury.14 In our experience
in this case and others, this is often the first symptom
that causes the patient to seek care.
Common complications of the orbital blowout
fracture include herniation of orbital fat into the
maxillary sinus,11 orbital emphysema,4,14,32 bleeding
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into the maxillary sinus,32 entrapment or rupture of
ocular muscles11,25,35,40 (especially the inferior rectus
muscle), ischemic muscular contractures,17 infection
or cellulitis, 12,34,43 double vision, 4,6,11,30,35,37
enopthalmosis4,11,37 (one eye appears receded in the
socket), and hypertropia30 (a condition where one
Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
eyeball sits higher than the other). Kang and Jang15
report one rare case where the entire intact eyeball
was trapped in the ethmoid sinus. These complica-
tions can be ruled out by a thorough physical
examination and CT scan. Physical findings will guide
the clinician on urgency of referral to more special-
ized care.
Evaluation for other injury is important. Shere et
al31 found that 70% of orbital blowout fractures
Journal of Orthopaedic & Sports Physical Therapy®
occurred with concomitant injury, including 51%
with other facial fractures, 30% with ocular injury,
and 15% with facial laceration. Only 0.4% had a
cervical spine injury. As with any blow to the head,
screening for mild traumatic brain injury is also
necessary.20,21 Important differential diagnoses to
consider include trochlear nerve injury, bruised
extraocular muscles, orbital hemorrhage, retinal tear,
and edema without blowout.4,30
Diagnosis
The therapist should maintain a high index of
suspicion for an orbital blowout fracture when evalu-
ating an athlete who reports blunt trauma to the
orbital region. The mechanism can be any blow to
the orbit or to the eyeball itself typically by a large,
blunt object such as a baseball, club, or fist. Diagnosis
J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006
is typically done by history and physical examination
and is confirmed by CT scan or magnetic resonance
imaging (MRI).
The therapist should conduct a thorough history
that includes a description of the mechanism of
injury and specific questions about pain around the
CASE
orbit, double vision, and pain with ocular movements.
Particular attention should be given to combined
adduction and infraduction (looking down and in),
numbness or tingling in the lower eyelid, nose, or
REPORT
upper lip, and a feeling of fullness or swelling in the
eye. The physical examination should include obser-
vation of ocular movements in all planes, palpation of
the orbital rim, observation for periorbital swelling or
ecchymosis, and enopthalmosis (recession of the
eyeball in the socket).22 Further screening for cranial
nerve injury or mild traumatic brain injury should be
completed as indicated by the history and physical
examination.
Imaging
Plain film radiographs are often negative, so a CT
scan or MRI is needed to rule out an orbital blowout
fracture.39 Brady et al4 does not recommend plain
radiographs because of a 50% false negative rate and
suggests that other imaging be done on a case-by-case
basis. Nishida et al24 recommend MRI because it
provides better imaging of soft tissue herniation.
Incarcerated tissues are easy to differentiate because
of the difference between herniated fat and muscle,
and better imaging of an incarcerated muscle. In our
case, we were not aware of the current literature on
the appropriate imaging for orbital blowout fractures.
We used our clinical judgment and high index of
suspicion to guide our recommendation for CT scan
imaging when the plain film radiographs ordered by
the emergency department physician were negative.
Management
Treatment of the patient with an orbital blowout
fracture can include, rest and activity modification,
antibiotics, and surgery. If the symptoms resolve in a
few days, the patient can be treated conservatively by
removing him from contact and collision sports.
However, if symptoms persist, the patient may need
surgical intervention and should be referred to see
an ophthalmologist.
Patients with visual disturbances or facial numbness
should be sent to the emergency department immedi-
ately as posttraumatic orbital emphysema can damage
ocular nerves and muscles and is easily relieved with
decompression.3 All patients should be referred to a
physician for consideration of antibiotic treatment to
prevent infection that may result from the introduc-
tion of sinus contents into the orbital cavity.43 Al-
though rare,2,23 infection can be vision and life
615
 threatening.2,33 The most distinctive features of or-
bital cellulitis are proptosis (protrusion of eyeball)
and limitation of ocular motility.12 Other indications
include conjunctival inflammation, orbital pain, re-
duced visual acuity, afferent pupillary defect, head-
ache, fever, rhinorrhea, malaise, and eyelid or facial
edema, warmth, or erythema.12,33 The onset of infec-
tion is often explosive.12 Authors disagree on the use
of prophylactic antibiotics.2,23,34,43 There does seem
to be a link between nose blowing and infec-
tion,2,23,33 so patients with an orbital blowout fracture
should be warned to avoid nose blowing.23,33 No
authors gave a recommended duration of nose blow-
ing restriction after an orbital blowout fracture.
However, Zafar and Penne44 recommend no nose
blowing for several weeks after surgery to repair an
orbital blowout fracture.
Surgical Indications
Indications for surgical intervention vary among
authors but most agree that surgery should be
delayed for 10 to 14 days to allow for spontaneous
resolution of symptoms.4,17-19,25,30 Surgery is indicated
if the eye is recessed more than 2 mm in the socket,
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extraocular muscles are restricted, or double vision
persists.4,30,40 Surgical techniques include reconstruct-
ing the orbital wall with plastics, limestone,
autologous bone, titanium mesh, or resorbable mem-
brane.8,18,26
Copyright © 2006 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Return to Sport
Return-to-sport decisions should be made in con-
sultation with the ophthalmologist and the patient. As
with any sports injur y, time of season and
psychosocial factors, such as scholarship concerns,
parental pressure, and the athlete’s desire to return
to sports, are important. We could find no studies
examining return to sport after this injury, so clinical
Journal of Orthopaedic & Sports Physical Therapy®
judgment and healing times, as well as follow-up
imaging and resolution of symptoms, are all factors to
consider.
In postoperative cases, Zafar and Penne44 allow
patients to start light lifting and straining 3 weeks
after surgery and return to most sports with protec-
tive eyewear 6 weeks after surgery. They do not
elaborate on the type of protective eyewear. The
usual standard at our facility, in the absence of
symptoms, is immediate return to noncontact sports,
but at least 3 to 4 weeks before rigorous training,
depending upon symptoms.
The use of a face shield after injury is not reported
in the literature. We feel that a face shield may allow
return to sport more quickly because its use prevents
the athlete from receiving a blow to the orbital
region. Each case, however, should be considered
individually and decisions should be made in consul-
tation with an ophthalmologist.
616
CONCLUSION
The orbital blowout fracture is an uncommon but
potentially serious injury that is easily dismissed as a
black eye or a swollen eye. It is important for physical
therapists to identify these injuries on the playing
field, in the training room, or in the clinic, and refer
the patient to the appropriate provider.
ACKNOWLEDGEMENTS
We would like to acknowledge LTC David Teller,
MD, ENT for his advice on return-to-sport criteria.
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 Appendix
APPENDIX
Department of Physical Education Head Injury Evaluation Sheet used to screen all boxers ringside after
bouts. Boxers are screened for mild traumatic brain injury and obvious facial injury. Any abnormal responses
result in full 20-minute screening in the training room to evaluate mental status changes and potential need
for transport to emergency department.
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618 J Orthop Sports Phys Ther • Volume 36 • Number 8 • August 2006