Orbital Floor Blowout Fracture

CASE

A 16-year-old male presents with head trauma. The patient was in gym class when another classmate ran into him, kneeing him in the left eye. There was no loss of consciousness. On presentation, the patient complains of headache, dizziness, nausea, visual disturbance, and photophobia. He has vomited several times. On review of systems, the patient also endorses double vision and numbness over the left cheek. The patient’s mother notes he is alert but is slow to respond to questions.  He has no prior history of facial fractures.

Physical Exam

BP 130/70, HR 58, RR 20, SpO2 99% on RA, Temp 98.6 F

The patient is alert and oriented.  He appears uncomfortable but is in no acute distress.

HEENT exam with left periorbital ecchymosis and edema, with tenderness to palpation. Diminished sensation to light touch over cheek and upper lip. Nasal bridge swelling and tenderness, with subtle nasal deviation to the right. No septal hematoma. Symmetric smile.

Pupils are equal, round, and reactive to light. No hyphema or subconjunctival hemorrhage. Left eye with decreased up-gaze as compared to the right. Extraocular movements of the left eye are painful.

The neck has normal range of motion. There is no cervical midline tenderness to palpation.

The patient’s history and examination are significant for trauma to the left eye and face. His examination reveals bony tenderness, with decreased sensation to light touch, and evidence of inferior rectus entrapment as evidenced by abnormal extraocular movements. These findings are concerning for orbital blow-out fracture. There is also concern for nasal bone fracture given nasal bridge swelling, tenderness, subtle deviation, and epistaxis. Given patient’s nausea, vomiting, dizziness, and slowed responses to questions (as per patient’s mother), intracranial injury was also considered.

The patient underwent a CT of the brain and face, with thin (1mm) cuts through the orbits (Figure 1).

Figure 1: Axial CT of the face (bone window) with fracture through the left orbital floor, with herniation of the orbital fat (“teardrop” sign) and inferiorly displaced inferior rectus muscle

Figure 1: Axial CT of the face (bone window) with fracture through the left orbital floor, with herniation of the orbital fat (“teardrop” sign) and inferiorly displaced inferior rectus muscle

DISCUSSION

Figure 2: Anatomy of the orbit (https://en.wikipedia.org/wiki/File:Orbital_bones.png)

Figure 2: Anatomy of the orbit (https://en.wikipedia.org/wiki/File:Orbital_bones.png)

The orbit is composed of six bones. The frontal bone forms the superior orbital rim and the roof of the orbit. The sphenoid bone and the zygomatic bone form the lateral wall of the orbit. The maxilla and the zygomatic bone form the infraorbital rim and floor of the orbit. Finally, the maxilla and ethmoid bones form the medial wall of the orbit (Figure 2).

Housed within, or within in close proximity to the bony orbit are the globe, six extra-ocular muscles, the infraorbital and supraorbital nerves, lacrimal duct system, medial and lateral canthal ligaments, and 4 pairs of sinuses (Neuman).

A blowout fracture is a fracture through any of the orbital walls, with an inferior fracture through the floor being the most common (Knipe). It is caused by direct force to the orbit. In children, nearly 50% of these injuries occur during sports, with the direct blow usually coming from a ball or another player (Hatton).

A trap door fracture is a sub-type of the orbital floor fracture. It is a linear fracture that inferiorly displaces and then recoils back to near-anatomic position. With this movement there is concern for entrapment of orbital fat and inferior rectus muscle, resulting in ischemia, restriction of ocular movement, and visual disturbance (Hacking). The trap door fracture is predominantly seen in the pediatric population, owing to increased elasticity of the orbital floor (Chung, Grant).

Clinically, a patient will present with periorbital edema and ecchymosis. Altered sensation or numbness over the cheek, upper lip, and upper gingiva is suggestive of infraorbital nerve injury. Proptosis of the eye is suggestive of orbital hematoma. A posteriorly displaced globe (enophthalmos) is suggestive of increased orbital volume secondary to fracture. An inferiorly displaced globe (orbital dystopia) is a result of muscle and fat prolapse into the maxillary sinus. Restricted and/or painful extraocular movements are suggestive of muscle entrapment (Neuman).

In children, a phenomenon called the oculocardiac reflex can occur. Stimulation of the ophthalmic division of the trigeminal nerve due to traction or pressure on the extraocular muscles or globe results in excitation of the vagus nerve, leading to bradycardia, nausea, and syncope. In severe cases, asystole can occur (Sires).

CT of the face, with thin (1mm) cuts through the orbit is the primary modality used for identification of orbital blowout fractures. Plain radiographs of the face and orbits are no longer the gold standard as they have poor sensitivity and specificity.  Trap door fractures may be occult, but any evidence of soft tissue herniation into the maxillary sinus (also known as the “teardrop” sign) should raise suspicion for a clinically significant fracture.

These injuries can be severe, and are often more significant in the pediatric population than the adult population, owing to associated soft tissue and muscular injuries. Almost half of children with this injury will require surgery, most frequently due to entrapment. Nearly half of pediatric patients will have ocular injuries (globe rupture, hyphema, retinal tear) and nearly one third of patients will have a second facial fracture (Hatton). 

Urgent ophthalmology and facial surgery consultations are indicated for orbital floor fractures with concern for entrapment (Chung).

Symptomatic treatment includes:

  • Head of bed elevation

  • Ice

  • Sinus precautions: no nose blowing, sneeze with the mouth open, no straw use or sniffing

  • Analgesia and anti-emetics as needed

 

For orbital fractures with extension into a sinus, the use of prophylactic antibiotics has limited data and often varies by institution (Neuman).

Corticosteroids are recommended for patients with diminished extraocular movements to reduce swelling and expedite improvement in diplopia (Neuman).

For orbital blowout fractures with evidence of entrapment and/or oculocardiac reflex, repair should be performed within 24-48 hours. Delayed repair (more than 2 weeks after injury) can be considered if mild-moderate diplopia is not spontaneously improving, or patient has worsening of enopthalmos > 2mm after initial edema and inflammation has resolved.  Other indications for surgical repair include large fracture (involvement of greater than 50% of the orbital floor) or multiple fractures (Chung).

 

CASE CONCLUSION

The patient was admitted for observation overnight in the setting of persistent nausea, vomiting, borderline bradycardia, and diplopia. He was placed on oral prednisone, as well as anti-inflammatory medication. Overnight his symptoms and heart rate improved, although he had persistent diplopia, with diminished upward gaze of the left eye. He was discharged home on hospital day 1, with plan for ophthalmology and facial surgery follow-up for operative planning.

Faculty Reviewer: Dr. Jane Preotle

 

REFERENCES & FURTHER READING

  1. Chung, Stella Y., and Paul D. Langer. “Pediatric Orbital Blowout Fractures.” Current Opinion in Ophthalmology, vol. 28, no. 5, 2017, pp. 470–476., doi:10.1097/icu.0000000000000407.

  2. Grant, John H., et al. “Trapdoor Fracture of the Orbit in a Pediatric Population.” Plastic and Reconstructive Surgery, vol. 109, no. 2, 2002, pp. 490–495., doi:10.1097/00006534-200202000-00012.

  3. Hacking, Craig. “Trapdoor Fracture.” Radiopaedia.org, radiopaedia.org/articles/trapdoor-fracture.

  4.  Hatton, Mark P., et al. “Orbital Fractures in Children.” Ophthalmic Plastic and Reconstructive Surgery, vol. 17, no. 3, 2001, pp. 174–179., doi:10.1097/00002341-200105000-00005. 

  5. Knipe, Henry, and Frank Gaillard.  “Orbital Blowout Fracture.” Radiopaedia.org, radiopaedia.org/articles/orbital-blowout-fracture-1.

  6. Neuman, Mark, and Richard G Bachur. “Orbital Fractures.” UpToDate, www.uptodate.com/contents/orbital-fractures.

  7. Sires, Bryan S. “Orbital Trapdoor Fracture and Oculocardiac Reflex.” Ophthalmic Plastic & Reconstructive Surgery, vol. 15, no. 4, 1999, p. 301., doi:10.1097/00002341-199907000-00014.

  8. Soll, D. B., and B. J. Poley. “Trapdoor Variety of Blowout Fracture of the Orbital Floor.” Plastic and Reconstructive Surgery, vol. 36, no. 6, 1965, p. 637., doi:10.1097/00006534-196512000-00017. 

AEM Early Access 23: Prognostic Accuracy of the HEART Score for Prediction of Major Adverse Cardiac Events in Patients Presenting with Chest Pain

Welcome to the twenty-third episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

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DISCUSSING (CLICK ON LINK FOR FULL TEXT, OPEN ACCESS THROUGH February 28):

Prognostic Accuracy of the HEART Score for Prediction of Major Adverse Cardiac Events in Patients Presenting with Chest Pain. Shannon M. Fernando MD, MSc, Alexandre Tran, MD, MSc, Wei Cheng, PhD, Bram Rochwerg, MD, MSc, Monica Taljaard, PhD, Venkatesh Thiruganasambandamoorthy, MBBS, MSc, Kwadwo Kyeremanteng, MD, MHA, Jeffrey J. Perry MD, MSc

LISTEN NOW: FIRST AUTHOR INTERVIEW WITH SHANNON M. FERNANDO, MD, MSC

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Shannon M. Fernando MD, MSc

Department of Emergency Medicine

University of Ottawa

Fifth Year Resident, Emergency Medicine

Fellow, Critical Care Medicine

Twitter: @shanfernands

ABSTRACT

Objective: The HEART score has been proposed for emergency department (ED) prediction of major adverse cardiac events (MACE). We sought to summarize all studies assessing the prognostic accuracy of the HEART score for prediction of MACE in adult ED patients presenting with chest pain.

Methods: We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews from inception through May 2018 and included studies using the HEART score for the prediction of short‐term MACE in adult patients presenting to the ED with chest pain. The main outcome was short‐term (i.e., 30‐day or 6‐week) incidence of MACE. We secondarily evaluated the prognostic accuracy of the HEART score for prediction of mortality and myocardial infarction (MI). Where available, accuracy of the Thrombolysis in Myocardial Infarction (TIMI) score was determined.

Results: We included 30 studies (n = 44,202) in analysis. A HEART score above the low‐risk threshold (≥4) had a sensitivity of 95.9% (95% confidence interval [CI] = 93.3%–97.5%) and specificity of 44.6% (95% CI = 38.8%–50.5%) for MACE. A high‐risk HEART score (≥7) had a sensitivity of 39.5% (95% CI = 31.6%–48.1%) and specificity of 95.0% (95% CI = 92.6%–96.6%) for MACE, whereas a TIMI score above the low‐risk threshold (≥2) had a sensitivity of 87.8% (95% CI = 80.2%–92.8%) and specificity of 48.1% (95% CI = 38.9%–57.5%) for MACE. A high‐risk TIMI score (≥6) was 2.8% sensitive (95% CI = 0.8%–9.6%), but 99.6% (95% CI = 98.5%–99.9%) specific for MACE. A HEART score ≥ 4 had a sensitivity of 95.0% (95% CI = 87.2%–98.2%) for prediction of mortality and 97.5% (95% CI = 93.7%–99.0%) for prediction of MI.

Conclusions: The HEART score has excellent performance for prediction of MACE (particularly mortality and MI) in chest pain patients and should be the primary clinical decision instrument used for the risk stratification of this patient population.

Money Minutes for Doctors #11 - Contracts, Part 2

Welcome back to our monthly financial podcast, Money Minutes for Doctors. In this episode we jump back into the subject of employment contracts with part two of one of the most important topics for a physician coming out of residency. As usual, our talk is with Ms. Katherine Vessenes, JD, CFP®, RFC, Founder and President of MD Financial Advisors. Enjoy!!

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About Ms. Vessenes:

Ms. Vessenes works with over 300 physicians and dentists from Hawaii to Cape Cod. Her firm uses a team of experts to provide comprehensive financial planning to help doctors build their wealth and protect their wealth while reducing taxes now and in the future. Katherine is a longtime advocate for ethics in the financial services industry; and has written three books on the subject of investment strategies. She has received many honors and awards including: numerous tributes from Medical Economics as a top advisor for doctors, multiple 5-Star Advisor Awards, honored as a Top Woman in Finance, in addition to being selected to be on the CFP® Board of Ethics. Katherine can be reached at: Katherine@mdfinancialadvisors.com or 952-388-6317. Her website: www.mdfinancialadvisors.com.

Quick Summary: 

Changes in health care are impacting all physicians, it has never been more important for doctors to carefully review their new contracts before they sign them. 

There has never been a contract that was not negotiable and improved in some way!

Liquidated Damages: Although I have only seen this in three contracts in the last year, this clause is becoming much more common. 

Liquidated damages is a legal construct that allows the parties to state up front, in writing, what the damages will be if the contract is breached. Parties agree in writing if the doctor violates the contract in any way, even if something as simple as not giving proper notice about leaving, the doctor will owe the employer the amount specified in the employment agreement, payments can exceed several hundred thousand dollars. 

Tip: never sign an agreement like this without consulting an attorney. It is definitely important to remove it from the agreement if the employer is agreeable. 

Tail Coverage: It is always nice to have your new employer pay for tail coverage if you leave. This can be quite expensive if you have to pay for it individually.  If you don’t see it provided in your contract, use this as a negotiation point.  

Tip: Make sure that you have tail coverage and that you don’t have to pay for it.

Tip #2: The most power you will ever have with your new employer is before you sign the agreement. Make sure you use this time to negotiate a contract that is fair to you, and protects you, too. Don’t hesitate to work with an attorney. 

Bonuses:

These should be clearly spelled out.  Learn the details and make sure they are achievable.  Make sure you ask “Of your recent hires that are similar to me, how did their bonuses pay out?”  Specifics not needed, but need to know how to plan for the future. Or could ask “What is it going to take for me to qualify for your bonus program?” Make sure you know how they are computed. 

Types of Bonuses:

  • Staring bonus – gets paid after you start, encourages you to stay w the firm

  • Retention bonus – if you stay past a certain time period, you are paid for staying on longer (i.e. 1 year)

  • Sign on bonus – should be paid when you sign the contract but often won’t receive the money until you start or even after the first year 

  • Production bonus – depends on how many patients you see per hour or how many RVU you bill etc.  These are becoming more common. 

Tip: if you don’t see bonuses offered in the contract this could be a negotiation point especially if your employer won’t negotiate on the salary

Negotiation Tips: 

  • Commonly see failure to negotiate, unfortunately more commonly seen in the female population.  Negotiations are expected and if you don’t you are leaving money behind. 

  • Overall “he who has the gold makes the rules”. Remember you have gold too, we are currently in a physician shortage! 

  • Know how in demand you are for your specialty and your location

  • He who speaks first loses. If you offer concrete terms the negotiator will latch on to that and the risk is that they may have been willing to offer more. Be sure to include pauses and don’t rush to fill the void, give your employer an opportunity to make you an offer

  • Negotiations should be done in person or at the very least over the phone.  You need the opportunity to assess body language etc. during the negotiation period

  • Never agree on the spot.  Take time to review, do research, review with your advisors.  Don’t respond to time pressures by your employer. 

  • Go in with a list of questions and then have a second list of your priorities that perhaps can be improved upon in your favor to “sweeten the deal”

  • Use role play or mental rehearsal to prepare yourself for the negotiation. 

  • Your negotiation period is the honeymoon phase so make the most of it!