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What Is a Medial Orbital Wall Fracture?

A medial orbital wall fracture is a break in the thin bone that forms the inner wall of the orbit, usually the lamina papyracea of the ethmoid bone. It often results from blunt trauma that suddenly raises orbital pressure and pushes the wall into the adjacent sinus. Patients can develop double vision, eye movement restriction, and enophthalmos. Because nearby tissues such as the medial rectus muscle and orbital fat can become trapped, careful evaluation is needed.

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What Is a Medial Orbital Wall Fracture?

A medial orbital wall fracture is a break in the thin bone that forms the inner wall of the orbit, usually the lamina papyracea of the ethmoid bone. It often results from blunt trauma that suddenly raises orbital pressure and pushes the wall into the adjacent sinus. Patients can develop double vision, eye movement restriction, and enophthalmos. Because nearby tissues such as the medial rectus muscle and orbital fat can become trapped, careful evaluation is needed.

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Mechanism and Associated Injuries

Medial wall fractures commonly occur in sports, assaults, and falls when a blunt object strikes the eye or periorbital region. The force drives the orbital contents against the thin medial wall, which cracks and displaces into the ethmoid sinus. The medial rectus muscle or surrounding soft tissue can herniate through the defect and become incarcerated. Fractures can accompany floor blowout fractures, nasal fractures, or orbital rim injuries. Nearby structures such as the nasolacrimal duct and ethmoid air cells can also be affected.

Clinical Features and Examination

Patients may report double vision, pain with eye movements, nasal bleeding, or a sense of fullness around the eye. On exam, there can be limitation of adduction or abduction if the medial rectus is trapped. Enophthalmos or globe displacement can appear once swelling subsides. Subcutaneous emphysema of the eyelids and conjunctival chemosis are sometimes present, especially after nose blowing. Sensation over the cheek is often normal in medial wall fractures, which helps distinguish them from isolated floor fractures.

Diagnosis and Imaging

Thin slice computed tomography of the orbits is the imaging study of choice for suspected medial wall fractures. It shows the fracture line, degree of displacement, and any herniation or entrapment of soft tissue. The scan also reveals associated floor or roof fractures and sinus involvement. Forced duction testing helps determine whether mechanical restriction of eye movement is present. Together, clinical findings and imaging guide decisions about observation versus surgery.

Management and Surgical Indications

Small, minimally displaced fractures without muscle entrapment or cosmetic issues are often managed with observation, ice, decongestants, and avoidance of nose blowing. Persistent double vision with positive forced ductions, severe motility limitation in children, or significant enophthalmos usually lead to surgical repair. Surgery involves freeing entrapped tissue and reconstructing the wall with an implant or graft. Follow up monitors ocular alignment, globe position, and orbital healing.

FAQs About Medial Orbital Wall Fractures

Do all medial orbital wall fractures need surgery?

No. Many small fractures without muscle entrapment or noticeable enophthalmos are treated conservatively and heal without operation.

Why is nose blowing discouraged after an orbital fracture?

Blowing the nose can force air from the sinus into the orbit through the fracture, worsening emphysema and swelling.

How soon is surgery done if the muscle is trapped?

Significant entrapment, especially in children with nausea and bradycardia, is usually repaired within days to reduce ischemia and long term motility problems.

Will double vision from a medial wall fracture go away?

Diplopia can improve as swelling decreases and after repair when needed, but some patients have residual small deviations that need prisms or further treatment.

References

EyeWiki (American Academy of Ophthalmology). ?Orbital Medial Wall Fractures.? https://eyewiki.org/Orbital_Medial_Wall_Fractures

NCBI Bookshelf (StatPearls). ?Orbital Floor Fracture.? https://www.ncbi.nlm.nih.gov/books/NBK534825/

National Library of Medicine (PMC). ?Medial Wall Fracture: An Update.? https://pmc.ncbi.nlm.nih.gov/articles/PMC3052654/

American Academy of Ophthalmology (AAO) EyeNet. ?Blowout! Managing the Orbital Floor Fracture.? https://www.aao.org/eyenet/article/blowout-managing-orbital-floor-fracture

American Association for Pediatric Ophthalmology and Strabismus (AAPOS). ?Blowout Fracture.? https://www.aapos.org/glossary/blowout-fracture