Characterization of orbital fracture patterns in head-injured patients using computed tomography

INTRODUCTION

Orbital trauma is most frequently encountered in individuals under the age of 30 and represents a substantial proportion of midfacial injuries. Notably, approximately 85% of orbital trauma cases requiring hospitalization involve fractures of the orbital walls, which constitute nearly 40% of all craniofacial fractures – second in prevalence only to nasal bone fractures, particularly among individuals in their third and fourth decades of life. The incidence exhibits a pronounced male predominance, with a reported male-to-female ratio of approximately 2:1. Common causative factors include motor vehicle collisions, interpersonal violence, and sports-related incidents.

Three principal biomechanical theories have been proposed to elucidate the pathogenesis of orbital fractures:

1. Hydraulic theory - Postulates that a sudden increase in intraorbital pressure, typically following blunt force trauma, results in decompression through the orbital floor or medial wall, which are structurally weaker, particularly the lamina papyracea and the region medial to the infraorbital canal

2. Globe-to-wall contact theory - Suggests that posterior displacement of the globe during trauma causes direct transmission of force to the orbital wall, resulting in fracture

3. Buckling hypothesis - Proposes that an external force applied to the orbital rim is transmitted posteriorly, producing a fracture through buckling of the orbital bony framework.^[1]

Anatomically, orbital fractures are classified into several categories: orbital floor fractures, medial wall fractures, naso-orbito-ethmoidal (NOE) fractures, zygomatico-orbital complex fractures, maxillary fractures (Le Fort types II and III), and frontobasal fractures.^[1,2]

In the context of polytrauma, prompt and thorough ophthalmologic evaluation is imperative to preserve visual function. Early detection of injuries involving the visual pathway plays a crucial role in guiding management decisions and optimizing long-term visual outcomes.

MATERIALS AND METHODS

A prospective observational study was undertaken at a tertiary care referral center over a 6-year period, from 2018 to 2024. A total of 508 patients presenting with head trauma were enrolled.

Eligible participants included individuals of all genders aged 18 years and above who presented within 7 days of sustaining trauma. Inclusion required radiologically confirmed orbital fractures, as identified through computed tomography (CT). Cases with associated head injuries were confirmed through neuroimaging modalities. All patients were managed within the tertiary care center during the study duration. Informed consent was obtained from all participants, in accordance with ethical guidelines.

The primary objective of the study was to assess the incidence and morphological patterns of orbital fractures and to evaluate the spectrum of associated ocular and intracranial injuries, as delineated by high-resolution CT imaging.

RESULTS

Table 1 shows a total of 508 patients presenting with head trauma were included in this study, comprising 408 males (80.4%) and 100 females (19.6%), yielding a male-to-female ratio of approximately 4:1. The age of the cohort ranged from 2 to 70 years, with individuals aged 20–30 years representing the most affected demographic (n = 194; 38%).

DISCUSSION

In this prospective, cross-sectional observational study involving 508 individuals presenting with head trauma, we aimed to characterize the spectrum of orbital and ocular injuries, with particular emphasis on their association with TBI. The study cohort was predominantly composed of young adults aged 20–30 years (38%), with a marked male preponderance (80.4%). RTAs emerged as the principal mechanism of injury, accounting for 99% of cases. This observation mirror finding reported by Patil et al., who similarly identified high rates of orbital trauma among young adult males involved in vehicular collisions.^[5]

Orbital fractures were identified in 153 patients (30%), a notably higher incidence than that reported by Gupta et al., who observed a 4.15% occurrence in a comparable trauma cohort.^[5] Among those with fractures, multi-wall involvement was prevalent, occurring in 83.7% of cases – a pattern indicative of high-energy impact and substantial force transmission to the midfacial skeleton. The most frequently encountered fracture configurations were NOE fractures (n = 166), followed by maxillary (n = 138), frontobasilar (n = 132), and zygomatico-orbital (n = 94) fractures. Interestingly, this distribution contrasts with that noted by Patil et al., where orbital floor fractures predominated, suggesting possible regional or mechanistic differences in trauma patterns.^[5]

Ocular involvement was frequent among patients with orbital fractures. Subconjunctival hemorrhage was the most commonly observed ocular manifestation, followed by eyelid lacerations – findings that are consistent with the series published by Terrill et al., who emphasized subconjunctival hemorrhage as a frequent indicator of underlying orbital trauma.^[7] Our data further indicate that multi-wall fractures, particularly those involving the NOE complex, are associated with more extensive and severe ocular injuries, reinforcing the need for early ophthalmologic assessment in such cases.^[13]

TBI was diagnosed in 106 of the 153 patients with orbital fractures (69%), with a disproportionately higher incidence in those with multi-wall fractures. Fronto-basilar and NOE fractures, in particular, demonstrated a strong correlation with intracranial involvement. These findings stand in contrast to those of Lee et al., who reported a significantly lower incidence of TBI (8.7%) in their orbital trauma population.^[10] While isolated orbital fractures exhibited a lower association with TBI, notable overlap was observed in zygomaticomaxillary complex fractures. Importantly, we documented one case with superior orbital fissure syndrome and orbital apex syndrome – both of which underscore the potential for devastating neuro-ophthalmic complications in the context of complex orbital trauma.

Statistical analysis confirmed a robust and significant association between the presence of orbital fractures and concomitant ocular and intracranial injuries. These findings underscore the critical role of early, multidisciplinary evaluation in the management of patients with craniofacial trauma. From a neuro-ophthalmologic perspective, orbital fractures should be regarded not only as structural injuries but also as potential indicators of more extensive multisystem trauma, warranting immediate and comprehensive clinical investigation.

In this prospective, cross-sectional study of 508 patients presenting with head trauma, the data underscore several key findings that have direct implications for trauma evaluation protocols, imaging strategies, and interdisciplinary collaboration in acute care settings. The demographic predominance of young adult males injured primarily in RTAs is consistent with prior trauma epidemiology, reflecting a high-risk group that warrants targeted public health interventions. The near-exclusive mechanism of RTAs (99%) suggests that high-velocity impact is a primary driver of orbital injuries in our population. This has implications not only for emergency department triage but also for anticipatory guidance, trauma system design, and preventive measures such as helmet and seatbelt usage enforcement. The 30% incidence of orbital fractures – particularly multi-wall fractures in over 83% of affected patients – reflects a significant burden of midfacial trauma. The high-energy nature of these injuries implies that the presence of an orbital fracture, especially of the NOE or fronto-basilar type, should serve as a clinical alert. These injuries are not isolated events but often occur in the setting of more extensive craniofacial disruption and potential intracranial involvement. Therefore, their identification should prompt immediate neuroimaging and a comprehensive craniofacial assessment. The distribution of fractures in this cohort diverges from previous studies, with a greater prevalence of complex fracture patterns (NOE, fronto-basilar, maxillary, and zygomatico-orbital) rather than isolated orbital floor injuries. This suggests a need for regionalized trauma protocols that consider the mechanism and pattern of injuries typical to specific populations and settings.

Ocular injuries were frequently associated with orbital fractures, reinforcing the importance of early and thorough ophthalmologic evaluation in this patient subset. Subconjunctival hemorrhage – often dismissed as a benign finding – was a common presenting sign, but its presence should raise suspicion for deeper, potentially vision-threatening trauma. Multi-wall fractures, particularly those involving the NOE complex, were strongly associated with more severe ocular damage, emphasizing the need for prompt ophthalmology consultation.

The most clinically significant finding was the strong correlation between orbital fractures and TBI, present in 69% of patients with orbital fractures. This association was particularly pronounced in patients with multi-wall fractures, suggesting that orbital fractures should be considered surrogate markers for possible intracranial pathology. This finding stands in stark contrast to previous reports of lower TBI rates (e.g., 8.7% reported by Lee et al.), likely due to differing trauma severities or case selection.^[11] This has direct implications for clinical workflows in emergency and trauma departments. Orbital fractures – especially of the NOE and fronto-basilar regions – should prompt an automatic escalation of care, including early head CT scanning and neurosurgical consultation. Failure to recognize the potential for associated TBI could lead to missed or delayed diagnoses, with potentially catastrophic outcomes. Moreover, the documentation of superior orbital fissure syndrome and orbital apex syndrome, although rare, highlights the need for a high index of suspicion for neuro-ophthalmic syndromes in complex orbital trauma. These conditions can lead to permanent vision loss or cranial neuropathies if not promptly identified and managed.

Our findings strongly support the adoption of multidisciplinary trauma protocols for patients with orbital fractures. Emergency physicians, radiologists, neurosurgeons, maxillofacial surgeons, and ophthalmologists must collaborate closely to ensure timely diagnosis, management, and surgical intervention when needed. Institutions managing craniofacial trauma should consider developing standardized clinical pathways that integrate early imaging, specialist involvement, and structured follow-up for these high-risk patients.

Finally, given the substantial overlap between facial skeletal injuries and neurologic complications, this study reinforces the concept that orbital fractures are not merely cosmetic or reconstructive concerns, but rather markers of potentially life-altering multisystem trauma. Their presence mandates a holistic and aggressive approach to patient assessment and care to minimize morbidity and optimize recovery.

CONCLUSION

Orbital fractures continue to represent a substantial source of morbidity among patients with head trauma, particularly in the setting of high-velocity mechanisms such as RTAs. Our study reinforces the strong association between multi-wall orbital fractures and the concomitant occurrence of both ocular injury and TBI, highlighting the intricate anatomical and functional interdependence of the orbit and neurocranial structures.

Our study findings suggest naso-orbito-ethmoid region fracture due to their anatomical complexity and frequency may serve as a clinical marker for more severe concomitant injuries.

These findings underscore the necessity of a multidisciplinary management paradigm – one that brings together the expertise of neuro-ophthalmologists, neurosurgeons, maxillofacial surgeons, and neurologists – to ensure timely diagnosis, risk stratification, and coordinated care. Early recognition and intervention are paramount, not only to preserve visual function but also to mitigate the long-term neurological and esthetic sequelae inherent to complex craniofacial trauma.