Theresa Kleverlaan, Charlotte Arnold, Gareth Nugent, Vijay Santhanam

An 18-year-old male presented to A&E having sustained a head-on face collision whilst playing football. The patient complained of dizziness, malaise and reported five episodes of vomiting. He was otherwise fit and well with no past medical history. Initial assessment was by an emergency physician, who determined that the vomiting was due to head injury. A CT scan reported a left orbital floor fracture with no muscle herniation. A subsequent referral was made to the maxillofacial surgeons. Examination revealed a small haematoma to the upper left eyelid. Pupils were equal and reactive to light with an intact accommodation reflex. There was no evidence of a relative afferent pupillary defect and visual acuity was 6/6 in both eyes. Eye movements demonstrated restricted movement on left upward gaze associated with diplopia, nausea and bradycardia. Fundoscopy could not be carried out due to photophobia. On closer inspection of the CT, inferior rectus entrapment was seen and a diagnosis of white-eyed blow out fracture was made. In theatre, intraoperative findings corroborated the clinical findings. The fracture was repaired, releasing the inferior rectus. The patient made an excellent recovery with no residual visual field defects noted at one year.

Discussion of the learning points led to a literature search. When applied to the orbital floor, Young’s modulus of elasticity shows considerable overlap in bone elasticity between children and young adults. This suggests that the trap door fracture is not exclusively a paediatric phenomenon as literature suggests and should also be looked for in young adults. This case reiterates the importance of performing a thorough assessment of the eyes, especially eye movements, in all patients presenting with periorbital trauma. Furthermore, CT should be regarded as an adjunct to thorough clinical examination and should be meticulously reviewed by a head and neck radiologist or an experienced clinician.

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