CLINICAL PEARLS AND PITFALLS A blowout fracture is a displaced fracture of the bones of the orbit Hallmark physical findings include impaired extraocular movements, pain with extraocular movements, or periorbital swelling or ecchymosis Palpation of the bony rim of the orbit may not exhibit severe point tenderness even in the presence of fracture, depending on the bone(s) involved Blowout fracture requires emergent evaluation by ophthalmology Smaller fractures can tether extraocular muscles, especially the inferior rectus muscle, causing bradycardia Current Evidence There are two proposed mechanisms for blowout fractures The first is that force is transmitted from the orbital rim to the medial wall or floor The second is that force applied to the globe is transmitted to the orbital walls The medial wall is the most common site of fractures CT is the diagnostic modality of choice Indications for operative management include rectus muscle entrapment, enophthalmos, central-gaze diplopia, restriction of extraocular movements, or loss of orbital support Goals of Treatment The primary goal of therapy in the ED is prompt recognition of blowout fractures and any associated intraocular injuries, including entrapment and commonly associated globe injuries Approximately 20% of displaced orbital fractures are associated with globe injury; therefore, emergent ophthalmology consultation is indicated in all cases Pain control is the primary goal of treatment of nondisplaced orbital fractures Clinical Considerations Clinical Recognition Blowout fracture is suggested if any of the following are present: restriction of eye movements following trauma, enophthalmos, infraorbital anesthesia, diplopia, step-off deformity, or subcutaneous emphysema The pathophysiology and diagnosis of blowout fractures are discussed in Chapter 28 Eye: Strabismus Fractures to the inferior and/or medial orbital wall are the most common as they are the thinnest bone The lateral wall is the least commonly fractured The