intraocular contents often sink back into the fracture, giving an enophthalmic appearance Conversely, proptosis can occur from orbital hemorrhage Superior wall fracture (roof fractures) may be associated with pulsating proptosis as a result of communication between the orbit and intracranial cavity Fractures of the inferior wall may be associated with numbness of the ipsilateral malar region caused by injury to the infraorbital nerve, which travels along the floor of the orbit Point tenderness and “step-off” signs during palpation of the bony rim of the orbit is highly concerning for fracture, although in some orbital fractures palpation may be remarkably normal The hallmark sign of orbital fracture is a restriction of extraocular movement Usually, the eye is unable to look away from the fracture site because of a tethering of intraocular muscle or other orbital tissues in the fracture (see Fig 28.6 ) Conversely, orbital hemorrhage at the fracture site can less commonly displace the globe away from the fracture and make it difficult for the eye to look in the direction of the fracture Entrapment may occur with orbital fractures, and can increase vagal tone, triggering the oculocardiac reflex This can result in bradycardia, heart block, and in rare cases, hemodynamic instability Axial (proptosis) or coronal displacement of the globe is an ominous finding because it may be a sign of orbital hemorrhage, which can cause compression of the optic nerve, requiring emergency surgical intervention Retrobulbar hemorrhage, presenting with severe pain, vision loss, and proptosis, may also be associated with orbital fractures Enophthalmos is also a sign that should lead to urgent radiologic evaluation and may require surgical intervention Triage Considerations Children who have sustained severe blunt facial trauma and/or eye trauma should be promptly evaluated Soft tissue swelling may increase over time, making evaluation more difficult While the majority of orbital fractures are treated conservatively, those with associated ocular or intracranial injury require immediate intervention Management Some controversy exists among ophthalmologists, otolaryngologists, and craniofacial surgeons regarding the urgency for radiologic evaluation and surgical intervention in the management of orbital wall fractures If a decision is made to proceed with radiologic imaging, CT scan of the orbit with both axial and coronal views remains the standard The brain should be included, particularly when an