White Eye Orbital Blowout Fracture

Children’s faces are built differently from adults. Their bones are springier, and their maxillary sinuses are smaller. For children over the age of 10 and young people up until the age of 20 this combination creates the opportunity for a unique pattern of injury. There are regular papers in Emergency Medicine literature1,2 and in those of oral and maxillofacial surgery3,4 and ophthalmology5 about ‘white eye’ blow-out fractures also known as linear fractures or trap-door fractures but they are frequently missed or easily overlooked.6

An impact to the front of the orbit which could generate a blow-out fracture in an adult, can cause a ‘white-eye blow-out fracture’. The published age range are between 4 to 533 years but more typically they are in the 10-20 age group. The fractured bone – most commonly the maxillary bone – is displaced downward by the impact but, instead of bursting and the fragments falling into the maxillary sinus, the bone springs apart accepting the herniating orbital contents and then springs back, trapping these soft tissues. If the tissue trapped includes the inferior oblique muscle, the stop-watch starts on how long this strangulated muscle can survive. If the muscle is not released it will suffer ischaemic necrosis from which there is no realistic possibility of recovery.

When the bone fractures, soft tissues are trapped by the spring back of the bone. This means that there may be none of the usual bleeding related signs orbital fractures – sub-conjunctival haemorrhage without a posterior border, unilateral epistaxis with no history of trauma to the nose or even peri-orbital ecchymosis. Air emphysema which is often seen in other peri-orbital fractures is rare in this type of injury, because of the ‘self-sealing’ nature of the soft tissue incarceration.

The consistent feature is profound restriction of eye movement up or down. Additional features may include ‘ocular-cardiac’ symptoms (nausea, headache, malaise, bradycardia). These vagal symptoms may cause a misdiagnosis of cerebral problems.1 Facial numbness or dysaesthesia caused by injury to the Infraorbital Nerve (branch of maxillary nerve CNV2) as it passes through the orbital floor can also happen.

Age Group

Usually between 10 and 20 years but published cases range from 4 to 53 years, demonstrating that the condition can present across a broad age spectrum, although less frequently outside the typical age range.

Mechanism of Injury

Typically, it is an impact from an elbow, knee or similarly shaped object to the front of the orbit. This may be during rough play, or sports but can also be an assault. It is rarely caused by a fall onto a flat surface (which can cause orbital fractures in older people).

Signs

• Restriction of up-gaze (and/or downgaze)
• Usually no associated visible haemorrhage (sub-conjunctival haemorrhage without a posterior border or unilateral epistaxis without history of trauma to the nose). However, the presence of subconjunctival haemorrhage and periorbital bruising did not exclude this injury.
• Altered sensation of infra-orbital nerve without clear history of direct trauma to the infra-orbital foramen. This may not always be present.
• May be accompanied by enophthalmos or hypoglobus but this is rare.

Symptoms

• Double vision on looking up and/or down (eye might be swollen closed, this has to be actively assessed).
• No change in visual acuity
• Oculo-cardiac symptoms (nausea, headache, bradycardia, syncope) related to vagal stimulation
• Numbness on face
• Peri-orbital swelling
• Rarely air emphysema

A non-contrast CT scan can be organised if it does not delay surgery, and if the diagnosis is uncertain.

Management

Urgent surgery to retrieve the orbital tissues from the constricted herniation improves the prognosis. Benefit has been noted even after the original fracture was missed but best results seem to be associated with urgent surgery (within hours of the original injury).

Prognosis

If treated surgically and promptly, the prognosis is good. If treatment is delayed, the sequalae is ischemia and subsequent fibrosis/necrosis of the entrapped inferior rectus muscle.

This can lead to permanent and untreatable vertical diplopia (double vision) and restrictive strabismus.

1. Tarbet C, Siegal N, Tarbet K. White-eyed blowout fracture with muscle entrapment misdiagnosed as increased intracranial pressure: An important clinical lesson. Am J Emerg Med. 2021 Oct;48:375.e1-375.e3.
2. Foulds JS, Laverick S, MacEwen CJ. ‘White-eyed’ blowout fracture in children. Emerg Med J [Internet]. 2013 Oct 1 [cited 2025 May 27];30(10):836–836.
3. Ethunandan M, Evans BT. Linear trapdoor or “white-eye” blowout fracture of the orbit: not restricted to children. Br J Oral Maxillofac Surg [Internet]. 2010 [cited 2025 May 27];49(2):142–7.
4. Gerber B, Kiwanuka P, Dhariwal D. Orbital fractures in children: A review of outcomes. Br J Oral Maxillofac Surg [Internet]. 2013 Dec 1 [cited 2025 May 27];51(8):789–93.
5. Jordan DR, et al. Intervention within days for some orbital floor fractures: the white-eyed blowout. Ophthal Plast Reconstr Surg. 1998;14(6):379–90.
6. Ng JY, et al. Pediatric Orbital Blow-Out Fractures: Surgical Outcomes. Asia Pac J Ophthalmol (Phila). 2012 Sep-Oct;1(5):265-9.