Complex Facial Injury In A Recreational Softball Player

HISTORY: 60-year-old male patient with no significant medical history presents to the emergency department after being struck in the right eye by a softball just prior to arrival. He was pitching in a recreational softball game when a batted ball struck him. He denies loss of consciousness. He complains of only right eye pain with a slight headache and denies dizziness, visual changes, sensory changes or weakness. He does not take blood thinners and he denies any other injuries. PHYSICAL EXAMINATION: Uncomfortable appearing male with a 4 cm laceration to the right upper eyelid with surrounding hematoma and periorbital ecchymosis. Pupils are 4 mm, equal and reactive bilaterally. Extraocular eye movements are intact without pain or restriction. Visual acuity in both eyes are 20/40 with right eye IOP of 12 mmHg compared to 13 mmHg on the left. Fluorescein staining shows negative seidel sign with small right corneal abrasion. Tenderness noted over the right maxilla and frontal scalp without crepitus. No focal neurologic deficits. No midline cervical tenderness. DIFFERENTIAL DIAGNOSIS: 1) Orbital fracture2) Retrobulbar hematoma3) Intracranial bleed 4) Maxillofacial fracture5) Globe rupture TEST AND RESULTS: Non-contrast CT Head -no acute intracranial pathologyNon-contrast CT Maxillofacial -Acute right-sided zygomaticomaxillary complex fracture including an inferiorly displaced right orbital blowout fracture of the lamina papyracea, minimally displaced fractures of the lateral wall of the right orbital wall and right maxillary sinus and a nondisplaced fracture at the frontozygomatic suture-Minimal right sided retrobulbar hemorrhage FINAL WORKING DIAGNOSIS: Acute right-sided zygomaticomaxillary complex fracture TREATMENT AND OUTCOMES: Both ophthalmology and maxillofacial surgery were emergently consulted. The patient was placed on sinus precautions and given a dose of IV ampicillin-sulbactam. Laceration was repaired. He was discharged on amoxicillin-clavulanic acid 875 mg BID and underwent delayed ORIF of his right orbital floor fracture after edema resolution. He was subsequently cleared for return to all activities.