Orbital fracture with proptosis and dystopia

A 7-year-old presented to ED with complaints of right eye pain and double vision. The patient had been involved in a sledding accident 1 week before, in which he crashed into a fence. There was no loss of consciousness. On examination in the ED, the right eye was proptotic and dystopic (image A), although with normal visual acuity and no deficits during visual field testing. The pupils were equal, round, and reactive to light; without evidence of an afferent pupillary defect. Dilated funduscopic examination was normal. Extraocular mobility demonstrated limitation of upward gaze and adduction of the right eye. CT imaging of the head including facial cuts was performed (images B and C).
(A) Patient with proptosis and orbital dystopia, with the right eye lower than the left. There is also limitation of upward gaze.
(B) Coronal CT image demonstrates a retroorbital hematoma (H) with downward displacement of the globe.
(C) Sagittal CT image also shows downward displacement of the globe and an associated epidural hematoma (arrow).