the fractured orbital floor is a common injury in adults , and is frequently caused by interpersonal violence . a 14-year - old boy was playing soccer , when he sustained a blow from a knee to his left orbit . he was assessed and , as he was nauseous and vomited once , a decision was made to admit him under the paediatric services to monitor his head injury . he had minimal periorbital bruising , and his visual acuity was 6/6 ; however , his ability to move his eye was reduced over the next 24h , and his diplopia worsened . this showed no brain injury ; however , the scan discovered a left orbital floor fracture with entrapment of the inferior rectus muscle ( fig .  1 ) . figure  1:preoperative ct scan showing a fracture of the left orbital floor with entrapment of the inferior rectus muscle . preoperative ct scan showing a fracture of the left orbital floor with entrapment of the inferior rectus muscle . he was subsequently transferred to our unit , and when he arrived 60h after his initial injury , his left eye showed no vertical movement and very limited downward gaze and some preserved lateral and medial movement . there was no subconjunctival haemorrhage ; 6/6 visual acuity ; his pupils were equal and reactive to light and he had marked diplopia in upward gaze . he was urgently taken to theatre , where an open exploration of his left orbit was performed . this was performed via a second crease incision , and his inferior rectus was successfully released . at 1 month following surgery , his diplopia and range of ocular movement has improved significantly but has not completely returned to normal . orbital floor fractures have the potential to cause significant morbidity both in the short and long term , and commonly present to the emergency department for initial assessment . the pathway for the majority of these injuries in adult patients involves rarely involves an indication for early surgery in cases uncomplicated by sight threatening complications . patients are often seen for a clinic review and , if necessary , later semi - urgent / elective surgery . there is a specific subset of orbital injuries which present as an emergency clinically suggestive of a head injury . this subset ,  white - eyed blowout , usually occurs in patients under 18 years of age . nausea and vomiting in children who have minimal signs of trauma and no loss of consciousness has been found to be a presenting sign of orbital fracture in up to 55.6% of cases . the oculovagal reflex is well described in ophthalmic surgery , but may be caused by any manner of pressure on the globe . the classic presentation in children is a white eye injury ( i.e. no subconjunctival haemorrhage ) with upgaze diplopia and general malaise . ct imaging normally reveals a trap door orbital floor fracture with herniation and acute entrapment of orbital muscle and is regarded as a maxillofacial emergency . it is the fact that the injury presents with marked nausea , vomiting , headache and irritability suggestive of a head injury that commonly distracts from the true aetiology . one - third of children with orbital blowout fractures are admitted for head injury observations , while the true cause for the symptoms goes unrecognized and uninvestigated . orbital blowout fractures in children require more swift intervention than in adults if muscle ischaemia and permanent impairment of the vision is to be avoided . the delay for head injury observation may therefore compromise the surgical outcome . inferior trapdoor fractures with muscle and soft tissue incarceration are the most common type of orbital fracture in children ( 27.893% ) . if delays to treatment and the associated morbidity are to be avoided , then the paediatric clinician must have a low threshold for investigating a suspected orbital fracture whilst remaining vigilant for significant head injury .
inferior  trapdoor orbital floor fractures with muscle and soft tissue incarceration are the most common type of orbital fracture in children . 
 delays to treatment can lead to a significant morbidity . 
 it has been recommended that children who present with a  white - eyed blowout fracture should have surgery performed within 48h of diagnosis , otherwise prognosis is poor . 
 a 14-year - old boy was initially misdiagnosed with a head injury due to the minor appearance of his orbital injury and his presenting complaint of nausea and vomiting . 
 this resulted in a significant delay to surgery . 
 the oculovagal reflex associated with orbital injuries is well documented ( wei and durairaj in pediatric orbital floor fractures . 
 j aapos 2011;15:17380 ) . 
 it should be considered by emergency department and paediatric staff when dealing with patients who have sustained a blow to the orbital region , despite not having a subconjunctival haemorrhage . 
 the importance of examination to detect other features of orbital blow - out and entrapment are stressed .