Why Joel Embiid is wearing a mask: An orbital bone fracture

Editor’s Note: On March 28, Joel Embiid suffered an orbital bone fracture in a game against the New York Knicks. He returned to play on April 19 for the NBA Playoffs wearing a protective face mask. Below, we explain his injury.

76ers star Joel Embiid suffered a fracture to the bones that support and protect his left eye during a collision with teammate Markelle Fultz Wednesday night. Now that his recovery may collide with the NBA playoffs, which start April 14, many sports fans may have a newfound interest in orbital bone repair.

We talked with Donald Mazur, a sports medicine surgeon with the Rothman Institute; Sonul Mehta, an oculoplastic and orbital surgeon at Penn Medicine, and Michael Rabinowitz, an oculoplastic and orbital surgeon at Wills Eye Hospital. None of them has treated Embiid. The exact nature of his injury has not been reported, but the Sixers have said that his orbital bone was fractured.  He also has a concussion.

What is an orbital fracture?

The orbit is a fancy medical word for the eye socket. The orbital rim, Rabinowitz said, runs above the cheekbone and encircles the outer edge of the socket. Eyes are also supported deeper in the skull by bone walls that surround them. A common type of orbital injury known as a blowout involves fracture to the orbital floor, which separates the eye from the maxillary sinus below it. These bones are often fractured together, he said.

Are basketball players more at risk than other athletes?

Camera icon Courtesy of Rothman Institute
Donald Mazur is a sports medicine surgeon with the Rothman Institute.

No, Mazur said. Hockey players and mixed martial arts fighters get more orbital fractures. But, he added, they’re “not uncommon” in basketball or soccer. In basketball, players are typically injured by an elbow or shoulder. In Embiid’s case, it was Fultz’s shoulder that did the damage.

Mehta said adults who are not professional athletes often wind up with this injury after auto accidents or fights.

When does a fracture need to be surgically repaired?

Not all orbital fractures require surgery. Rabinowitz said surgery is needed if a patient has persistent double vision. Some may also have nausea or even heart symptoms. Sometimes muscles get caught in fractures. This is more common in children, who have flexible bones, than in adults. If there is concern that the eye will sink, surgery is also a good idea. Because of the demands of the job, an elite athlete may be more likely than the average person to choose surgery. The same might be true for a pilot.

“This is a person who uses his eyes and his depth perception as his livelihood,” Rabinowitz said.

Mehta said that if muscle is entrapped, people need surgery right away. If surgery is clearly needed for other reasons, she said, it’s better to intervene fairly quickly to minimize muscle scarring.

How is this fixed?

Camera icon Courtesy of Wills Eye Hospital
Michael Rabinowitz is an oculoplastic and orbital surgeon at Wills Eye Hospital.

This part may make you cringe. Rabinowitz makes a 2- to 2.5-centimeter incision on the inside of the lower eyelid with surgical scissors. He then tunnels to the injured bones with blunt instruments. If the rim is fractured, he starts there. It’s a bit like a jigsaw puzzle, he said — it’s easier to do the inside if you finish the border first. Fixing the rim involves screwing in curved titanium plates. These come in a variety of shapes to match facial structure and injury. Typically, the plates are 1.5 to 2 centimeters long.

Once the rim is fixed, the surgeon can fix the floor. This involves placing a thin, porous, biocompatible implant above the broken bone. As the bone heals, it will grow into the implant. The kind Rabinowitz uses is made of polyethylene. “Under the microscope, it looks like coral,” he said.

Rabinowitz said the procedure is  common for surgeons like him. If only the floor is fractured, it takes 45 minutes to an hour. If the rim is involved, it takes an hour and a half. If other facial bones are involved, the time would double.

What are the potential complications?

Most people come through this surgery without problems, Rabinowitz said. About 20 percent have double vision at first. Usually, that’s because of swelling. “The chance of persistent double vision is very, very rare,” he said.

“Most people don’t have any further issues with it,” Mehta said. “They end up doing really well.”

Will Embiid look the same?

Yes. “He’ll still be handsome,” Mazur said.

The plate won’t show, Rabinowitz said. It will be covered by layers of muscles and fat.

How long does it take to heal?

The doctors said that bones in the face heal faster than bones in other parts of the body because of the rich blood supply.

Rabinowitz tells most patients to refrain from strenuous activity for two weeks and then stay away from contact sports for a couple months. An athlete like Embiid, who will have access to high-quality protective masks, could likely go back quicker, he said.

Camera icon Courtesy of Penn Medicine
Sonul Mehta is an oculoplastic and orbital surgeon at Penn Medicine.

Mehta tells patients who aren’t playing sports to expect two to four weeks for recovery. In the beginning, they’ll feel congested because the eye socket is so close to the sinus. She tells them not to blow their noses hard and, if possible, to avoid hard coughing and sneezing.

Mazur estimated three to five weeks for Embiid to be back on the court.