Orbital fractures are common sequelae of paediatric facial trauma, frequently arising from sports injuries, falls or accidents. Rapid and accurate radiographic diagnosis is crucial for appropriate management. The well-established “black eyebrow sign” describes superior orbital air tracking and is a classic marker of orbital blowout fractures. We introduce a novel radiographic finding, the “reverse eyebrow sign”, characterized by inferolateral orbital air tracking. This pattern may serve as an early and reliable indicator of complex orbital and midfacial fractures in paediatric patients. Case 1: A 11-year-old male presented with lower eyelid swelling and periorbital ecchymosis after a blunt facial trauma during a rugby match. Facial radiograph demonstrated lateral and inferior orbital air consistent with reverse eyebrow sign. CT confirmed an orbital floor fracture with depression into the maxillary sinus and associated anterior and medial wall involvement, with extraconal air localized inferolaterally. Retrobulbar fat herniation was present without muscle entrapment or optic nerve injury. Case 2: A 13-year-old male sustained left facial trauma from an e-scooter accident, presenting with swelling and restricted ocular movements. Facial radiograph demonstrated inferolateral air tracking consistent with reverse eyebrow sign. CT revealed comminuted fractures of the orbital floor, maxillary sinus walls, and zygoma with infraorbital canal involvement. Inferolateral air tracking and masticator space gas locules were confirmed. Mild exophthalmos was present without muscle entrapment or intraocular haemorrhage. While the black eyebrow sign signifies superior orbital air in isolated blowout fractures, the reverse eyebrow sign indicates inferolateral orbital air tracking and is associated with more extensive injuries; typically involving the orbital floor, maxillary sinus, and zygomatic complex. Its presence may reflect comminuted or multifacial fracture patterns, serving as a radiographic red flag for more complex trauma requiring multidisciplinary evaluation. Recognizing this sign on initial imaging may help clinicians anticipate the severity of injury, plan appropriate intervention and improve patient outcomes. Read More

Meeting name: SPR 2026 Annual Meeting , 2026

Authors: Jha Rahul, Pikhen Vishal, Heir Mandip, Dickinson Fiona

Keywords: Trauma, Fracture Diagnosis, Fractures