A 13-Year-Old Schoolboy Was Hit in the Left Eye by Another

A 13-year-old schoolboy was hit in the left eye by another boy during recess. During the next hour, both the eyelids of the victim swelled up until he could barely see. Examination in the emergency department revealed a bluish-red discoloration of both eyelids of his left eye with narrowing of the palpebral fissure. The discoloration extended to the forehead and the left cheek. Careful separation of the eyelids showed a localized hemorrhage of the inferolateral part of the bulbar conjunctiva (part of the conjunctiva adherent to the sclera of the eyeball). When the conjunctiva was gently moved with the tip of the examiner's little finger, the hemorrhage moved also.
When the patient was asked to look medially, the physician could clearly see the posterior limit of the conjunctival hemorrhage. Does this patient have a simple "black eye," or is this a fracture of the anterior cranial fossa of the skull? What role does the orbital septum play in enabling one to distinguish between these lesions? Is the appearance of the conjunctival hemorrhage important in making the diagnosis?