**Question:** A 20 year old man is hit on the eye with a ball. On examination there is restriction of lateral and upward gaze and diplopia. There is no obvious visible sign of injury to the eye ball, but there is some enophthalmos, the likely diagonosis is ?

A. Orbital floor fracture
B. Orbital wall fracture
C. Orbital roof fracture
D. Orbital floor and medial wall fracture

**Correct Answer:** D. Orbital floor and medial wall fracture

**Core Concept:**
Orbital fractures are a type of facial fracture that occurs when the bones surrounding the eye are broken. These fractures can lead to various ocular and extraocular symptoms depending on the specific fracture pattern. In this case, the patient presents with restriction of lateral and upward gaze, diplopia (double vision), enophthalmos (eye appears sunken), and no visible injury to the eye ball.

**Why the Correct Answer is Right:**
The correct answer, D, involves an orbital floor and medial wall fracture. Both the orbital floor and medial wall play a crucial role in maintaining the anatomy and function of the orbit. The orbital floor is responsible for supporting the globe of the eye, while the medial wall helps to hold the eye in place and maintain the normal shape of the orbit.

**Why Each Wrong Option is Incorrect:**
A. Orbital floor fracture: Although an orbital floor fracture can cause some of the symptoms described, a fracture involving the medial wall is also required to explain the presented symptoms.
B. Orbital wall fracture: Orbital wall fractures alone would not cause the described symptoms.
C. Orbital roof fracture: Orbital roof fractures would not typically result in the symptoms of lateral and upward gaze restriction, diplopia, and enophthalmos.
D. Orbital floor and medial wall fracture: This option accounts for the full range of symptoms presented by the patient, including lateral and upward gaze restriction, diplopia, and enophthalmos.

**Clinical Pearl:**
Orbital fractures can be challenging to diagnose due to the absence of visible signs on clinical examination. However, the combination of symptoms presented by the patient suggests a fracture involving the orbital floor and medial wall. In such cases, imaging studies like CT scan or MRI are necessary to confirm the diagnosis and guide appropriate management.