ZYGOMATIC (MALAR) FRACTURES
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1 b854_chapter-12.qxd 1/31/2011 9:40 AM Page 129 ZYGOMATIC (MALAR) FRACTURES CHAPTER 12 Anatomical articulations FZ Fronto-zygomatic ZT Zygomaticotemporal ZMB Zygomatico - maxillary buttress IO Infraorbital Forms the lateral part of the orbit Provides lateral facial projection Protects the globe All fractures of the zygoma potentially involve the orbital floor. Minor discrepancies of zygomatic bone position can cause marked asymetry. The zygomatic bone transmits 3 nerves Infraorbital Zygomaticofacial Zygomaticotemporal Zygomaticosphenoid junction is a key articulation when there is gross comminution of the other fracture articulations. Useful in cases of revision trauma. Anatomical articulation ZS Zygomaticospenoid 129
2 b854_chapter-12.qxd 1/31/2011 9:40 AM Page 130 An Atlas of Craniomaxillofacial Trauma Classification There are several classifications of lateral facial fractures, the Henderson classification is the most useful. Henderson Classification Type 1 Type 2 Type 3 Type 4 Type 5 Type 6 Type 7 Description Undisplaced Zygomatic arch Tripod fracture Intact FZ suture Tripod fracture Distracted FZ suture Associated orbital floor fracture Orbital rim fracture Comminuted and other fracture Fig. Tripod fracture of zygoma. Note fracture of zygomaticotemporal articulation (arrow). Zygomatic injuries may be part of a wider and more complex pattern, always exclude other fractures. Fig. Same fracture. Note displacement at the zygomaticofrontal junction, zygomaticomaxillary buttress, and infraorbital margin. Of significance is the comminution of the infraorbital margin which complicates fracture management, and implies an orbital floor extension. 130
3 b854_chapter-12.qxd 1/31/2011 9:40 AM Page 131 Chapter 12 ZYGOMATIC (MALAR) FRACTURES CLINICAL FEATURES Clinical Features Soft tissue Bone deformity Eyes Nerves Nasal Occlusal Signs and Symptoms Periorbital ecchymosis Subconjunctival haematoma Chemosis Buccal Sulcus haematoma Flattening of malar prominence Step deformity Crepitus Zygomatic arch depression Diplopia Enophthalmos If associated orbital floor fracture Infraorbital paraesthesia anaesthesia Zygomaticotemporal paraesthesia Zygomaticofacial paraesthesia Alveolar nerve anaesthesia Epistaxis Nasal deformity (if fracture continuous with nose) Trismus (zygomatic arch) Occlusal disturbance (if fracture extends into alveolar process) Fig. Classic zygomatic facies, periorbital ecchymosis. Associated soft tissue swelling may make examination of the globe difficult. Bone deformity and asymmetry may be demonstrated by careful palpation. Remember to always examine the globe. Visual acuity and globe integrity must be documented. 131
4 b854_chapter-12.qxd 1/31/2011 9:40 AM Page 132 An Atlas of Craniomaxillofacial Trauma Fig. Preseptal haematoma is common. Fig. Subconjunctival haemorrhage is pathognomonic of a fracture around the orbit. Fig. Fractured zygomatic arch. The small dent (black arrow) may not be initially apparent and may be masked by soft tissue swelling. Limitation mouth opening and pain may be the only symptoms. There are no eye signs or numbness of the infraorbital nerve. 132
5 b854_chapter-12.qxd 1/31/2011 Chapter 12 9:40 AM Page 133 ZYGOMATIC (MALAR) FRACTURES INVESTIGATIONS Imaging Fig. Plain occipitomental (OM) view demonstrating a low energy Henderson type 4 fracture. Note the diastasis at the fronto-zygomatic suture. This makes the fracture unstable. Fig. OM 15 showing distraction at FZ, MB, and ZT articulations. Fig. OM 30 of same fracture. Note additional detail at lateral aspect of infraorbital margin (single arrow). Also the distance between the coronoid process and the arch of zygoma is reduced on fracture side (left side). 133
6 b854_chapter-12.qxd 1/31/2011 9:40 AM Page 134 An Atlas of Craniomaxillofacial Trauma CT Scan Fig. Considerable information can be obtained from CT images. This axial view shows the typical result of high energy transfer. The force applied was anterior posterior in direction (arrow) and the zygomatic bone has rotated around the temporozygomatic suture (TZ) resulting in a posteromedial displacement. There has been comminution of the orbital rim (COR) and an extended nasomaxillary fracture (NM). There are fragments of bone (OF) together with blood in the maxillary antrum, highly suggestive of an additional orbital floor fracture. Fig. Coronal view from the same case confirms the large orbital floor fracture (OF), with comminution of the zygomaticomaxillary buttress (ZMB). The distracted frontozygomatic suture (ZF) is also demonstrated. Fig. The sagittal view reveals the true extent of the orbital floor component of the zygomatic fracture. As the fracture is behind the equator of the eye enophthalmos is highly likely. All zygomatic fractures will have an orbital floor component. Often this will be insignificant, but if the floor is comminuted and/or deficient, then late (6 months plus) enophthalmos is probable. 134
7 b854_chapter-12.qxd 1/31/2011 9:40 AM Page 135 Chapter 12 CT Scan 3D ZYGOMATIC (MALAR) FRACTURES Fig. 3-Dimensional CT scans offer easy visualisation and interpretation of complex injuries, as in this extended zygomaticcraniofacial fracture. Note the preservation of the inner margin of the zygomatic bone and sphenoid bone, this will simplify anatomical reduction. Fig. Tripod fracture with gross comminution. Distraction at 4 key points (arrow). Note gross comminution. Infraorbital articulation required primary bone grafting. Fig. Coronal scan showing gross comminution of zygomaticomaxillary buttress (large arrow). FZ diastasis (small arrow). Fig. Fractured zygomatic arch (white arrow). This diagram also illustrates the inward nature of the force which produced the fracture, the reverse of the direction required to reduce it. 135
8 b854_chapter-12.qxd 1/31/2011 9:40 AM Page 136 An Atlas of Craniomaxillofacial Trauma Management Emergency Preservation of visual acuity Exclusion of ocular pathology Exclusion of retrobulbar haematoma On Admission Sight threatening injuries are very possible in zygomatic injuries. Emergency management and therefore prognosis is dependent upon early diagnosis. Analgesia Antibiotic Sleep head up Ice packs to reduce soft tissue swelling Operative Planning Imaging Plain film Low energy Isolated zygomatic arch CT High energy Suspected orbital floor involvement Comminution of fracture articulation Modes of fracture reduction Sites of osteosynthesis Other treatment options CT should be considered in every zygomatic fracture other than the most trivial. The exception is an uncomplicated arch fracture. Treatment Options Non-operative management Undisplaced fracture Medical or surgical comorbidity precluding operative surgery (see below) No fracture mobility No comminution of bony pillars Sensible, competent patient Able to attend regular follow-up The decision not to operate is extremely patient-focused. A malunited zygoma can cause a significant asymmetry and secondary reconstruction or camouflage is a poor second to appropriate primary management. 136
9 b854_chapter-12.qxd 1/31/2011 9:40 AM Page 137 Chapter 12 ZYGOMATIC (MALAR) FRACTURES Treatment Options Operative management surgical access reduction fixation post-operative management Treatment MUST be fully planned prior to surgery. There is no place for taking a patient for theatre and plating if it s not stable. Decision Making Treatment planning the fractured zygoma is perhaps the most confusing to the inexperienced surgeon. FZ Frontozygomatic ZT Zygomaticotemporal PA Piriform aperture (lateral margin of nasal aperture) ZM Zygomaticomaxillary IO Infraorbital In treatment planning consider the zygoma as a starfish. The principle is to reconstruct the limbs of the starfish (if they are fragmented) and then replace the zygoma to the correct anatomical position. The reconstructed starfish legs ensure the correct position of the bone. 137
10 b854_chapter-12.qxd 1/31/2011 9:40 AM Page 138 An Atlas of Craniomaxillofacial Trauma Surgical access Incision Site of Osteosynthesis Indication Advantages Disadvantages Buccovestibular Zygomatico-maxillary Intraoral point of No scar None buttress elevation Straightforward Piriform aperture 2 points of osteosynthesis Transconjunctival Infraorbital rim Displaced orbital rim Very aesthetic Entropion (very rare) Usually bloodless Access limited (see below) Transconjunctival with FZ suture to midway up Any extended zygomatic Very aesthetic Very technique sensitive extension medial wall fracture Unparalled access Lateral cantholysis difficult Lateral cantholysis Usually bloodless Lid malposition possible Medial transcaruncular Lower lid Infraorbital rim Displaced orbital rim Usually aesthetic Access may be suboptimal Blepharoplasty (less than Not extendable Mid tarsal transconjunctival) Ectropion possible Technically Increased scleral show common straightforward Visible scar Infraorbital Infraorbital rim Displaced orbital rim Straightforward Very poor aesthetics Rapid ectropion and scleral show rare Coronal Zygomaticotemporal Posterior displacement of Aesthetic (if no Time consuming Frontozygomatic zygoma particularly with alopecia) Technique sensitive fragmentation of Allows excellent Scar can become hypertrophic zygomatic arch positioning of zygoma 138
11 b854_chapter-12.qxd 1/31/2011 9:40 AM Page 139 Chapter 12 ZYGOMATIC (MALAR) FRACTURES Reduction The aim of reduction is to replace the fractured and malpositioned bone into the correct anatomical position. The mode of reduction is designed to inversely mirror the force that caused the injury initially. Approach Indication Comment Temporal (Gillies Most displacements Excellent approach incision) Cosmetic unless alopecia Elevation point remote from fixation point Buccovestibular Medial and posterior Cosmetic displacements Difficult to position complex fracture patterns Difficult if gross comminution Elevation point in field of fixation Frontozygomatic Rare (if laceration present) Poor fulcrum (Dingman) Difficult to manouvre fragment Point of elevation in field of fixation FZ incision frequently has to be extended to accommodate elevator Hook Posterior displacement Very good for posterior Medial displacement Classically performed percutaneously when point of access is remote from field of fixation May be replicated by a transoral route although field of fixation is compromised 139
12 b854_chapter-12.qxd 1/31/2011 9:40 AM Page 140 An Atlas of Craniomaxillofacial Trauma Bristow s pattern Kilner pattern Rowe s pattern Fig. Zygomatic elevators. Fig. Bone hook. 140
13 b854_chapter-12.qxd 1/31/2011 9:40 AM Page 141 Chapter 12 ZYGOMATIC (MALAR) FRACTURES Fig. Gillies temporal incision. Here the temporalis fascia is identified. The zygomatic elevator is passed under the fascia and slid down under the zygomatic bone. Fig. Surface marking for entrance point of zygomatic hook. Avertical line is drawn from the lateral canthus, and a horizontal line from the corner of the nose. The intersection point marks the incision point. Fixation Fig. The frontozygomatic suture is fixed with a 1.5 mm plate. This is a very useful point of fixation. It may be approached by a variety of approaches. 141
14 b854_chapter-12.qxd 1/31/2011 9:41 AM Page 142 An Atlas of Craniomaxillofacial Trauma Fig. Open zygoma fracture. Note the bone graft (arrow) this was to make good a continuity defect. Fig. For complex zygomatic fractures, the coronal approach allows for extensive degloving of the facial bones. Here the fractured zygoma is part of a wider fracture configuration. 142
15 b854_chapter-12.qxd 1/31/2011 9:41 AM Page 143 Chapter 12 ZYGOMATIC (MALAR) FRACTURES Fig. Post-operative radiographs of a complex zygomatic fracture. Note fixation at FZ, IO, and ZM regions. The need for 7 screws at the FZ region was due to the gross comminution at that site. The fixture at the infraorbital site is a 1 mm localising plate. This is to ensure that the patient does not feel the metalwork thus minimising the risk of subsequent plate removal. Post-operative management Imaging Occipito mental view in no internal orbital reconstruction CT scan if there is internal orbital work CT scan if reduction not considered perfect intraoperatively CT scan if fragmentation of fracture articulations Medication Dexamethasone peri- and postoperatively Antibiotic therapy continue for 5 days Analgesics as required Follow-up Week 1 removal of sutures Week 3 check bone and orbital position Month 3 final facial appearance if indicated interval plate removal Aesthetic and functional outcome is dependent on soft tissue and orbital involvement. Non-union is rare. Malunion may require zygomatic osteotomy or medpore onlay. Plate removal is unusual, although ZM buttress plates may become exposed or be palpable. Ensure dental follow-up. Injured anterior teeth commonly observed with these injuries. 143
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