Management of Zygomatico-Orbital Fracture

Question 1

What are the different classifications in maxillofacial fractures?

Answer 1

1. Naso ethmoidal fractures
2. Lateral middle third (zygoma)
3. Central middle third
4. Mandibular fractures

Question 2

What are the different types of middle third fracture?

Answer 2

1. Nasal bone
2. Unilateral maxillary fracture
3. Le Fort I fracture
4. Le Fort II fracture
5. Le Fort III fracture
6. Various combinations

Question 3

Why are fractured cheekbones most common?

Answer 3

As they are prominent and most likely to be traumatised

Question 4

Which structures can become damaged in an anterior fracture in the orbital naso-ethmoidal region?

Answer 4

Eyelids

Cornea

Sclera

Question 5

Which structures can become damaged in a medial wall fracture in the orbital naso-ethmoidal region?

Answer 5

Medial rectus muscle

Nose

Lacrimal duct and sac

Medial canthal ligament

Ethmoid sinus

Cribiform plate

Question 6

What can fracture at the superior orbital fissure damage?

Answer 6

Occulomtor nerve III- supplies all eye muscles apart from SO/LR

Trochlear nerve IV- supplies lateral rectus

Abducent nerve VI- supplies superior oblique

Branches of ophthalmic nerve

Ophthalmic veins

Question 7

What can fracture at the inferior orbital fissure cause damage to?

Answer 7

IO nerve- supplies skin under eye, lateral side of nose, side of cheek

IO vein and artery

Question 8

How does damage to nerves due to fracture at inferior orbital fissure present?

Answer 8

Numbness in region under eye

Question 9

What is usually done before proper examination of patient with zygomatic-orbital complex fractures can be completed?

Answer 9

Intubate patient

Question 10

What are the signs and symptoms of fractures in zygomatic-orbital complex?

Answer 10

 Facial asymmetry- flatness
 Numbness in face
 Pain
 Swelling- loose area
 Difficulty moving eye- damage to nerves if damage to SO fissure (syndrome)
 Restriction of looking up (nerves intact)- entrapment of muscles (can cause diplopia)

Question 11

Signs and symptoms of fractures in zygomatico-orbital complex Continued:

Answer 11

 Blood in eye- subconjunctival ecchymosis
 Bruising under eye- periorbital ecchymosis
 Epistaxis- bleeding from nose (caused by damage to maxillary sinus which is connected to nose via middle meatus at hiatus semilunaris)
 Limited mouth opening- coronoid process can act as an obstruction to fractured zygoma

Question 12

What are the steps in examination of zygomatic-orbital fractures?

Answer 12

Palpate for irregularities or step deformity at SO rim, IO, rim, zygomatic arch, intra-orally at zygomatic buttress

Ascertain if there is any mobility in maxilla

Check vision for signs of diploplia
-> check all 9 directions of eye (chart)

Question 13

What is the difference between haemorrhage and ecchymosis?

Answer 13

Haemorrhage is a fresh bleed

Ecchymosis- bruising due bleeding that presents at a later stage

Question 14

What sign suggests fracture in region of maxillary sinus radiographically?

Answer 14

If sinus appears radiopaque as opposed to black (air filled)
-> suggests that it is filled with blood due to fracture

Question 15

What does reduced distance between zygomatic bone and coronoid process suggest?

Answer 15

Fracture and is responsible for flattened appearance

Question 16

What is a ‘hanging drop” defect? What can it result in?

Answer 16

Bleeding and herniation of fat under muscle into sinus
-> Difficulty looking up (diplopia)- entrapment of inferior rectus muscle

Question 17

How is herniation of orbital contents fixed?

Answer 17

With mesh or bone graft

Question 18

What is done in the initial care phase of maxillofacial fractures?

Answer 18

Exclude ocular injury

Give prophylactic ABs

Advise against nose blowing

Question 19

How are maxillofacial fractures treated?

Answer 19

Closed reduction +/- fixation
-> Gillis Temporal approach
-> using hook underneath cheek bone to reduce

ORIF- expose fracture line and apply plate

Question 20

What are the different approaches used in ORIF for surgery to treat maxillofacial fractures?

Answer 20

IO approach

Transconjuctival approach- expose inferior orbital rim

Coronal flap exposure

Localised facial incisions
-> frontal zygomatic suture