management of zygomatico-orbital trauma

Question 1

4 classifications of maxillofacial fractures

Answer 1

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

Question 2

central middle third fractures

6

Answer 2

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

Question 3

orbit edges

Answer 3

Anterior surface (sclera, eyelids, cornea)
Medial wall
Floor
Lateral wall
Roof
Apex

Question 4

eye is moved by

Answer 4

4 recti (medial, superior, inferior and lateral)

Question 5

eye rotation by

Answer 5

2 oblique muscles (superior and inferior)

Question 6

medial of orbit

Answer 6

Medial rectus muscle, nose, lacrimal duct and sac, medial canthal ligament, ethmoid sinus, cribriform plate

Question 7

5 things that exit the superior orbital fissure

Answer 7

• Oculomotor nerve III – supplies all muscles of eye bar lateral rectus and superior oblique
• Trochlear nerve IV – supplies superior oblique
• Abducent nerve VI – supplies lateral rectus
• Branches of ophthalmic nerve
• Ophthalmic veins

Question 8

3 thinsg that exit the inferior orbital fissure

Answer 8

• Infraorbital nerve – supplies skin under eye, nose, cheek (numbness here)
• Infraorbital vein
• Infraorbital artery

Question 9

examination of the maxilllofacial region

4 areas

needs to be

Answer 9

organised, sequenced, methodical

A. Soft tissue
B. Nerves
C. Skeleton
D. Dentition

BLS first before exam (intubate maybe)

Question 10

signs/symptoms of zygomatico-orbital fracture

Answer 10

Numbness

Flatness of face/asymmetry

Pain

Brusing

Swelling

Difficulty moving eye
* Superior orbital fissure syndrome (eye paralysed – as occlumotor, trochlear, abducens also damaged)
* Restriction of eye movement (e.g. cannot look up) – due to entrapment of muscle, diplopia (double vision)
* Restriction of extra-oculomotor eye muscles (recti)

Limited mouth opening
* # of zygoma can interfere with coronoid process thus limiting mouth opning

Question 11

clinical signs of malar fracture

Answer 11

Periorbital bruising & swelling

Subconjunctival ecchymoses (blood in eye)

Sensory deficit - Infraorbital nerve

Diplopia / Visual impairment

Subcutaneous emphysema

Epistaxis (bleeding from nose, as blood in maxillary sinus)

Step deformity

Question 12

haemorrhage is

Answer 12

fresh bleeding

Question 13

ecchymoses is

Answer 13

later stage bleeding

Question 14

what is wrong here

Answer 14

first is occipitomental view
* maxillary sinus – should appear black as filled with air
* here left is filled is white – zygomatico-orbital fracture causing radiopacity of maxillary sinus

fracture on left – radiopacity of left maxillary sinus, zygoma is flat??

Question 15

what is this

Answer 15

coronal view of CT scan

left – drop appearance, bleeding into maxillary sinus, possible drop of fatty tissue, pt complain of diplopia when look up (entrapment inferior rectus muscle)

Question 16

intial care for zygomatico-orbital #

3

Answer 16

exclude ocular injury
prophylactic antibiotics
avoid blowing nose

Question 17

definitive management for zygomatic-orbital #

5

Answer 17

Review when swelling subsided

Further radiographs +/- CT scans

Informed consent

Closed reduction +/- Fixation (less common, but would be Gillies)

**Open reduction + internal fixation **
* intra-oral incisions
* local facial incisions
* coronal flap exposure
expose fracture line and apply a plate – either at front (zygomatic suture), buttress area or infraorbital

Question 18

classic characteristics of zygomatico-orbital trauma

5

Answer 18

numbness
flatness
limitation of mouth opening
diplopia
epitaxis

Question 19

floor of orbit trauma concern

Answer 19

infraorbital nerve and vessels
antrum
nasolacrimal canal inferior rectus and oblique muscle

Question 20

lateral wall of orbit trauma concern

Answer 20

lateral canthal ligament & muscle
VI n. and lateral rectus muscle
middle cranial fossa
dura and temporal lobe of brain

Question 21

roof of orbit trauma concern

Answer 21

anterior cranial fossa
dura and frontal lobe of the brain
superior rectus and oblique muscles
frontal sinus
Supraorbital nerve

Question 22

apex of orbit trauma concern

Answer 22

optic nerve
ophthalmic artery and veins

Question 23

floor of orbit trauma symptoms/signs

Answer 23

• enophthalmos, diplopia
• positive forced duction test
• infraorbital anaesthesia
• antro-orbital communication
• naso-lacrimal duct damage

Question 24

lateral wall of oribite trauma symptoms/signs

Answer 24

• exophthamlos, inward displacement
• lateral canthal displacement
• lateral rectus palsy

Question 25

general picture for orbit trauma

Answer 25

periorbital haematoma, enophthalmos proptosis, swelling

Question 26

medial wall of orbit trauma signs/symptoms

Answer 26

• nasoethmoidal, nasal shortening
• bridge depression
• telecanthus, diplopia
• naso-lacrimal apparatus damage
• cribriform plate damage, CSF leak
• medial displacement of the globe

Question 27

roof of orbit trauma signs/symptoms

Answer 27

dural tear and brain damage
CSF leak
trochlear damage
diplopia
frontal anaesthesia
exophthalmos

Question 28

apex of orbit trauma signs/symptoms

Answer 28

blindness