management of zygomatico-orbital trauma Flashcards
4 classifications of maxillofacial fractures
- Naso ethmoidal fractures
- Lateral middle third (zygoma)
- Central middle third
- Mandibular fractures
central middle third fractures
6
- Nasal bone
- Unilateral maxillary fractures
- Le fort I fracture
- Le fort II fractures
- Le fort III fracture
- Various combinations
orbit edges
Anterior surface (sclera, eyelids, cornea)
Medial wall
Floor
Lateral wall
Roof
Apex
eye is moved by
4 recti (medial, superior, inferior and lateral)
eye rotation by
2 oblique muscles (superior and inferior)
medial of orbit
Medial rectus muscle, nose, lacrimal duct and sac, medial canthal ligament, ethmoid sinus, cribriform plate
5 things that exit the superior orbital fissure
- 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
3 thinsg that exit the inferior orbital fissure
- Infraorbital nerve – supplies skin under eye, nose, cheek (numbness here)
- Infraorbital vein
- Infraorbital artery
examination of the maxilllofacial region
4 areas
needs to be
organised, sequenced, methodical
A. Soft tissue
B. Nerves
C. Skeleton
D. Dentition
BLS first before exam (intubate maybe)
signs/symptoms of zygomatico-orbital fracture
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
clinical signs of malar fracture
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
haemorrhage is
fresh bleeding
ecchymoses is
later stage bleeding
what is wrong here
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??
what is this
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)
intial care for zygomatico-orbital #
3
exclude ocular injury
prophylactic antibiotics
avoid blowing nose
definitive management for zygomatic-orbital #
5
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
classic characteristics of zygomatico-orbital trauma
5
numbness
flatness
limitation of mouth opening
diplopia
epitaxis
floor of orbit trauma concern
infraorbital nerve and vessels
antrum
nasolacrimal canal inferior rectus and oblique muscle
lateral wall of orbit trauma concern
lateral canthal ligament & muscle
VI n. and lateral rectus muscle
middle cranial fossa
dura and temporal lobe of brain
roof of orbit trauma concern
anterior cranial fossa
dura and frontal lobe of the brain
superior rectus and oblique muscles
frontal sinus
Supraorbital nerve
apex of orbit trauma concern
optic nerve
ophthalmic artery and veins
floor of orbit trauma symptoms/signs
- enophthalmos, diplopia
- positive forced duction test
- infraorbital anaesthesia
- antro-orbital communication
- naso-lacrimal duct damage
lateral wall of oribite trauma symptoms/signs
- exophthamlos, inward displacement
- lateral canthal displacement
- lateral rectus palsy
general picture for orbit trauma
periorbital haematoma, enophthalmos proptosis, swelling
medial wall of orbit trauma signs/symptoms
- nasoethmoidal, nasal shortening
- bridge depression
- telecanthus, diplopia
- naso-lacrimal apparatus damage
- cribriform plate damage, CSF leak
- medial displacement of the globe
roof of orbit trauma signs/symptoms
dural tear and brain damage
CSF leak
trochlear damage
diplopia
frontal anaesthesia
exophthalmos
apex of orbit trauma signs/symptoms
blindness
