Zygoma Fractures Flashcards
1.1 Drescription of physical findings
Midfacial and periorbital edema with malar depression and enophthalmos
1.1 Drescription of CT findings
Depressed ZM complex fracture with comminution at ZM buttress
1.1 In a displaced ZM complex fracture, the orbital floor is..
(by definition) fractured
1.2.1 Mechanism of injury is helpful in:
determining the angle of force and severity of injury
1.2.1 Important history in zygoma fractures:
- 2.1 - previous facial injuries or fractures
- change in/loss of/double vision (important to r/o orbital injuries prior to operative intervention)
- numbness of cheek/upper lip s/o infraorbital nerve V2 injury
- change in occlusion
1.2.2 On PE of a zygoma fracture, I would start with:
ATLS protocol to identify potentially life-threatening conditions
1.2.2 After ATLS I would perform a detailed examination of the face, including:
- palpation for tenderness, crepitus, or step-off
- sensory and motor examinations
- eye, nasal, and intra-oral examinations
- examination of ears and tympanic membrane
1.2.2 Signs of a ZM complex fracture are:
- malar depression, which may be masked by soft-tissue swelling early on
- subconjunctival and periorbital ecchymosis
- enophthalmos and/or hypoglobus
- inferior slant of the palpebral fissure
- numbness in the infraorbital nerve distribution
- upper buccal sulcus ecchymosis
1.2.3 Pertinent imaging of a zygoma fracture would include a high resolution maxillofacial CT scan, to evaluate the 5 articulations of the zygoma for displacement and comminution:
- lateral orbital rim (zygomaticofrontal, ZF)
- inferior orbital rim
- zygomaticomaxillary buttress
- zygomatic arch and temporal articulation
- lateral orbital wall (zygomaticosphenoid, ZS)
In addition to evaluation of the articulations of the zygoma, I would evaluate for:
orbital floor defects - best seen on coronal images
1.2.4 Consultations I would obtain in evaluation of zygoma fractures would include:
- trauma - based on the MOI and if other injuries were suspected
- ophthalmology in all orbital fractures to r/o ophthalmologic injury (prior to intraoperative manipulation as this would exacerbate eye injury)
1.3 In treating a zygoma fracture, I would start with:
- the ABCs of trauma, and ensure that all emergent injuries are managed first
I would attempt definitive treatment of facial fractures within 2 weeks, as longer delay increases:
-risk for infection and need for osteotomies as bone healing takes place
Simple non-displaced fractures:
-do not need surgery and may be managed conservatively
Fractures that are significantly displaced or comminuted:
-require ORIF, with plating at facial buttresses
Critical points of fixation of zygoma fractures include:
- the ZF region or lateral orbital rim
- infraorbital rim
- ZM buttress
* at least 3 points of fixation are necessary for 3D stability
When necessary, the zygomatic arch may be stabilized at a 4th point of fixation
Operative approach of a zygoma fracture is determined by:
-status of zygomatic arch
If the arch is comminuted or irreducible, a _____ incision will be needed for reduction and fixation of the arch
-coronal incision
If the zygoma can be reduced and fixed, an _____ approach can be used
- anterior approach
The 3 incisions of the standard anterior approach in management of a zygoma fracture are:
- lateral part of upper blepharoplasty incision - for access to the lateral orbital rim and wall
- lower eyelid incision - for inferior orbital rim and orbital floor
- upper buccal sulcus incision - for access to maxillary buttresses
Isolated zygomatic arch fractures may be reduced via:
-temporal (Gillies) or intraoral (Keen) approach
When the zygoma is displaced, the orbital floor is:
-fractured (by definition)
If the patient has enophthalmos, hypoglobus, or in the presence of a sizable defect, after the ZM complex is reduced, the orbital floor should be reconstructed with an implant (e.g., titanium) or bone graft
1.4 Complication: retrobulbar hematoma
-requires immediate lateral canthotomy with inferior cantholysis to drain the hematoma
1.4 Complication: malposition
-from inadequate reduction
1.4 Complication: enophthalmos, proptosis, vertical dystopia
-from orbital floor undercorrection or overcorrection, requiring repositioning
1.4 Complication: anesthesia/paresthesia in infraorbital nerve distribution
-due to nerve contusion, generally resolves within 6 months
1.4 Complication: lower lid ectropion/entropion
-with subciliary/transconjunctival incision
manage with eyelid massage and surgical correction if not responsive
1.4 Complication: infection
-requires antibiotics and possible hardware removal
