Zygoma Fractures

Question 1

1.1 Drescription of physical findings

Answer 1

Midfacial and periorbital edema with malar depression and enophthalmos

Question 2

1.1 Drescription of CT findings

Answer 2

Depressed ZM complex fracture with comminution at ZM buttress

Question 3

1.1 In a displaced ZM complex fracture, the orbital floor is..

Answer 3

(by definition) fractured

Question 4

1.2.1 Mechanism of injury is helpful in:

Answer 4

determining the angle of force and severity of injury

Question 5

1.2.1 Important history in zygoma fractures:

Answer 5

1. 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

Question 6

1.2.2 On PE of a zygoma fracture, I would start with:

Answer 6

ATLS protocol to identify potentially life-threatening conditions

Question 7

1.2.2 After ATLS I would perform a detailed examination of the face, including:

Answer 7

• palpation for tenderness, crepitus, or step-off
• sensory and motor examinations
• eye, nasal, and intra-oral examinations
• examination of ears and tympanic membrane

Question 8

1.2.2 Signs of a ZM complex fracture are:

Answer 8

• 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

Question 9

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:

Answer 9

1. lateral orbital rim (zygomaticofrontal, ZF)
2. inferior orbital rim
3. zygomaticomaxillary buttress
4. zygomatic arch and temporal articulation
5. lateral orbital wall (zygomaticosphenoid, ZS)

Question 10

In addition to evaluation of the articulations of the zygoma, I would evaluate for:

Answer 10

orbital floor defects - best seen on coronal images

Question 11

1.2.4 Consultations I would obtain in evaluation of zygoma fractures would include:

Answer 11

1. trauma - based on the MOI and if other injuries were suspected
2. ophthalmology in all orbital fractures to r/o ophthalmologic injury (prior to intraoperative manipulation as this would exacerbate eye injury)

Question 12

1.3 In treating a zygoma fracture, I would start with:

Answer 12

• the ABCs of trauma, and ensure that all emergent injuries are managed first

Question 13

I would attempt definitive treatment of facial fractures within 2 weeks, as longer delay increases:

Answer 13

-risk for infection and need for osteotomies as bone healing takes place

Question 14

Simple non-displaced fractures:

Answer 14

-do not need surgery and may be managed conservatively

Question 15

Fractures that are significantly displaced or comminuted:

Answer 15

-require ORIF, with plating at facial buttresses

Question 16

Critical points of fixation of zygoma fractures include:

Answer 16

1. the ZF region or lateral orbital rim
2. infraorbital rim
3. 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

Question 17

Operative approach of a zygoma fracture is determined by:

Answer 17

-status of zygomatic arch

Question 18

If the arch is comminuted or irreducible, a _____ incision will be needed for reduction and fixation of the arch

Answer 18

-coronal incision

Question 19

If the zygoma can be reduced and fixed, an _____ approach can be used

Answer 19

• anterior approach

Question 20

The 3 incisions of the standard anterior approach in management of a zygoma fracture are:

Answer 20

1. lateral part of upper blepharoplasty incision - for access to the lateral orbital rim and wall
2. lower eyelid incision - for inferior orbital rim and orbital floor
3. upper buccal sulcus incision - for access to maxillary buttresses

Question 21

Isolated zygomatic arch fractures may be reduced via:

Answer 21

-temporal (Gillies) or intraoral (Keen) approach

Question 22

When the zygoma is displaced, the orbital floor is:

Answer 22

-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

Question 23

1.4 Complication: retrobulbar hematoma

Answer 23

-requires immediate lateral canthotomy with inferior cantholysis to drain the hematoma

Question 24

1.4 Complication: malposition

Answer 24

-from inadequate reduction

Question 25

1.4 Complication: enophthalmos, proptosis, vertical dystopia

Answer 25

-from orbital floor undercorrection or overcorrection, requiring repositioning

Question 26

1.4 Complication: anesthesia/paresthesia in infraorbital nerve distribution

Answer 26

-due to nerve contusion, generally resolves within 6 months

Question 27

1.4 Complication: lower lid ectropion/entropion

Answer 27

-with subciliary/transconjunctival incision

manage with eyelid massage and surgical correction if not responsive

Question 28

1.4 Complication: infection

Answer 28

-requires antibiotics and possible hardware removal