Physical signs and symptoms of zygoma fractures include
- Subconjunctival hemorrhage and periorbital ecchymosis are seen in as many as 50% of patients.
- Disturbance of sensation in the region of the infraorbital nerve
- Palpable step-offs in the upper lateral orbital rim, inferior orbital rim, and upper buccal sulcus
- Emphysema within the orbit or overlying soft tissues of the cheek
- Trismus -- is difficulty with mastication and can occur because of masseter spasm or bony impingement of the coronoid process.
- Malposition of the globe and /or diplopia (double vision)--Diplopia may be secondary to change in pupillary alignment or to entrapment of the inferior rectus muscle by the orbital wall fracture. Patients with entrapment may complain of diplopia on upward gaze.
- Globe injury needs to be ruled out as well. Traumatic optic neuropathy is a complication that has been reported in about 2 to 5 percent of severe facial trauma.
These are deformities that occur because of untreated or mistreated fractures. They are not uncommon (unfortunately). They include
- Underprojection of the cheek and a wide face.
- Overprojection is possible, but not as common as the first.
- Globe malposition--either enophthalmos (a sunken eye, is the most common) or exophthalmos (eye protrudes out of the socket).
- Soft-tissue deformities from inadequate suspension after extensive surgical exposure. Cheek ptosis, inferior displacement of the lateral canthus, temporal hollowing, and lower lid ectropion are the most common.
- Undisplaced -- require no therapy, see Medical Care below
- Arch fractures -- considered a stable fracture
- Unrotated body fractures -- can usually be treated by closed reduction
- Medially rotated body fractures -- considered an unstable fracture
- Laterally rotated body fractures -- considered a stable fracture
- Complex fractures having additional fracture lines across the zygomatic body
- Stable, nondisplaced fractures may be observed weekly for healing.
- Avoidance of nose blowing is mandatory in the medical care of these patients. The disrupted orbital walls can allow air to be forced into the retrobulbar space and cause pain and visual loss. This avoidance of nose blowing should last for several weeks to a couple of months.
- Avoid sleeping face down or with pressure on the affected side of the face
- The routine use of systemic antibiotics for isolated zygomatic arch fractures generally is not recommended.
- Patients commonly are placed on a soft diet for six weeks. A dietary consultation may be warranted.
- All contact sports and most strenuous activity also should be avoided for several weeks.
BASIC PRINCIPLES OF SURGICAL REPAIR
- The Gilles approach may be used. It can be done under either local anesthesia with sedation or under general anesthesia. A vertical incision is made in the temporal hairline, and the elevator is then tunneled underneath the temporalis fascia, keeping in mind the superficial temporal artery branches and the temporal division of facial nerve, which is nearby. Then lateral pressure with superior anterior rotation is exerted to pop the fracture back in place.
- A more aggressive approach using open-reduction techniques and rigid stabilization with plating systems (eg, Synthes or Leibinger) is the standard of care today. This approach provides direct access to the frontozygomatic suture, orbital floor, and infraorbital rims.
- Precise reconstruction with rigid internal fixation of the zygoma at 2 or 3 points (across the frontozygomatic suture, the inferior orbital rim, and the lateral midfacial buttress) is needed to counter the force of the masseter muscle. The orbital contents can be supported as for simple orbital floor fractures.
Many of these are included in the list of secondary deformities listed above.
- Diplopia has been quoted to occur between 3.4 and 8 percent. It is most often thought to be secondary to extraocular muscle contusion, swelling, and occasionally entrapment as well. As a result, forced duction test is recommended prior to closure to make sure there is no muscle entrapment, and when in doubt CT can be used.
- Anesthesia/dysesthesias, usually in the infraorbital nerve region, has been reported between 0.4 and 11.6 percent postoperatively as well; however, usually they resolve on their own, but if they last more than three to twelve months, then one may suspect impingement as a possible cause.
- Enophthalmos, as you see in this picture here, is most often secondary to inadequate fracture reduction. This has been reported to occur anywhere between 1 and 23 percent postoperatively. If enophthalmos is noted during the early postoperative period, reoperation is a viable option. Most often, the enophthalmos is thought to be due to the fact that the zygoma has been fixed too far posteriorly and laterally; however, in the late postoperative period, reoperation will often require osteotomy (re-fracture).
- Complications related to hardware eventually requiring removal is also not uncommon. The most commonly cited reason for needing removal is palpability, specifically in the infraorbital rim and the frontal zygomatic suture region. In this study, they also saw an isolated case of plate fracture.
- The rare complication of sudden onset blindness resulting from retrobulbar hemorrhage following reduction of even simple zygomatic fractures means that in some instances, this procedure may be unsuitable for outpatient surgery. This serious complication, although rare (0.3% of treated zygomatic fractures), is potentially reversible upon early recognition of the symptoms and signs of retrobulbar hemorrhage (eg, pain, proptosis, loss of vision, decreased motility). If the surgeon suspects a retrobulbar hemorrhage, a lateral canthotomy and cantholysis should be performed as soon as possible. This should be completed at the bedside if the patient has visual compromise and is not near the operating suite.
Facial Trauma, Zygomatic Complex Fractures by Zachary Segal MD, et al--eMedicine Article
Craniofacial Trauma; Supplement to Plastic & Reconstr Surgery, Vol 120, No 7, Suppl 2, Dec 2007; Larry H Hollier, Jr MD and James F Thornton MD
Orbital Fracture, Zygomatic by Stuart R Seiff, MD, et al--eMedicine Article
Facial and Mandibular Fractures by Michael L. Richardson, M.D., University School of Medicine
Blindness after Reduction of Facial Fractures; Plastic & Reconstructive Surgery. 102(6):1821-1834, November 1998; Girotto, John A. M.D.; Gamble, William Bryan M.D.; Robertson, Bradley M.D., D.D.S.; Redett, Rick M.D.; Muehlberger, Thomas M.D.; Mayer, Mike M.D.; Zinreich, James M.D.; Iliff, Nicholas M.D.; Miller, Neil M.D.; Manson, Paul N. M.D.
Zygomaticomaxillary Complex Fracture by Tang Ho, M.D.;
October 7, 2004--Grand Rounds Baylor College of Medicine
Manual of Internal Fixation in the Cranio-Facial Skeleton: Techniques By Joachim Prein