ZYGOMATIC COMPLEX FRACTURES

PRESENTED BY-MAHAK RALLIFINAL YEAR

INTRODUCTION

Zygomatic bone is intimately associated with the maxilla, frontal and temporal bones zygomatic complex.

The zygomatic bone fractures in the region of the zygomatico-frontal suture, the zygomaticotemporal suture and the zygomatico-maxillary suture.

The zygomatic arch may be fractured without displacement of the zygomatic bone.

CLASSIFICATION BASED ON THE EXTENT OF INVOLVEMENT OF

STRUCTURES WITHIN THE ORBIT- all fractures of the body of the zygomatic complex must involve the orbit but the importance of that involvement depends on the degree and direction of displacement.

1. Minimal or no displacement2. Inward and downward displacement3. Inward and posterior displacement4. Outward displacement5. Comminution of the complex as a whole.

INWARD AND DOWNWARD DISPLACMENT

Whitnall’s tubercle is depressed together with

suspensory ligament of the eye.

INWARD AND POSTERIOR DISPLACEMENT

The level of suspensory ligament is unchanged but the

floor of orbit may be extensively damaged

OUTWARD DISPLACEMENT of the zygomatic complex

occurring in conjunction with impacted central middle third

fractures.

COMMINUTION of the whole zygomatic

complex with considerable depression.

Fracture of the zygomatic arch alone, not involving the orbital

walls.

FRACTURES OF THE ZYGOMATIC ARCH ALONE

Minimal or no displacement V-type fracture Comminuted

Displacement of ZMC around vertical axis through frontozygomatic suture is more stable than displacement around horizontal axis through infra orbital foramen and zygomatic arch.

Comminuted fractures are highly unstable.

KNIGHT & NORTHWOOD CLASSIFICATION ON THE BASIS OF OCCIPITOMENTAL

VIEW:

1. No significant displacement2. Fracture of zygomatic arch only3. Unrotational body fracture4. Medial rotational body fracture5. Lateral rotational body fracture6. Complete rotational body fracture

ROWE & KILLEY CLASSIFICATION

Type I No significant displacementType II Fractures of the zygomatic archType III Rotation around vertical axis

a. Inward displacementb. Outward displacement

Type IV Rotation around longitudinal axisa. Medial displacement of frontal processb. Lateral displacement of frontal bone

Type V Displacement of complex bloca. Medial b. Inferiorc. Lateral

Type VI Displacement of orbito-antral partitiona. Inferiorly b. Superiorly (rare)

Type VII Displacement of orbital rim segmentType VIII Complex comminuted fractures

MANSON CLASSIFICATION Low energy Middle energy High energy

SIGNS AND SYMPTOMS

Circumorbital oedema and ecchymosis and subconjuctival haemorrhage

Tenderness

SIGNS AND SYMPTOMS Flattening of the malar prominence

and zygomatic arch

SIGNS AND SYMPTOMS Trismus

Epistaxis- Maxillary sinus drains into the nose through middle meatus, unilateral haemorrhage is possible whenever there is haemorrhage into the sinus as a result of disruption of the sinus mucosa.

SIGNS AND SYMPTOMS

Nerve damage- Neuropraxia or neurotmesis of the infraorbital nerve causing anaesthesia and paraesthesia of the temple, cheek, one side of the upper lip and side of the nose.

Enopthalmos

Enopthalmos Lateral or inferior displacement of zygoma

Inferior displacement of eyeball within he orbit due to increase in the volume of orbit due to fracture of its walls (worsened by herniation of fat)

Restriction of eye movement due to entrapment of inferior rectus and inferior oblique muscles

Sunken eye appearance

Diplopia

Blurred double vision Maybe : temporary/permanent

monocular/binocularTemporary Haematoma/oedema of extraocular muscles

Lasts 5-7days

Permanent Paralysis or muscle entrapment in the fractured segments

Monocular Double vision through one eye with the other eye closedCaused due to detached lens or traumatic injury to the globe of eye

Binocular Double vision is experienced when looking through both eyes simultaneously

Tests for diplopia

Finger gaze test Traction test Hess diplopia chart Diplopia chart Field of binocular single vision

DIAGNOSIS Initial evaluation of the patient with a

zygomatic fracture includes documentation of the bony injury and the status of surrounding soft tissue (eyelids, lacrimal apparatus, canthal tendons and globe) and cranial nerves II to VI.

Visual acuity and the status of the globe and retina should be established; an ophthalmologist should be consulted for suspected or questionable ophthalmic injury.

DIAGNOSIS

History Physical examination Radiographs – waters view,

submentovertex view and Caldwells view

Radiographic diagnosis

MANAGEMENT Isolated

Zygomatic arch

fractureExtraoral Approach:

Gillie’s Approach.Dingman Approach

Intraoral approach-

Keen approach

Percutaneo-us

method

Approaches to ZF suture

Upper eye lid

Approach.

Lateral Brow

Approach.

Hemicoro-nal

Approach

Zygomatic buttress fracture

Transoral

approach

Transcutan-eous cheek

approach

Approaches for infraorbital

rim

Transconjuctival

Subciliary

Lowerlid approach

Infraorbital

approach

Gillies approach (closed reduction)

Procedure The Gillies technique

describes a temporal incision (2 cm in length), made 2.5 cm superior and anterior to the helix, within the hairline.

A temporal incision is made. Care is taken to avoid the superficial temporal artery

Procedure An instrument is inserted

deep over the temporalis muscle. Using a back-and-forth motion the instrument is advanced until it is medial to the depressed zygomatic arch.

A Rowe zygomatic elevator is inserted just deep to the depressed zygomatic arch and an outward force is applied.

Gillies approach

using Rowe’s

zygoma elevator

Dingman’s approach (lateral eyebrow) It involves an incision near the ZF suture with

dissection beneath the temporal fascia and place an elevator along the frontal process of the zygoma and underneath the zygomatic arch .

Keen’s approach-intraoral

An incision 1cm in length is made in the buccal sulcus behind the zygomaticbuttress A bone hook or curved elevator is passed behind, supraperiosteally, to contact the deep part of the zygomatic bone; here an upward, outward and forward pressure is exertedAdvtg- less amount of force is required for reduction

Quin’s modification Making an incision in the mucosa at the level of the

maxillary alveolus and extending it inferiorly along the anterior border of the ramus.

The dissection continues along the lateral aspect of the coronoid process, ending at the level of the maxillary alveolus and extending it inferiorly along the anterior border of the ramus.

The dissection continues along the lateral aspect of the coronoid process, ending at the level of the zygomatic arch at the site of the fracture. An elevator is placed between the coronoid process and the zygomatic arch, and the fracture is reduced.

Percutaneous method

Stacey bone hook and Caroll-Girard screw

Percutaneous method

This method consists of inserting a hook through the skin below and behind the zygomatic bone so that it engages the deep aspect and allows reduction by strong outward traction on the handle of the instrument.

Transconjuctival or inferior fornix approach Retroseptal method:

In this method an incision is sited 2mm below the tarsal plate to reach the orbital rim.

Preseptal method: In this method incision is made at the edge of the tarsal plate to create a space infront of the orbital septum to reach the orbital rim

Subciliary approach

Bicoronal/hemicoronal approach

Subtarsal approach

Fixation

Direct fixation through open reduction- plate and screw technique

Internal orbital reconstruction- transantral/endoscopic approach

Fixation Type of fixation Indication Approach One point fixation Undisplaced fracture at

frontozygomatic suture, simple noncomminuted zmc fracture

ZF suture-through supraorbital eyebrow approach.

Two point fixation Displaced fracture unstable after reduction. Fracture at ZF suture, infraorbital rim, buttress

Through lower eyelid incision (infraorbital) or maxillary vestibular incision.

Three point fixation

Grossly displaced zygoma fracture at ZF suture, ZM buttress and infraorbital rim

Through lateral eyebrow, infraorbital and Maxillary vestibular incision.

Four point fixation- fixation at ZF suture, infraorbital rim, ZM buttress and zygomatic arch.In cases of complex fracture of zygoma

Complications Infraorbital paraesthesia Malunion and assymmetry Diplopia Traumatic hyphema Enopthalmos Traumatic optic neuropathy- mild visual deficit to

complete loss of vision Superior orbital fissure syndrome-include ptosis,

ophthalmoplegia, forehead anesthesia, and a fixed dilated pupil. Proptosis may be present. Treatment may include reduction of fractures, steroids, orbital apex exploration, and aspiration of retrobulbar hematoma if present

Trismus Retrobulbar haemorrhage

Retrobulbar haemorrhage

CF- pain, proptosis, dilation of the pupil, opthalmoplegia and decreasing visual acuity.

RX- IV mannitol, acetozolamide +steroids along with surgical decompression to reduce intra-ocular pressure

Thank you.