CITY OF MANILAUNIVERSIDAD DE MANILA

(Formerly City College of Manila)Mehan Gardens, Manila

College of Nursing

In partial Fulfillment for the requirements

on the Related Learning Experience

(HEENT)

Submitted by:

Costales, Butch V.

NR-22

Submitted to:

Prof. Pastora M. Baro RN, MAN

Clinical Instructor

January 15, 2011

Date Submitted

Introduction

The zygomatic bone occupies a prominent and important position in the facial skeleton. It

plays a key role in determining facial width as well as acting as a major support of the midface.

Its anterior projection forms the malar eminence and is often referred to as the malar bone. The

zygoma has several important articulations in significant portion of the floor and lateral wall of

the orbit. In addition, the zygoma meets the lateral skull to form the zygomatic arch.

Etiology and pattern of zygomatic complex fractures: a retrospective study.

Department of Oral and Maxillofacial Surgery, University of Benin Teaching Hospital, Edo State, Nigeria.

Fractures of the zygomatic complex are among the most frequent in maxillofacial trauma.

The zygomatic complex is responsible for the mid-facial contour and for the protection of the

orbital contents. The etiology of zygomatic complex fractures include road traffic accidents,

assaults, falls, sports and missile injuries

The study of Obuekwe, Owotade, and Osaiyuwu has shown that road traffic accidents are

responsible for most zygomatic complex fractures in our environment. Urgent enforcement of

road traffic legislation is necessary to minimize zygomatic complex fractures due to road traffic

accidents.

Pathophysiology

The zygoma is the main buttress between the maxilla and the skull, but, in spite of its

sturdiness, its prominent location makes it prone to fracture. The mechanism of injury usually

involves a blow to the side of the face from a fist, from an object, or secondary to motor vehicle

accidents. Moderate force may result in minimally or nondisplaced fractures at the suture lines.

More severe blows frequently result in inferior, medial, and posterior displacement of the

zygoma. Comminuted fractures of the body with separation at the suture lines are most often the

result of high-velocity motor vehicle accidents.

The zygoma has 2 major components, the zygomatic arch and the body. The arch forms

the the inferior and lateral orbit, and the body forms the malar eminence of the face. Fractures to

the zygoma are usually the result of blunt trauma. Direct blow to the arch can result in isolated

arch fractures. These are the most common. While tripod fractures are more serious and are

caused by more extensive trauma.

In general, displaced fractures involve the inferior orbital rim and orbital floor, the

zygomaticofrontal suture, the zygomaticomaxillary buttress, and the zygomatic arch. However,

occasionally, a direct blow to the arch results in an isolated depressed fracture of the arch only.

Types

Zygomatic Arch Fracture- can fracture in 2-3 places along the arch.

1. Lateral to each end of the arch.

2. Fracture in the middle of the arch causing a V fracture which could impinge on the

temporalis muscle.

Patients usually present with pain on opening their mouth.

Clinical findings:

>Palpable bony defect over the arch

>Depressed cheek with tenderness on palpation.

>Pain in cheek and jaw movement and limited mandibular movement which is due to

impingement of the coronoid process of the

mandible on the arch during mouth opening or

impingement of the temporalis muscle.

Picture: patient with blunt trauma to the zygoma.

Flattening of the right malar eminence is evident.

Zygomatic Tripod Fracture

Tripod fractures consist of fractures through:

>Zygomatic arch

>Zygomaticofrontal suture

>Inferior orbital rim and floor

Picture: Diagram of a tripod fracture. Note the

disruption of both the lateral orbital rim and the orbital

floor, as well as the zygomatic arch.

Clinical features:

>Periorbital edema and ecchymosis

>Hypesthesia of the infraorbital nerve

>Palpation may reveal step off

>Concomitant globe injuries are common

General Signs and Symptoms 

>Pain with jaw movement

>Flattened cheekbone

>Palpable depression at fracture site

>Altered sensation underneath the eye on the affected side

>Numbness of the cheek, infraorbital region & upper teeth on injured side

>Visual complaints

>Swelling, Edema, Ecchymoses

>Eyelid swelling

>Inability to close mouth properly

>Blood in the side of the eye on the affected side sometimes is present.

Complications

Paresis of the orbicularis oculi and zygomaticus muscles- a condition typified by partial loss of movement, or impaired movement of orbicularis oculi and zygomaticus muscles

sensory deficits secondary to insult of the zygomaticofacial and zygomaticotemporal branches

persistent diplopia - is double vision caused by a defective function of the

extraocular muscles or a disorder of the nerves that innervate (stimulate) the muscles.

orbital dystopia- malposition or displacement of the bony cavity surrounding the eye

significant residual deformity- an acquired or congenital distortion of facial parts

Diagnostic Procedures

Radiographic evaluation of the fracture is mandatory and may include both plain films

and a computed tomographic (CT) scan. The CT scan has now essentially replaced plain films as

the gold standard in both evaluation and treatment planning. If physical findings and plain films

are not suggestive of a zygomatic fracture, the evaluation may end here. However, if they do

suggest fracture, a coronal and axial CT scan should be obtained. The CT scan will accurately

reveal the extent of orbital involvement, as well as degree of displacement of the fractures. This

study is vital for planning the operative approach.

Nursing Management

Perioperative nursing care of patients with zygomatic complex fracture

Stomatological Department of Yongkang First People's Hospital, Yongkang 321300, Zhejiang Province, China

This study of the researchers Shi BM, Yang QF and Zhou MX suggests that key points of

perioperative nursing are psychological nursing, including elimination of fear and pessimism.In

addition, nurses should take active hemostatic, antishock as well as, anti-infection measures with

good postoperative care of incision, nutrition and observation of complications.

Treatment

Medical Therapy

If surgical correction is performed, prescribe prophylactic antimicrobial therapy if a

history of endocarditis or other conditions requiring antibiotics is known.

Surgical Therapy

Reconstruction of the zygomatic arch following injury is necessary for restoration of

malar symmetry and support for the maxilla and masticatory loads. Repair of the zygomatic arch

is usually performed in concert with repair of zygomaticomaxillary complex (ZMC) fracture

stabilization. In 1999, Turk et al found that direct repair and plating of the zygomatic arch was

not indicated in more than 1500 patients, secondary to spontaneous reduction with repair of other

ZMC fracture components.  If an aesthetic deformity is the product of an arch fracture or if

trismus is present, direct repair and fixation are indicated.

As with all surgical procedures, successful outcomes are the result of a planned approach

that affords excellent exposure of the operative site and of the use of meticulous surgical

technique. More specifically, repair of zygomatic arch fractures requires a precise reduction and

definitive stabilization to ensure positive outcomes.

Treatment for Zygomatic Arch Fracture:

>Consult maxillofacial surgeon

>Ice and analgesia

>Possible open elevation

Treatment for Zygomatic Arch Fracture:

Nondisplaced fractures without eye involvement

>Ice and analgesics

>Delayed operative consideration 5-7 days

>Decongestants

>Broad spectrum antibiotics since the fracture crosses into the maxillary sinus.

>Tetanus Toxoid

Displaced tripod fractures usually require admission for open reduction and internal fixation

Patient with a left displacedzygomatic fracture.

An open

reduction with rigid

miniplate fixation was performed

with postoperative result shown.

Lecture Outline:Introduction

The Zygomatic Bone occupies a prominent and important position in the facial skeleton.

Etiology

>Road traffic accidents>Assaults>Falls>Sports and missile injuries

The study of Obuekwe, Owotade, and Osaiyuwu has shown that road traffic accidents are responsible for most zygomatic complex fractures

Pathophysiology

blow to the side of the face => fist, object, or secondary to motor vehicle accidents.

Comminuted zygomatic fractures with separation at the suture lines=> results from high-velocity motor vehicle accidents.

Displaced fractures involve >inferior orbital rim and orbital floor, >the zygomaticofrontal suture, >the zygomaticomaxillary buttress, and >the zygomatic arch

Types

Zygomatic Arch Fracture

Zygomatic Tripod Fracture

consist of fractures through:

>Zygomatic arch

>Zygomaticofrontal suture

>Inferior orbital rim and floor

SS/Sx

>Pain with jaw movement>Flattened cheekbone>Palpable depression at fracture site>Altered sensation underneath the eye on the affected side>Numbness of the cheek, infraorbital region and upper teeth on injured side>Visual Complaints>Swelling, Edema, Ecchymoses>Eyelid swelling>Inability to close mouth properly>Blood in the side of the eye on the affected side sometimes is present.

Complications

>Paresis of the orbicularis oculi and zygomaticus muscles>Sensory deficits>Persistent Diplopia>Orbital Dystopia>Significant Residual Deformity

Diagnostic Procedures

>Radiographic Evaluation-mandatorymay include both plain films and CT scan.>CT scan- plain films are replaced as the gold standard in evaluation and treatment planning>Coronal and Axial CT scan will accurately reveal the extent of orbital involvement as well as degree of displacement of the fractures

Nursing management

Perioperative nursing care of patients with zygomatic fractures keypoints are eliminating fear and pessimism of the client.

Nurses should take >active hemostatic>antishock>anti-infection

post-operative care >incision>nutrition

>observation of complication

Treatment

Medical Therapy>Prophylactic Antimicrobial therapySurgical Therapy>Reconstruction of Zygomatic Arch

significant residual deformity orbital dystopia

Paresis of the orbicularis oculi and zygomaticus muscles

persistent diplopia