Zygomatic Fractures

These diagrams and illustrations have been designed to help you learn, memorise and recall key information.

INTRODUCTION

 

Zygomatic fractures can be likened to a chair with four legs (articulations/buttresses): -

A) Frontal  - contributes to the lateral orbital wall

B) Sphenoidal (greater wing) – also contributes to the lateral orbital wall

C) Maxillary - contributing to the orbital floor

D) Temporal - contributing to the zygomatic arch

 

Usually zygomatico-maxillary fractures cause disruption at most of these points.

The zygomatic-frontal suture is the strongest and usually the last to fracture.

The zygoma is mal-positioned therefore in anetro-posterior, horizontal and vertical directions.  

 

BASIC CLASSIFICATION          

- Low-energy - less surgical expsoure is required.

- High-energy - comminution at each articulation (more surgical exposure is required).

 

NORTH & KNIGHT CLASSIFICATION

- Un-displaced

- Arch fracture

- Depressed body fracture

- Depressed body fracture (medially rotated)

- Depressed body fracture (laterally rotated)

- Comminuted fracture

 

PRESENTATION         

Subconjunctival haemorrhage

- Lat. to limbus with no posterior limit.

Malar flattening (when viewed from above)

Step-off at orbital rims

Infraorbital paraesthesia

Inferior displacement of lat. canthus

- Downward-sloping palpebral fissure

Trismus - if zygomatic arch abuts coronoid process.

Swelling, bruising & epistaxis

Enopthalmos or Dystopia

Diplopia on upward gaze.

           

IMAGING       

CT (axial & coronal). To assess …      

- Degree of comminution (High/low energy)

- Medial / Lateral rotation of zygoma

- AP position of zygoma

- Position of lat. orb. wall

- Need for reconstruction of orbital floor

 

MANAGEMENT          

Un-displaced fractures can be managed conservatively (with regular re-evaluation).

Sometimes they are stable following reduction and no fixation is required.

However, they are usually unstable due to the pull of the masseter.

For adequate reduction, at least 3 of 4 articulations must be assessed intra-op.

 

ACCESS INCISION FOR LOW ENERGY

Upper Lid blepharoplasty incision - to access ZF & ZS.

Buccal incision - to access ZM.

Lower lid incision not needed if ZF, ZS and ZM have been reduced.

 

ACCESS INCISION FOR HIGH ENERGY

Coronal flap enables wide exposure.

Resuspension of the malar soft tissues is key to prevent malar ptosis.

Orbital floor recon is more frequently needed (via lower lid incision).

 

ACCESS INCISION FOR ISOLATED ARCH FRACTURES

Isolated arch fractures are almost purely a cosmetic concern (although trismus can occur).

Can be reduced via a Gilles Lift (usually stable and fixation is not therefore required).

 

COMPLICATIONS

Often these fractures settle well following fixation.

Lower lid incision complications can occur though.

Infection (of the plate) / Extrusion / Migration.

Bleeding (including retro-orbital haematoma).

Scars (including ectropion of the lower lid).

Diplopia (can occur early & usually settles in 24hrs).

Nerve injury (infra-orbital / facial).

Non-Mal-union.

Sinus problems.

 

PAEDIATRIC CASES

Permanent dentition is at risk with maxillary buttress screws.

Resorbable fixation systems are used when possible.

 

Zygomatic Fractures Diagram
Zygomatic Fractures Diagram
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