Case 2 Zygomatic Fractures
2.1 Description
Right mid-facial and periorbital edema with malar depression and mild right hypoglobus, with presumed enophthalmos
Computed tomography (CT) demonstrates comminuted, displaced right zygomaticomaxillary complex (ZMC) fracture, and fracture of coronoid process of mandible
By definition, the right orbital floor is fractured in a displaced zygomatic injury
2.2 Work-Up
2.2.1 History
Mechanism of injury: Helpful in determining angle of force and severity of injury
Change in vision, loss of vision, or diplopia
Must rule out orbital injury prior to operative intervention
Trismus can occur with medial displacement of the zygomatic arch impinging on the temporalis muscle
Relevant medical history (previous facial injuries or fractures), surgical history (previous facial surgeries), and social history (alcohol, smoking, drug use)
2.2.2 Physical Examination
Signs of ZMC fractures are malar depression (masked by soft tissue swelling early on), periorbital ecchymoses, enophthalmos, and/or hypoglobus (usually masked by orbital swelling), inferior slant of the palpebral fissure, and tenderness at infraorbital rim and along zygomaticofrontal (ZF) suture
Numbness of the cheek, nose, upper lip, and teeth: Typical of V2 distribution
Associated eye examination: Look for visual changes, diplopia, or extra-ocular muscle entrapment
2.2.3 Pertinent Imaging or Diagnostic Studies
b” High resolution maxillofacial CT scan
Evaluate the five articulations of the zygoma: (1) lateral orbital rim (zygomaticofrontal), (2) inferior orbital rim, (3) zygomaticomaxillary buttress, (4) zygomatic arch, and (5) lateral orbital wall (zygomaticosphenoid)
Evaluate orbital floor defect on coronal cut images
2.3 Patient Counseling
Older patients, in particular, may consider nonoperative management despite displaced fractures. Surgeons must help weigh risks against benefits of surgery.
Patients must be informed of possible development of enophthalmos/hypoglobus, malar asymmetry/depression, or appreciable bony step-offs. These clinical examination findings may become more prominent as facial swelling subsides.
With operative management, adverse events/complications must be discussed, including asymmetric malar positioning, development of possible entropion/ectropion and a remote possibility of vision loss.
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