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  • Zygomatic Fractures

    Oculoplastics/Orbit
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    Orbital Fractures

    Fractures of the orbit are often encountered by surgeons who manage trauma. The magnitude of fractures within the orbit may vary considerably. Simple fractures such as the common blowout fracture may involve only a portion of the internal orbit. More extensive fractures may include simultaneous injury to the rim of the orbit and multiple internal walls. Orbital fractures involving some or all of the zygomatic articulations-zygomatic-sphenoid, zygomatic-frontal, zygomatic-maxillary, and zygomatic-temporal (Figure 1) are commonly encountered. These fractures of the zygomaticomalar complex (ZMC) should be readily recognized by surgeons who manage trauma. Repair should be undertaken with the goal of achieving alignment of the entire lateral orbit, which is a critical component of orbital volume restoration.

    Courtesy of Eli L. Chang, MD
    Figure 1. Articulations of the zygomaticomalar complex.

    Complications

    Poor reduction and fixation of zygomatic fractures will result in a number of functional and aesthetic complications, the most disturbing of which is the persistence of diplopia. Other possible functional deficits that may occur include limitation of mouth opening and lower eye lid retraction. Common aesthetic sequelae include malar flattening, orbital dystopia, and enophthalmos. Great care should be taken to achieve proper alignment and fixation in the primary management of these fractures in order to avoid these postoperative complications.

    Assessment

    Assessment of zygomatic fractures should proceed only after standard protocols for evaluating blunt head trauma have been executed (Figures 2 and 3). Once life-threatening injuries have been addressed, attention should be focused on the condition of the eye and other vital orbital structures. Fractures of the zygoma and orbit are commonly associated with ophthalmic and posterior orbital trauma (Otolaryngol Head Neck Surg. 2004;130(2):164-170).

    Courtesy of Eli L. Chang, MD
    Figure 2. CT scan axial view. ZMC fracture of the left side.

    Courtesy of Eli L. Chang, MD
    Figure 3. CT scan coronal view. ZMC fracture of the left side.

    Associated eye injuries can include scleral lacerations, hyphema, commotio retinae, retinal detachments, ruptured globes, and compressive optic neuropathy. Typically, 29.8% of orbital fractures are associated with a concomitant eye injury (Otolaryngol Head Neck Surg. 2004;130(2):164-170)

    In general, the surgeon should take great care to address vision-threatening injuries prior to and during the repair of these fractures, as poor surgical technique may aggravate existing eye injuries or possibly induce trauma to the orbital apex (J Craniomaxillofac Surg. 2003;31(3):191-192).

    Surgical Approaches

    Operative exposure of zygomatic fractures has been accomplished through a variety of approaches including intraoral (Keen), temporal (Gillies), brow incision, and bicoronal flap techniques (Plast Reconstr Surg. 1975;56(3):254-259). In 1973 Tessier (J Maxillofac Surg. 1973;1(1):3-8) and Converse et al (Plast Reconstr Surg. 1973;52(6):656-657) introduced the use of the transconjunctival approach in combination with a lateral canthotomy for exposure of the orbital floor and maxilla.

    Later, Nunery modified the approach to use the lateral canthotomy approach exclusively for repair of zygomatic and orbital floor fractures (Ophthal Plast Reconstr Surg. 1985;1(3):175-183). Reduction and fixation were accomplished through the lateral canthotomy with the aid of bone clamps and interosseous wiring for fixation (Ophthal Plast Reconstr Surg. 1985;1(3):175-183).

    Other techniques that have been used to reposition the zygomatic complex include the use of towel clips, antral balloons, hemostats and clamps, and a variety of elevators.7-10 The elevator that we have found to be particularly effective is the T-bar screw (Carroll-Girard screw or Byrd screw) (Figure 4). This corkscrew-shaped instrument has a broad horizontal handle that allows easy manipulation and rotation of the zygoma in all directions. Although the T-bar screw is often used through a cutaneous incision (South Med J. 1992;85(12):1193-1202), we have found the combination of the T-bar screw placed using a swinging-eyelid approach offers a simple and effective method for repair of these fractures (Figures 5-8) (Ophthalmology. 2005;112(7):1302-1309).

    Courtesy of Eli L. Chang, MD
    Figure 4.T-bar screw with drill guide and drill bit

    Courtesy of Eli L. Chang, MD
    Figure 5. Exposure of the inferior orbital rim through a swinging eyelid approach demonstrating the fracture site.

    Courtesy of Eli L. Chang, MD
    Figure 6. Exposure of the lateral wall of the orbit through a lateral canthus incision.

    Courtesy of Eli L. Chang, MD
    Figure 7. Placement of the T-bar screw through a swinging eyelid approach.

    Courtesy of Eli L. Chang, MD
    Figure 8. Traction being applied to manipulate the fractured bone via the T-bar screw.

    Alignment and Fixation

    The exposure afforded by the lateral canthotomy incision allows proper visualization of several important bony landmarks including the greater wing of the sphenoid, the inferior orbital rim, and the frontozygomatic suture line. The use of 3 points of alignment for producing superior alignment of such fractures is a critical point in the repair process (Arch Otolaryngol Head Neck Surg. 1989;115(8):961-963). The greater wing of the sphenoid serves as a superb point of reference for proper alignment as a result of its broad articulation and stability (Figure 9).

    Courtesy of Eli L. Chang, MD
    Figure 9. Sphenozygomatic suture line used for alignment of the zygomatic complex.

    The stability of the reduction determines the type and number of fixation sites. For many years, 2-point fixation at the frontozygomatic suture and the infraorbital rim using interosseus wiring was the mainstay for treating zygoma fractures.6,14-16 Although adequate for selected cases, fixation with interosseous wiring has been found to result in late asymmetry and cosmetic deformity in as many as 45% of repaired fractures.15,17,18

    The frontozygomatic suture line is the key fixation point in the repair of these fractures (Figure 10).19,20 We have found the use of 2-point fixation with rigid mini plating systems at the frontozygomatic suture line and infraorbital rim prevents postoperative rotation of the zygoma. The rigid fixation system can be surgically applied to appropriate reference points while the bone is held in the reduced position by an assistant.

    Courtesy of Eli L. Chang, MD
    Figure 10. Titanium mini-plating system placed across fronto-zygomatic suture line for stability.

    In cases of severely comminuted fractures and midface instability, wider exposure and more extensive fixation, including the use of the maxillary buttress, may be indicated.21,22 In cases of comminuted fractures without solid bone for placement of the screw, we note that the T-bar screw may not be helpful for reduction purposes.

    Conclusion

    In summary, ophthalmic complications are often associated with acute fractures of the zygomatic complex, and late ophthalmic complications may occur as a result of poor repair of these fractures. To address each of these adverse consequences, ophthalmologists should familiarize themselves with repair techniques and possible complications of these fractures. Our current approach allows accurate reduction and repair using a surgical approach familiar to many ophthalmologists. As a result, appropriate fracture repair can be accomplished safely with a relatively small incision, which allows concurrent attention to ophthalmic and orbital injuries.

    References

    1.  Shere JL, Boole JR, Holtel MR, Amoroso PJ. An analysis of 3599 midfacial and 1141 orbital blowout fractures among 4426 United States Army Soldiers, 1980-2000. Otolaryngol Head Neck Surg. 2004;130(2):164-170.

    2.  Chang EL, Bernardino CR, Watkins LM, Rubin PA. Rebleed of traumatic hyphaema after closed reduction of nasal fracture. J Craniomaxillofac Surg. 2003;31(3):191-192.

    3.  Shaw RC, Parsons RW. Exposure through a coronal incision for initial treatment of facial fractures. Plast Reconstr Surg. 1975;56(3):254-259.

    4.  Tessier P. The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J Maxillofac Surg. 1973;1(1):3-8.

    5.  Converse JM, Firmin F, Wood-Smith D, Friedland JA. The conjunctival approach in orbital fractures. Plast Reconstr Surg. 1973;52(6):656-657.

    6.  Nunery WR. Lateral canthal approach to repair of trimalar fractures of the zygoma. Ophthal Plast Reconstr Surg. 1985;1(3):175-183.

    7.  Banovetz JD, Duvall AJ. Zygomatic fractures. Otolaryngol Clin North Am. 1976;9(2):499-506.

    8.  Jackson VR, Abbey JA, Glanz S. Balloon technique for treatment of fractures of the zygomatic bone. J Oral Surg. 1956;14(1):14-19.

    9.  Hoyt CJ. The simple treatment of zygomatic fractures: the Gillies approach after fifty years. Br J Plast Surg. 1979;32(4):329-330.

    10.  Matsunaga RS, Simpson W, Toffel PH. Simplified protocol for treatment of malar fractures. Based on a 1,220-case, eight-year experience. Arch Otolaryngol. 1977;103(9):535-538.

    11.  Kreutziger KL. Zygomatic fractures: reduction with the T-bar screw. South Med J. 1992;85(12):1193-1202.

    12.  Chang EL, Hatton MP, Bernardino CR, Rubin PA. Simplified repair of zygomatic fractures through a transconjunctival approach. Ophthalmology. 2005;112(7):1302-1309.

    13.  Holmes KD, Matthews BL. Three-point alignment of zygoma fractures with miniplate fixation. Arch Otolaryngol Head Neck Surg. 1989;115(8):961-963.

    14.  Dingman RO. Reconstructive Plastic Surgery. Philadelphia: WB Saunders, 1964.

    15.  Karlan MS, Cassisi NJ. Fractures of the zygoma. A geometric, biomechanical, and surgical analysis. Arch Otolaryngol. 1979;105(6):320-327.

    16.  Karlan MS, Skobel BS. Reconstruction for malar asymmetry. Arch Otolaryngol. 1980;106(1):20-24.

    17.  Kellman RM, Schilli W. Plate fixation of fractures of the mid and upper face. Otolaryngol Clin North Am. 1987;20(3):559-572.

    18.  Champy M, Lodde JP, Kahn JL, Kielwasser P. Attempt at systematization in the treatment of isolated fractures of the zygomatic bone: techniques and results. J Otolaryngol. 1986;15(1):39-43.

    19.  Oyen OJ, Melugin MB, Indresano AT. Strain gauge analysis of the frontozygomatic region of the zygomatic complex. J Oral Maxillofac Surg. 1996;54(9):1092-1095;discussion 1095-1096.

    20.  Davidson J, Nickerson D, Nickerson B. Zygomatic fractures: comparison of methods of internal fixation. Plast Reconstr Surg. 1990;86(1):25-32.

    21.  Manson PN, Hoopes JE, Su CT. Structural pillars of the facial skeleton: an approach to the management of Le Fort fractures. Plast Reconstr Surg. 1980;66(1):54-62.

    22.  Gruss JS, Mackinnon SE. Complex maxillary fractures: role of buttress reconstruction and immediate bone grafts. Plast Reconstr Surg. 1986;78(1):9-22.

    Author Disclosure

    The authors state that they have no financial interest in any of the products or techniques discussed in this article.