Zygomatic Orbital Fracture Clinical Presentation

  • Author: Stuart Seiff, MD, FACS; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 15, 2012
 

History

  • Vision can be threatened as a result of direct ocular injury or intraorbital hemorrhage.
  • Binocular diplopia is noted in as many as 30% of zygomatic fractures. This can be secondary to muscle entrapment, neuromuscular injury, or intramuscular hematoma.
  • Difficulty with mastication, otherwise known as trismus, can occur because of masseter spasm or bony impingement of the coronoid process.
  • In some patients, ipsilateral epistaxis also is noted as a result of lacerated maxillary sinus mucosa.
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Physical

  • Since most of these patients are involved in multisystem trauma, involvement by a trauma team for airway, breathing, and circulatory status is essential.
  • Ophthalmic evaluation, including globe integrity, should be performed promptly. Inferior displacement of the lateral canthal tendon is common. Proptosis may be present due to orbital edema or hemorrhage. Acute orbital hematoma may cause vision compromise and should be managed appropriately.[5]
  • Periorbital and/or subconjunctival ecchymosis are seen in as many as 50% of patients.
  • Significant malar depression can be seen with step defects at the infraorbital rim, frontozygomatic suture, and zygomatic buttress of the maxilla intraorally.
  • Fractures of the zygomatic bone evoke pain on palpation in 70% of patients.
  • Paresthesias in the distribution of the infraorbital, zygomaticofacial, or zygomaticotemporal nerves can occur.
  • Posterior displacement of the fracture fragment may impinge on movement of the mandible causing difficulty with mastication. Inferior displacement of the lateral canthal angle may indicate inferior migration of the fractured zygomatic bone. Although these are not true orbital blowout fractures, entrapment of orbital contents, enophthalmos, and diplopia with restriction of motility may occur because of the contributions of the zygomatic bone to the orbital floor. Use of the Hertel exophthalmometer in the assessment of relative enophthalmos or exophthalmos may be complicated because the lateral orbital rim, which is displaced in most zygomatic complex fractures, serves as a reference point for this instrument. Consideration should be given to the use of the Naugle exophthalmometer in these cases, which uses the frontal bone as a reference.[6]
  • Crepitus from subcutaneous emphysema or proptosis and visual loss from orbital emphysema may occur with forceful nose blowing. Patients should be cautioned against this.
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Causes

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. Studies show that 80% of these injuries are due to motor vehicle accidents.

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Contributor Information and Disclosures
Author

Stuart Seiff, MD, FACS  Emeritus Professor of Ophthalmology, University of California, San Francisco, School of Medicine; Chief, Department of Ophthalmology, San Francisco General Hospital; Consultant, Oculofacial and Aesthetic Plastic Surgery, California Pacific Medical Center and Mills Peninsula Medical Center

Stuart Seiff, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, and California Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Jesus Torres, MD  Fellow, Section of Oculoplastic Surgery, Hospital de Viladecans, Spain

Jesus Torres, MD is a member of the following medical societies: American Academy of Ophthalmology and International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Dan D DeAngelis, MD, FRCS(C)  Lecturer, Ophthalmic Plastic and Reconstructive Surgery, Assistant Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Ophthalmologist, Department of Ophthalmology and Vision Sciences, Hospital for Sick Children

Dan D DeAngelis, MD, FRCS(C) is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, California Medical Association, Canadian Medical Association, Canadian Ophthalmological Society, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Susan Carter, MD  Clinical Associate Professor of Ophthalmology, Institute of Ophthalmology and Visual Science, New Jersey Medical School

Susan Carter, MD is a member of the following medical societies: American Academy of Ophthalmology and American Society of Ophthalmic Plastic and Reconstructive Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Ron W Pelton, MD, PhD  Private Practice, Colorado Springs, Colorado

Ron W Pelton, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Society of Ophthalmic Plastic and Reconstructive Surgery, AO Foundation, and Colorado Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark T Duffy, MD, PhD  Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic

Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience

Disclosure: Allergan - Botox Cosmetic Honoraria Speaking and teaching

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the assistance of Ryan I Huffman, MD, with the literature review and referencing for this article.

References

  1. Gruss JS, Van Wyck L, Phillips JH, et al. The importance of the zygomatic arch in complex midfacial fracture repair and correction of posttraumatic orbitozygomatic deformities. Plast Reconstr Surg. Jun 1990;85(6):878-90. [Medline].

  2. Song WC, Choi HG, Kim SH, et al. Topographic anatomy of the zygomatic arch and temporal fossa: A cadaveric study. J Plast Reconstr Aesthet Surg. Oct 21 2008;[Medline].

  3. Zingg M, Laedrach K, Chen J, et al. Classification and treatment of zygomatic fractures: a review of 1,025 cases. J Oral Maxillofac Surg. Aug 1992;50(8):778-90. [Medline].

  4. Covington DS, Wainwright DJ, Teichgraeber JF, et al. Changing patterns in the epidemiology and treatment of zygoma fractures: 10-year review. J Trauma. Aug 1994;37(2):243-8. [Medline].

  5. Barry C, Coyle M, Idrees Z, et al. Ocular findings in patients with orbitozygomatic complex fractures: a retrospective study. J Oral Maxillofac Surg. May 2008;66(5):888-92. [Medline].

  6. He D, Li Z, Shi W, Sun Y, Zhu H, Lin M, et al. Orbitozygomatic Fractures With Enophthalmos: Analysis of 64 Cases Treated Late. J Oral Maxillofac Surg. Jul 11 2011;[Medline].

  7. Laine FJ, Conway WF, Laskin DM. Radiology of maxillofacial trauma. Curr Probl Diagn Radiol. Jul-Aug 1993;22(4):145-88. [Medline].

  8. Friedrich RE, Heiland M, Bartel-Friedrich S. Potential of ultrasound in the diagnosis of midface fractures. Clinical Oral Investigations. 2003;7:226-229. [Full Text].

  9. Parashar A, Sharma RK, Makkar SS. Treatment of simple zygoma fractures. Plast Reconstr Surg. Oct 2008;122(4):1285; author reply 1285-6. [Medline].

  10. McLoughlin P, Gilhooly M, Wood G. The management of zygomatic complex fractures--results of a survey. Br J Oral Maxillofac Surg. Oct 1994;32(5):284-8. [Medline].

  11. Randall DA, Bernstein PE. Epistaxis balloon catheter stabilization of zygomatic arch fractures. Ann Otol Rhinol Laryngol. Jan 1996;105(1):68-9. [Medline].

  12. af Geijerstam B, Hultman G, Bergstrom J, et al. Zygomatic fractures managed by closed reduction: an analysis with postoperative computed tomography follow-up evaluating the degree of reduction and remaining dislocation. J Oral Maxillofac Surg. Nov 2008;66(11):2302-7. [Medline].

  13. Smyth AG. A modified miniplate for use in malar complex fractures. Br J Oral Maxillofac Surg. Jun 1995;33(3):169-70. [Medline].

  14. Czerwinski M, Izadpanah A, Ma S, et al. Quantitative analysis of the orbital floor defect after zygoma fracture repair. J Oral Maxillofac Surg. Sep 2008;66(9):1869-74. [Medline].

  15. Trivellato PF, Arnez MF, Sverzut CE, Trivellato AE. A retrospective study of zygomatico-orbital complex and/or zygomatic arch fractures over a 71-month period. Dent Traumatol. Apr 2011;27(2):135-42. [Medline].

 
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The zygoma forms a firm buttress for the orbit and typically fractures at its sutures.
Waters view demonstrating a zygomatic complex fracture involving the zygomaticofrontal suture, inferior orbital rim, and opacification of the maxillary sinus.
CT scan of the orbit demonstrating disruption of the zygomatic arch.
CT scan demonstrating disruption of the lateral wall of the orbit and medial inferior orbital rim.
 
 
 
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