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Orbital Fracture, Zygomatic: Differential Diagnoses & Workup

Author: Stuart Seiff, MD, FACS, Emeritus Professor of Ophthalmology, University of California San Francisco; Chief, Department of Ophthalmology, San Francisco General Hospital; Consultant, Oculofacial and Aesthetic Plastic Surgery, California Pacific Medical Center and Mills Peninsula Medical Center
Coauthor(s): Jesus Torres, MD, Fellow, Section of Oculoplastic Surgery, Hospital de Viladecans, Spain; Dan D DeAngelis, MD, FRCS(C), Ophthalmic Plastic and Reconstructive Surgery, Assistant Professor, Department of Ophthalmology and Vision Sciences, University of Toronto; Susan Carter, MD, Clinical Associate Professor of Ophthalmology, Institute of Ophthalmology and Visual Science, New Jersey Medical School
Contributor Information and Disclosures

Updated: May 13, 2009

Differential Diagnoses

Enophthalmos
Globe Retraction
Orbital Fracture, Floor
Orbital Fracture, Medial Wall

Other Problems to Be Considered

Midface fractures

Workup

Laboratory Studies

  • The only tests needed are those for preoperative evaluation as required by the surgery facility.

Imaging Studies

  • Orbital imaging is appropriate.
  • Radiographic evaluation of the fracture is mandatory and may include both plain films and a CT scan. Typically, CT scan is the study of choice. There is little role for MRI in the management of these injuries.6
  • A Waters view radiograph may show evidence of the zygomatic fracture and subsequent displacement (see Media file 2). 
  • CT scans (orbit and sinuses) have now essentially replaced plain films as the standard imaging study in both evaluation and treatment planning. CT scans are generally easier to read than plain films and give more helpful information (see Media files 3-4).  
    • An axial CT scan with 1-mm sections and a coronal CT scan with 3-mm cuts (facial series) should be obtained to best delineate the anatomy.
    • The CT scan accurately reveals the extent of orbital involvement and the degree of displacement of the fractures. The integrity of the mandible as well as of the temporomandibular joint should be evaluated.
  • CT scans are vital in planning the operative approach. The CT scans should be available for review in the operating room. Furthermore, evaluation with CT scans is helpful for the approximately 50% of patients who have concomitant intracranial injury.
  • Ultrasonography could be useful as a screening tool to aid in the detection of zygoma and orbital rim fractures. With experience, ultrasonography could also be used for intraoperative evaluation after a closed reduction where direct visualization of alignment is not possible.7

Staging

Several classifications of zygomatic fractures have been described in the literature, but none seem to be universally accepted. Most classifications are based on the degree of comminution, whether the fracture is simple or compound, and the site of the fractures. In 75% of cases, these fractures are displaced inferiorly, medially, and posteriorly.3

More on Orbital Fracture, Zygomatic

Overview: Orbital Fracture, Zygomatic
Differential Diagnoses & Workup: Orbital Fracture, Zygomatic
Treatment & Medication: Orbital Fracture, Zygomatic
Follow-up: Orbital Fracture, Zygomatic
Multimedia: Orbital Fracture, Zygomatic
References
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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. Laine FJ, Conway WF, Laskin DM. Radiology of maxillofacial trauma. Curr Probl Diagn Radiol. Jul-Aug 1993;22(4):145-88. [Medline].

  7. 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].

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

  9. 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].

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

  11. 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].

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

  13. 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].

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Further Reading

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Keywords

zygomatic orbital fracture, zygomatic orbital fractures, zygomatic fracture, zygomatic fractures, tripod fracture, facial fracture, facial bone fracture, orbit, orbital rim, ophthalmic injury, eye injury, trimalar fracture

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Contributor Information and Disclosures

Author

Stuart Seiff, MD, FACS, Emeritus Professor of Ophthalmology, University of California San Francisco; 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), Ophthalmic Plastic and Reconstructive Surgery, Assistant Professor, Department of Ophthalmology and Vision Sciences, University of Toronto
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.

Medical Editor

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 Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Colorado Medical Society, Utah Medical Association, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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 Consulting fee Consulting; Quest medical - lacrimal balloons Honoraria Speaking and teaching; Ortho-Neutrogenia Consulting fee Consulting

CME Editor

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.

 
 
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