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Zygomatic Orbital Fracture Workup

  • Author: Stuart Seiff, MD, FACS; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Aug 19, 2014
 

Laboratory Studies

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

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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.[7]

A Waters view radiograph may show evidence of the zygomatic fracture and subsequent displacement, as shown below.

Waters view demonstrating a zygomatic complex frac Waters view demonstrating a zygomatic complex fracture involving the zygomaticofrontal suture, inferior orbital rim, and opacification of the maxillary sinus.

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 the images below.

CT scan of the orbit demonstrating disruption of t CT scan of the orbit demonstrating disruption of the zygomatic arch.
CT scan demonstrating disruption of the lateral wa CT scan demonstrating disruption of the lateral wall of the orbit and medial inferior orbital rim.

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.[8]

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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]

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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, California Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Dan D DeAngelis, MD, FRCSC Assistant Professor of Ophthalmic Plastic and Reconstructive Surgery, 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, FRCSC 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, 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, American Society of Ophthalmic Plastic and Reconstructive Surgery

Disclosure: Nothing to disclose.

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, International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

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, AO Foundation, American Society of Ophthalmic Plastic and Reconstructive Surgery, Colorado Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference 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. 1990 Jun. 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. 2008 Oct 21. [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. 1992 Aug. 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. 1994 Aug. 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. 2008 May. 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. 2011 Jul 11. [Medline].

  7. Laine FJ, Conway WF, Laskin DM. Radiology of maxillofacial trauma. Curr Probl Diagn Radiol. 1993 Jul-Aug. 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. 2008 Oct. 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. 1994 Oct. 32(5):284-8. [Medline].

  11. Randall DA, Bernstein PE. Epistaxis balloon catheter stabilization of zygomatic arch fractures. Ann Otol Rhinol Laryngol. 1996 Jan. 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. 2008 Nov. 66(11):2302-7. [Medline].

  13. Smyth AG. A modified miniplate for use in malar complex fractures. Br J Oral Maxillofac Surg. 1995 Jun. 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. 2008 Sep. 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. 2011 Apr. 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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