This document discusses facial fractures, focusing on zygomatic complex fractures. It covers the anatomy of the zygomatic bone, signs and symptoms of zygomatic fractures, methods for diagnosis including radiography, classification systems for fractures, and various surgical approaches for treating different types of zygomatic fractures. Treatment can range from observation of minor fractures to open reduction and internal fixation for significantly displaced fractures involving multiple bone fragments. Complications are also reviewed.
Frontal sinus fractures are currently managed by various medical specialists, including otolaryngologists/head and neck surgeons, maxillofacial surgeons, plastic surgeons, and neurosurgeons. As a result, consensus does not exist regarding the timing, indications, and treatment modality of these injuries.
Frontal sinus fractures are currently managed by various medical specialists, including otolaryngologists/head and neck surgeons, maxillofacial surgeons, plastic surgeons, and neurosurgeons. As a result, consensus does not exist regarding the timing, indications, and treatment modality of these injuries.
Traditional classification were given 100 years back when RTA , assaults, sports injuries, industrial accidents were minimal.
Over the past 100 years RTA (high speed & Low speed) assaults, sports injuries (high contact/ low contact), industrial accidents have increased.
Fracture patterns which are not matching the traditional injuries pattern.
Can speed up diagnosis and treatment planning
Cohorting / clubbing of complication to Specific Fractures.
It facilitate communication between peers and assist documentation and research.
It also have prognostic value for patients and assist Surgeons in planning their management.
It serves as a basis for treatment and for evaluation of the results.
Different fractures/ Areas of fracture has different treatment plan / approaches.
Undisplaced fracture : conservative/ surgical
Displaced Fractures: Surgical/ conservative with traction
The naso-orbitoethmoid complex (NOE) fracture represents the most wearisome and challenging of all facial fractures due to the complexity and intricacy of its surgical & anatomic components. A good working knowledge with regards its surgical anatomy, clinical features, sequence of treatment & surgical approaches, potential pitfalls in its treatment & postoperative consideration,. Appropriate diagnosis and timely treatment is crucial to avoid unfavorable & difficult to treat sequelae.
Naso-orbital-ethmoid (NOE) fractures: Management principles, options and rec...Dibya Falgoon Sarkar
Comprehensive discussion on diagnosis and management of NOE fractures. Surgical anatomy and approaches to NOE region is also discussed. Reconstruction of NOE complex is discussed. Recent advances in management of NOE fractures are also highlighted in this presentation
Orbital fracture, types, blow in fracture ,blow out fracture ,clinical features ,superior orbital fissure syndrome ,management ,complications ,reconstruction techniques ,Oculocardiac reflex
Traditional classification were given 100 years back when RTA , assaults, sports injuries, industrial accidents were minimal.
Over the past 100 years RTA (high speed & Low speed) assaults, sports injuries (high contact/ low contact), industrial accidents have increased.
Fracture patterns which are not matching the traditional injuries pattern.
Can speed up diagnosis and treatment planning
Cohorting / clubbing of complication to Specific Fractures.
It facilitate communication between peers and assist documentation and research.
It also have prognostic value for patients and assist Surgeons in planning their management.
It serves as a basis for treatment and for evaluation of the results.
Different fractures/ Areas of fracture has different treatment plan / approaches.
Undisplaced fracture : conservative/ surgical
Displaced Fractures: Surgical/ conservative with traction
The naso-orbitoethmoid complex (NOE) fracture represents the most wearisome and challenging of all facial fractures due to the complexity and intricacy of its surgical & anatomic components. A good working knowledge with regards its surgical anatomy, clinical features, sequence of treatment & surgical approaches, potential pitfalls in its treatment & postoperative consideration,. Appropriate diagnosis and timely treatment is crucial to avoid unfavorable & difficult to treat sequelae.
Naso-orbital-ethmoid (NOE) fractures: Management principles, options and rec...Dibya Falgoon Sarkar
Comprehensive discussion on diagnosis and management of NOE fractures. Surgical anatomy and approaches to NOE region is also discussed. Reconstruction of NOE complex is discussed. Recent advances in management of NOE fractures are also highlighted in this presentation
Orbital fracture, types, blow in fracture ,blow out fracture ,clinical features ,superior orbital fissure syndrome ,management ,complications ,reconstruction techniques ,Oculocardiac reflex
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2. OUTLINE
• Zygomatic Complex Fractures
• Orbital and Ocular Trauma
• Frontal Sinus and Naso-Orbito-Ethmoid Complex Fractures
• Gunshot Injuries
• References
3. ZYGOMATIC COMPLEX FRACTURES
• The zygoma articulates with the frontal, sphenoid, temporal, and maxillary bones.
• Tri-malar or tripod fracture are inaccurate.
• Zygomatic complex fracture includes disruption of the four articulating sutures:
zygomatico-frontal, zygomatico-temporal, zygomatico-maxillary and the
zygomatico-sphenoid sutures.
• All zygomatic complex fractures involve the orbital floor.
• Nerve supply.
4. ZYGOMATIC COMPLEX FRACTURES
• The temporalis fascia attaches to the frontal process of the zygoma and zygomatic arch.
The fascia produces resistance to inferior displacement of a fractured fragment by the
downward pull of the masseter muscle.
5. DIAGNOSIS
• Zygomatic fractures are not life threatening.
• Initial evaluation of the patient with a zygomatic fracture includes documentation of the
bony injury and the status of surrounding soft tissue (eyelids, lacrimal apparatus, canthal
tendons, and globe) and cranial nerves II to VI.
6. SIGNS AND SYMPTOMS
• Pain
• Periorbital edema and Ecchymosis [most common early clinical signs and present in 61% of
all zygomatic injuries]
• Paresthesia or anesthesia over the cheek, lateral nose, upper lip and maxillary anterior teeth
resulting from injury to the zygomaticotemporal or infraorbital nerves.
• Nerve injury occurs in 18 to 83% of all patients with zygomatic trauma.
• When the arch is medially displaced, the patient may complain of trismus.
• Epistaxis and diplopia may be present.
• Malar Depression
7. SIGNS AND SYMPTOMS
• Downward displacement of the zygoma produces an Antimongoloid slant to the
lateral canthus, enophthalmos, and accentuation of the supra-tarsal fold of the
upper eyelid.
• Radiographs: CT scan of the facial bones, in axial and coronal planes, is standard
for all patients with suspected zygomatic fractures.
8.
9. DOLAN’S LINES
• Dolan's lines are the collective name given to three lines that aid in evaluating
for maxillofacial fractures on an occipitomental skull radiograph. They are usually
used as an adjunct to McGrigor-Campbell lines.
• orbital line traces the inner margins of the lateral, inferior, and medial orbital walls,
and the nasal arch
• zygomatic line traces the superior margin of the zygomatic arch and body, extending
along the frontal process of the zygoma to the zygomaticofrontal suture
• maxillary line traces the inferior margin of the zygomatic arch, body, and buttress,
and the lateral wall of the maxillary sinus
10.
11.
12.
13. RADIOGRAPHIC EVALUATION
• Waters’ View
• The single best radiograph for evaluation of zygomatic complex fractures.
• Postero-anterior projection with the head positioned at a 27˚ angle to the vertical and the
chin resting on the cassette.
• This projects the petrous pyramids off the maxillary sinuses, permitting visualization of
the sinuses, lateral orbits and infraorbital rims
• In patients who are unable to assume a facedown position, a reverse Waters’ projection
provides similar information.
14.
15. RADIOGRAPHIC EVALUATION
• Caldwell’s View; Postero-anterior projection with the face at a 15˚ angle to the
cassette. This study is helpful in the evaluation of rotation (around a horizontal
axis).
• Submentovertex View; (jug-handle) from the submandibular region to the vertex
of the skull. It is helpful in the evaluation of the zygomatic arch and malar
projection.
16.
17.
18. CLASSIFICATION OF FRACTURES
• Pattern of segmentation and displacement.
• Low-Energy Fractures; fractures that demonstrated little or no displacement, incomplete
fractures of one or more articulations may be present.
• Middle-Energy Fractures; fractures that demonstrated complete fracture of all articulations
with mild to moderate displacement.
• High-Energy Fractures; characterized by comminution in the lateral orbit and lateral
displacement with segmentation of the zygomatic arch.
19. CLASSIFICATION OF FRACTURES
• Type A fractures; incomplete low-energy fractures with fracture of only one zygomatic
pillar: the zygomatic arch, lateral orbital wall, or infraorbital rim.
• Type B fractures; designated complete “mono-fragment” fractures with fracture and
displacement along all four articulations.
• Type C “multi-fragment” fractures included fragmentation of the zygomatic body.
20.
21.
22. TREATMENT
• Management of zygomatic complex and zygomatic arch fractures depends on the degree
of displacement and the resultant esthetic and functional deficits.
• Treatment may therefore range from simple observation of resolving swelling,
extraocular muscle dysfunction, and paresthesia to open reduction and internal fixation
of multiple fracture.
23. TREATMENT
• Nondisplaced and minimally displaced zygomatic arch fractures may require no surgical
correction.
• The first operative treatment described was by usage of intraoral finger pressure [ Wood
block – tension]
• Incision in the mucosa at the level of the maxillary alveolus and extending it inferiorly along
the anterior border of the ramus. An elevator is placed between the coronoid processes and
zygomatic arch, and the fracture is reduced.
24. GILLIE’S APPROACH
• Standard technique
• A temporal incision (2 cm in length) is made behind the hairline. [Temporalis Fascia]
• The temporal fascia is incised horizontally to expose the temporalis muscle.
• A sturdy elevator, such as a urethral sound or Rowe zygomatic elevator is inserted
underneath the temporal surface of the zygoma.
• The bone should be elevated in an outward and forward direction, with care taken not to
put force on the temporal bone.
• The arch should be palpated at all times as a guide to proper reduction.
• The wound is closed in layers.
25.
26. TREATMENT
• Pre-Auricular Incision – J- Shaped Elevator
• Aluminum Foam Rubber Splint – 3 – 5 days
• Open reduction with internal fixation is seldom necessary for treatment of
isolated zygomatic arch fractures.
27. ZYGOMATIC COMPLEX FRACTURE
TREATMENT
• Middle-Energy Zygomatic Complex Fractures Middle-energy, displaced zygomatic
complex fractures require reduction and internal fixation.
• Carroll-Girard screw, which is inserted trans-cutaneously into the malar
eminence.
• Excellent three dimensional control to reduce the fracture.
• The zygomatico-maxillary buttress is exposed first, zygomatico-frontal buttress is
exposed next and also stabilized with a plate if required.
28. HIGH-ENERGY ZYGOMATIC COMPLEX
FRACTURES MANAGEMENT
• Coronal Flap
• Transcutaneous or trans-conjunctival incision is used to explore and reconstruct the
internal orbit.
• Intraoral approach; maxillary vestibule incision 3 to 5 mm above the mucogingival
junction. [ 3-7]
• Periosteal incision.
• Supra-tarsal fold incision or Lateral Eyebrow incision.
32. RETROBULBAR
HEMORRHAGE
• Rare but severe complication
• Result of either the initial injury or the operative correction.
• Disruption of the retinal circulation may lead to irreversible ischemia and
permanent blindness.
• An emergent ophthalmologic consultation is necessary
• Decompression with lateral canthotomy and cantholysis should not be delayed