Downloaded 41 times
More Related Content
Similar to Zygoma fractures
Zygoma fractures
- 1.
- 2. ANATOMY • Buttress ofmidfacial skeleton • Malar eminence, lateral & inferior portions of orbit • Strongest attachment with frontal bone • Muscle attachments – masseter, Temporalis, zygomaticus M. & m., Levator labii superioris • Zygomaticofacial & Zygomaticotemporal foramen
- 3. Etiology • RTA 80% •Assault 20% • Male:female 4:1 • 2nd – 3rd decade • Left zygoma fracture MC than right
- 4. CLASSIFICATION • KNIGHT ANDNORTH CLASSIFICATION • Group 1 – No displacement – 6% • Group 2 – isolated displaced arch fractures – 10% • Group 3 – Displaced body fractures (unrotated) – 33% • Group 4 – Medially rotated body fractures – 11% • Group 5 – Laterally rotated body fractures – 22% • Group 6 – Additional fractures crossing main fracture – 18%
- 5. Rowe’s and Killeyclassification (1968) • Type I: no significant displacement • Type II : fracture of zygomaticarch • Type III : rotation arroundhorizontal axis –inward or outward displacement • Type IV: rotation around longitudinal axis –medial or lateral • Type V: displacement of the complex block –medial/inferior/lateral • Type VI: displacement of orbitoantralpartition • Type VII: displacement of orbital rim segment • Type VIII: complex comminuted fracture.
- 6. CLINICAL FEATURES –Orbital symptoms • Periorbital ecchymosis • Periorbital edema • Downward slant of palpebral fissure (antimongoloid slant) • Subconjunctival ecchymosis • Diplopia
- 7. Facial symptoms • Asymmetryof the midface • Depression/flattening of the malar prominence • Step off or gap deformities of infraorbital/lateral orbital rim • Sensory deficit (hypoesthesia, anaesthesia) in the distribution of the Infra orbital nerve
- 8. Oral symptoms • Ecchymosisof the gingivobuccal maxillary sulcus • Restriction of mandibular opening or closing –blockage of coronoid process •impacted zygomatic arch •retro displaced zygoma
- 9. Nasal symptoms • Ipsilateralepistaxis • Ipsilateral hemosinus
- 10. DIAGNOSIS • History • Clinicalexamination • X-ray Water’s view - Zygoma buttresses, orbital floor, inf. orbital rim, ZF suture, ZM buttress Caldwell view – ZF suture • CT- Facial bones – gold standard • 3D CT – normal vs abnormal rim and malar eminence
- 13. MANAGEMENT POINTS TO NOTE •Presence of fracture • Displacement • Degree of comminution POINTS OF ALIGNMENT • ZF suture • Infraorbital rim • ZM buttress • Zygomatic arch • Greater wing of sphenoid (Lat .wall of orbit) • Orbital floor
- 14. Conservative management • Non-displacedfractures- 9-50 % • Minimal degree of displacement Unlikely to result in - ◦ Cosmetic deformity ◦ Disturbance of vision ◦ Paraesthesia ◦ Mandibular movements impaired
- 15. Surgical approaches Extra-oral approach –Bicoronalor hemicoronal –Gillies: Temporal • Supra orbital approach : Lateral eyebrow Upper eyelid • Infraorbital Sub tarsal Sub ciliary/infra ciliary Transconjunctival • Percutaneous
- 16. Surgical approaches • Intra-oralapproach Transoral: maxillary vestibular Endoscopic transantral
- 17. Bicoronal or hemicoronal •Fractures with extreme posterior displacement of malar eminence and lateral displacement of arch
- 18. –Entire calvarial vault –Anteriorand lateral skull base –Frontal sinus/Ethmoid –Zygoma –Zygomatic arch –Orbit (lateral/cranial/medial) –Nasal dorsum –Temporomandibular joint (TMJ) –Condyle and subcondylar region
- 19. Temporal (Gillies) approach •2.5 cm superior and anterior to the helix • within the hairline. • 2 cm length • avoid sup. temporal artery. • Plane - deep to the temporalis fascia superficial to the temporalis muscle. • Instrument is advanced until it is medial to the depressed zygomatic arch.
- 20.
- 21. Bristow Elevator Roweelevator
- 22.
- 23. Superolateral orbital rimApproaches Fractures with ZF suture diastasis • Lateral eyebrow approach • Upper eyelid approach
- 24. Lateral eyebrow approach •limited access • zygomaticofrontal process • immediate vicinity of suture line
- 25. The upper-eyelid orupper blepharoplasty approach • Better access to superolateral orbital rim
- 26. Lower eyelid approaches Fractureswith communition of orbital floor. A. Subciliary B. Subtarsal: lower or mid eyelid C. Infraorbital: inferior orbital rim D. Subciliary approach can be extended laterally to gain access to the lateral orbital rim
- 27.
- 28. Areas accessible • lowercircumference of the orbital cavity
- 29. Areas accessible byextended subciliary approach • the entire lateral rim • with heavy traction even beyond the level of the zygomaticofrontal suture • lateral orbital wall back to the zygomatico-sphenoid suture
- 30. Transconjunctival approach A. Transconjunctival (inferiorfornix transconjunctival using a retroseptal or preseptal route) B. Transcaruncular (medial transconjunctival) C. Transconjunctival with lateral skin extension (lateral canthotomy)
- 31. • Transconjunctival incision thefloor of the orbit and infraorbital rim as well as the upper edge of the anterior maxilla(A). • Transcaruncular incision, the medial wall of the orbit behind the posterior lacrimal crest can be exposed (B).
- 32. Dingman approach • Semiclosed approach • Medially displaced arch fractures • 2 incisions – lateral brow and lower eyelid incision • ZF and ZM suture lines exposed • Elevator through upper incision (closed) • Orbital floor exploration (open)
- 33.
- 34. Percutaneous: screw andtraction method
- 35.
- 36. Transoral(Keen) approach –lateralmaxillary vestibular incision • direct access to the zygomatic arch. • 2 cm long • Upper gingival buccal- mucosal incision • just at the base of the zygomaticomaxillary buttress
- 37.
- 38. Endoscopic assisted repair •Orbital floor defects • Visualising zygomatic arch reduction • - Through maxillary sinus • - Through intraoral buccal sulcus incision
- 39. Indirect reduction methods 1.Gilliestemporal approach 2.Transoral: Keen’s approach 3.Percutaneus approach 4.Dingman approach
- 40. Fixation methods • K-wireor pin fixation • Inter fragmentary wiring • Plate and screw fixation
- 41. K-Wire or Pinfixation • Rapid & inexpensive • Alignment not as good as open method • Fracture reduced by closed reduction • Stabilised with K-wire to contralateral maxilla or zygoma • 4 weeks
- 42. Plate and ScrewFixation
- 43.
- 44. Isolated Zygomatic archfracture • reduced by closed reduction by Gillies or Keen’s approach • No need for internal fixation • Temporalis and masseter muscle and fascia with soft tissue splint the arch sufficiently to stabilize the fragments
- 45. Complications • Acute exacerbationof sinus disease • Non union/ Malunion • Diplopia • Visual loss • Globe injury • Enophthalmos • Persistent infraorbital nerve numbness • Plate exposure or screw loosening