Fracture, Zygoma

By admin On Sep 16, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Fracture, Zygoma

Martha A. Dodson

Basics

Pediatric Considerations

Maxillofacial fractures are rarely seen in the pediatric population.
Children have a comparatively larger cranium than facial skeleton, leading to a higher incidence of head trauma.
Falls and motor vehicle accidents account for the majority of facial trauma in children.
Consider nonaccidental trauma, particularly in children under age 6.

Description

Fractures of the zygoma result from blunt trauma to the side of the face.
The most common mechanisms include motor vehicle accidents, falls, and physical assault.
The direction and magnitude of force will determine the fracture type and degree of displacement.
- A blow to the side of the face directed posteriorly and medially will produce a zygomatic body (tripod) fracture.
- A lateral blow often results in an isolated zygomatic arch fracture.
Zygoma fractures may have associated paranasal sinus fractures.

Risk Factors

Motor vehicle collisions
Falls
Assault
Blunt-force trauma from athletic equipment including ball(s)

General Prevention

Appropriate use of athletic helmet/face shield
Proper use of vehicle safety restraints

Commonly Associated Conditions

Facial lacerations
Ecchymosis
Edema
Palpable defect
Trismus
Orbital floor fracture
Maxillary sinus fracture

Diagnosis

Pediatric Considerations

Sedation may be required to properly examine some children.
If a head injury is suspected, sedation is not recommended.
If circumstances or injuries raise suspicions of child abuse, a comprehensive investigation for previous nonaccidental trauma is essential.
If a high-velocity or severe blunt-force mechanism is suspected, a thorough evaluation for associated injuries (cervical spine, head, globe, other maxillofacial bones, etc.) is imperative.
Radiographs:
- The submental vertex (jug-handle) view is used to diagnose fractures of the zygomatic arch.
- Plain films are not as useful in the evaluation of zygomatic body fractures.
- The Waters (occipitomental) view shows the inferior orbital rims and possibly layering of blood in the maxillary sinus.
- The articulation between the zygoma and frontal bone can be evaluated on the Caldwell view.

Pre Hospital

ABCs:
- Airway
- Breathing
- Circulation
Cervical spine: Immobilization PRN.
Cautions:
- Airway compromise may occur with severe maxillofacial injuries.
- Assume that the patient with face or head injury has also sustained a cervical spine injury until proven otherwise.

History

Direct blow to face with ball, elbow, or sports equipment
May or may not have loss of consciousness
May complain of double vision owing to orbital floor disruption
May complain of trismus

Physical Exam

Signs and symptoms:
- Malar edema or flattening
- Periorbital ecchymosis, drooping lateral canthus
- Lateral subconjunctival hemorrhage, diplopia
- Infraorbital anesthesia, trismus/open bite
Physical examination:
- Intraoral palpation of the zygomatic body and arch for bony step deformity
- Palpation of arch for crepitance and/or step-off deformity
- Assess sensation of the inferior orbital area (cheek, upper lip, and gingiva).
- Examine the globe and orbit carefully.
  - Periorbital ecchymosis and lateral subconjunctival hemorrhages are common.
  - Assess visual acuity, pupillary function, and extraocular movements.
  - Inferior displacement of the globe may lead to diplopia and enophthalmos. Carefully evaluate extraocular movements.
- Mandibular movement may be restricted.
- Trismus may be seen if there is impingement of the mandibular coronoid process by displacement of the zygomatic body.
- Zygomatic arch fractures may impede the temporalis muscle or coronoid process.
- Lastly, temporalis muscle contusion or temporomandibular joint (TMJ) effusion may cause pain that limits range of motion (ROM).
- Unilateral epistaxis may be present and typically resolves spontaneously.

Diagnostic Tests & Interpretation

Imaging

CT scan is the diagnostic standard for evaluation of zygomatic body fractures.
CT scan is not usually needed for isolated fractures of the zygomatic arch.

Differential Diagnosis

Facial contusions
La Forte fractures

Treatment

Pediatric Considerations

Multiple injuries are often seen in children, including head trauma, skull fracture, and orthopedic injuries.
Definitive repair of facial fractures should not be delayed beyond 3 or 4 days.
The facial bones heal rapidly in children, and delays of more than 3–4 days may result in malunion and cosmetic deformity.
Consult social services and local child welfare agency if needed.

ED Treatment

Assume that the patient with head and maxillofacial trauma has a cervical spine injury. The neck should be immobilized until radiographic clearance is obtained.
Do not blindly clamp bleeding vessels because this may cause inadvertent damage to the facial nerve, parotid duct, etc.
Early consultation with oral maxillofacial or plastic surgeon

P.267

Analgesics, antibiotics, and tetanus prophylaxis if open injury
Airway management is particularly important if there are associated maxillofacial or mandibular injuries causing airway compromise. Isolated zygoma fractures do not typically require aggressive airway intervention.

Medication

Perioperative antibiotics for contaminated field

Additional Treatment

Referral

Refer all open and/or displaced and comminuted fractures to oral and maxillofacial surgery.

Surgery/Other Procedures

Open reduction with internal fixation (ORIF): Secured with plates and screws and occasionally wire.
Delayed fracture displacement, poor cosmetic outcome, and difficulty with mandibular movement are indications for ORIF.
Isolated arch fractures are amenable to outpatient treatment. These typically require open reduction of fracture fragments. If the reduction is unstable, internal fixation is then performed.
Nondisplaced tripod fracture can be treated conservatively as an outpatient with close follow-up.

In-Patient Considerations

Initial Stabilization

ABCs
Cervical spine immobilization PRN

Admission Criteria

Displaced or comminuted zygomatic body fractures require open reduction and internal fixation.
Associated head, neck, or other traumatic injuries requiring admission

IV Fluids

Medications:

Sedative/Analgesics*	Adult Dose (mg/kg IV)	Pediatric Dose (mg/kg IV)
Diazepam	0.1–0.2	0.1–0.2
Fentanyl	2–10 (µg/kg)	2–3 (μg/kg)
Ketamine	2	1–2
Meperidine	1–2	1–2
Midazolam	0.1	0.15
Morphine sulfate	0.1–0.2	0.1–0.2
*All these sedative/analgesics should be titrated to effect.

Ongoing Care

Consider custom face mask for return to play.

Diet

As tolerated safely given extent of oral/maxillary involvement

Patient Education

Proper usage of safety equipment

Additional Reading

Bell RB, Dierks EJ, Brar P, et al. A protocol for the management of frontal sinus fractures emphasizing sinus preservation. J Oral Maxillofac Surg. 2007;65:825–839.

Colucciello SA, Sternbach G, Walker SB. The treacherous and complex spectrum of maxillofacial trauma: etiologies, evaluation, and emergency stabilization. Emerg Med Rep. 1995;16;7:59–69.

Covington DS, Wainwright DJ, Teichgraeber JF, et al. Changing patterns in the epidemiology and treatment of zygoma fractures: 10-year review. J Trauma. 1994;37:243–248.

Hunter JG. Pediatric maxillofacial trauma. Pediatr Clin North Am. 1992;39:1127–1143.

Kaufman BR, Heckler FR. Sports-related facial injuries. Clin Sports Med. 1997;16:543–562.

Rumsey C, Sargent LA. Zygomatic fractures. Trauma Q. 1992;9:76–85.

Codes

ICD9

802.4 Closed fracture of malar and maxillary bones
802.5 Open fracture of malar and maxillary bones