When Zygomatic fractures require surgical intervention (ORIF)

Mayta
Mar 7, 2024
4 min read

Functional Problems	Cause	Surgical Repair Needed
Trismus (Restricted Mouth Opening)	Injury to masticatory muscles or TMJ due to trauma.	May include physical therapy and surgical realignment if necessary.
Diplopia (Double Vision)	Misalignment or entrapment of ocular muscles from orbital fractures.	Surgery to realign orbital bones and free entrapped muscles.
Limitation of EOM (Extraocular Movements)	Entrapment or injury to muscles controlling eye movements from orbital fractures.	Correcting orbital fractures to restore normal eye movement.

Cosmetic Problems	Cause	Surgical Repair Needed
Asymmetry	Displaced fractures and inadequate healing.	Surgical realignment using ORIF, possibly with cosmetic procedures to correct soft tissue deficits.
Enophthalmos (Sunken Eyes)	Increase in orbital volume due to fractures.	Orbital floor repair with grafts or implants to reduce volume and correct eye position.
Anti-Mongoloid Slant	Orbital or zygomatic fractures affecting the lateral canthal tendon.	Canthoplasty or canthopexy to correct the position of the eyelids.

Surgical Intervention	Description	Indication
Open Reduction and Internal Fixation (ORIF)	Surgically exposing and realigning fracture sites, using plates and screws for stabilization.	Displaced fractures, significant facial asymmetry, impaired ocular function.
Closed Reduction	Manual manipulation to realign fractured bone without incisions, sometimes using tools for assistance.	Less severe or minimally displaced fractures.
Zygomatic Arch Repair	Targeted repair for zygomatic arch fractures, accessed through the mouth or a small incision.	Isolated arch fractures affecting facial width or causing trismus.
Orbital Floor Reconstruction	Rebuilding the orbital floor to correct issues like muscle entrapment, using grafts or synthetic materials.	Diplopia, enophthalmos due to orbital volume changes.

This is crucial in the context of facial trauma and reconstructive surgery, often seen with zygomaticomaxillary complex (ZMC) fractures or other facial bone injuries.

Functional Problems:

Trismus
Cause: Trismus, or restricted mouth opening, is often caused by trauma to the masticatory muscles, inflammation, or direct injury to the temporomandibular joint (TMJ). In the context of facial fractures, it may result from impingement or mechanical restriction due to displaced bone fragments.
Repair: Treatment involves reducing inflammation, managing pain, and restoring normal anatomy through surgical intervention if necessary. Physical therapy exercises to improve mobility and the use of devices to gradually increase the jaw opening can also be beneficial.
Diplopia
Cause: Double vision is typically due to misalignment of the ocular muscles or entrapment of the muscles controlling eye movements, which can happen with orbital fractures.
Repair: Surgical repair aims to free entrapped muscles and realign the orbital bones to restore normal eye movement and alignment. This might involve the use of plates and screws to stabilize the orbit.
Limitation of EOM (Extraocular Movements)
Cause: Similar to diplopia, limitation in EOM can result from muscle entrapment or injury to the nerves controlling eye movements due to orbital fractures.
Repair: Surgery to correct the orbital fractures and release trapped muscles is crucial. Ensuring the proper alignment of the orbital walls and repair of the orbital floor, if herniated, helps restore full range of motion.

Cosmetic Problems:

Asymmetry
Cause: Facial asymmetry post-trauma usually results from displaced fractures and inadequate initial healing.
Repair: Surgical realignment of the bones, often using open reduction and internal fixation (ORIF), is necessary to restore symmetry. This may be accompanied by cosmetic procedures such as implants or fat grafting to correct soft tissue deficits.
Enophthalmos
Cause: Sunken appearance of the eye commonly results from an increase in the orbital volume due to a fracture of the orbital floor or medial wall.
Repair: Surgical intervention to repair the orbital floor, using grafts or implants to reduce the orbital volume, can correct enophthalmos and restore the normal position of the globe.
Anti-Mongoloid Slant
Cause: This refers to a downward slant of the outer corner of the eye, often resulting from orbital or zygomatic fractures that affect the lateral canthal tendon.
Repair: Canthoplasty or canthopexy procedures are used to correct the tendon's position, restoring the natural slant of the eyelids.

Approach to Repair:

Comprehensive Assessment: A detailed evaluation using clinical examination and imaging studies (CT scans) is essential to understand the full extent of the injuries.
Multidisciplinary Team: Collaboration with ophthalmologists, oral and maxillofacial surgeons, and plastic surgeons is often necessary for optimal functional and cosmetic outcomes.
Tailored Surgical Plan: The surgical approach is customized for each patient, depending on the severity and combination of the issues present. The timing of the surgery, whether immediate or delayed, also plays a critical role in the overall outcome.

Zygomaticomaxillary Complex Fracture (Tripod Fracture)

The Zygomaticomaxillary Complex (ZMC) fracture, also known as a tripod fracture, is a type of facial fracture involving three primary sutures that attach the zygomatic bone to the rest of the skull. This fracture typically affects four key anatomical structures:

Frontozygomatic Suture: The junction where the zygomatic bone meets the frontal bone near the outer edge of the orbit.
Zygomaticomaxillary Suture: The line of articulation between the zygomatic bone and the maxillary bone, affecting the inferior orbital rim and lateral maxillary sinus wall.
Zygomaticotemporal Suture: The junction between the zygomatic bone and the temporal bone, affecting the lateral orbital wall and floor.
Zygomaticosphenoid Suture: The articulation inside the orbit, affecting the posterior lateral wall.

The term "tripod" refers to the fracture occurring at three points, essentially detaching the zygomatic bone from the rest of the facial skeleton. Although called a "tripod," it's essential to note that the fracture involves these four critical areas.

Zygomatic fractures, including the zygomaticomaxillary complex (ZMC) or "tripod" fractures, are typically classified based on the anatomical location and extent of the fracture. Understanding the classification helps in determining the appropriate treatment and management strategy. Here’s a general overview:

1. Knight and North Classification

This is a commonly referenced system for zygomatic fractures, which categorizes the fractures based on displacement and functional impact:

Type I: Fractures without significant displacement and no requirement for surgical intervention.
Type II: Fractures with some displacement but without rotational misalignment, possibly requiring surgical intervention.
Type III: Fractures with significant displacement and rotation, almost always requiring surgical intervention to restore proper anatomical alignment and function.

2. Zingg Classification

This system classifies zygomatic fractures based on the involvement of specific sutures:

Group A: Fractures involving one suture.
Group B: Fractures involving two sutures.
Group C: Fractures involving three or more sutures, similar to the "tripod" fracture.

3. AO/OTA Classification

AO/OTA Classification in detail

AO/OTA Classification System Overview

The AO/OTA classification system divides fractures into three major categories based on the bone involved and the location of the fracture. Each category is further divided into groups and subgroups to provide a more detailed description of the fracture pattern. The system uses a numeric coding system where:

The first digit represents the bone or bone group.
The second digit represents the specific part of the bone.
The third digit (and letters) are used to describe the fracture pattern and complexity.

Applying AO/OTA to Zygomatic Fractures

While the AO/OTA classification is primarily known for long bone fractures, applying a similar structure to zygomatic fractures would involve:

Identifying the bone involved: For zygomatic fractures, this would specify the zygomatic complex.
Location of the fracture: This could detail whether the fracture affects the zygomatic arch, the orbital rim, the maxillary sinus area, or a combination of these sites.
Fracture pattern and complexity: This would describe whether the fracture is non-displaced or displaced, the number of fragments, and whether there is comminution (i.e., the bone is broken into multiple pieces).

Specific Example for Zygomatic Fractures

An example of how a zygomatic fracture might be classified using a hypothetical AO/OTA-like system could be:

1 (Facial Bones) - 5 (Zygoma) - .1 (Non-displaced fracture of the zygomatic arch)
1.5.2 (Displaced fracture involving the zygomatic arch and orbital rim)
1.5.3A (Complex fracture involving the zygomatic arch, orbital rim, and maxillary sinus with minimal comminution)
1.5.3B (Complex fracture as above with significant comminution)

The AO Foundation and Orthopaedic Trauma Association (AO/OTA) provides a comprehensive classification system for fractures that is used globally. For zygomatic fractures, it classifies based on the location and complexity of the fracture. This system is more commonly used for research and detailed surgical planning.

The specific details regarding surgical intervention for zygomatic fractures were not directly provided in the documents available. However, I can offer an overview based on general medical knowledge about the typical surgical interventions for zygomatic fractures.

Zygomatic fractures often require surgical intervention to restore facial symmetry, functional integrity (such as vision and jaw movement), and aesthetic appearance. The choice of surgical technique depends on the fracture's location, severity, and the presence of any associated injuries. Here are some of the common surgical interventions for zygomatic fractures:

1. Open Reduction and Internal Fixation (ORIF)

Procedure: Surgical exposure of the fracture sites, followed by realignment of the fractured bone segments to their anatomical position.
Fixation: Use of plates and screws to stabilize the bones in their correct position.
Indication: Used for displaced fractures or where there's significant facial asymmetry, impaired ocular function, or compromised facial structure.

2. Closed Reduction

Procedure: Manual manipulation of the bone without making an incision to realign the fractured segments.
Technique: May involve the use of tools like elevators or hooks inserted through the mouth or small punctures to reposition the bone.
Indication: Less severe or minimally displaced fractures where the bone can be manipulated back into place without the need for open surgery.

3. Zygomatic Arch Repair

Procedure: Specifically targets fractures of the zygomatic arch, which can often be accessed through the mouth or via a small incision near the hairline.
Technique: Reduction of the arch is crucial for restoring the width of the face and cheek prominence.
Indication: Isolated zygomatic arch fractures causing facial asymmetry or impingement on the temporalis muscle, leading to trismus.

4. Orbital Floor Reconstruction

Procedure: Repair of fractures to the orbital floor, often needed when there is entrapment of the inferior rectus muscle or orbital fat, leading to diplopia or restricted eye movement.
Materials: Use of autologous bone grafts, alloplastic materials, or titanium mesh to reconstruct the orbital floor.
Indication: Diplopia, enophthalmos, or hypoglobus resulting from orbital volume changes due to the fracture.

Postoperative Care

Monitoring: Patients typically undergo close monitoring for signs of infection, proper healing, and the resolution of any functional impairments.
Rehabilitation: Physical therapy may be recommended to restore jaw movement and other functional outcomes.

Considerations

The timing of the surgery can be crucial, with some advocating for early intervention to prevent long-term complications, while in other cases, delayed surgery may be advisable to allow swelling to reduce.