The zygomaticomaxillary fracture or zygomaticomaxillary complex fracture is the name for a group of fractures that occur on the face and can substantially change the structure and the function of the midface, including the globe. These fractures are also called tripod fractures. The surgical treatment of zygomaticomaxillary fractures is quite risky because of the possibility of complications.
The Zygomatic arch and complex play a crucial role in the structure and the functioning of the face. Studies show that the fractures of the zygoma are one of the most common types of fractures to happen. Cases of domestic violence and automobile accidents contribute to such high and unfortunate numbers. While the former two causes are more relevant to adults, in children the main causes of primary trauma are injuries related to sports, car accidents and falls. Fortunately, with the installation of airbags and seatbelts the no. of facial trauma has decreased. But still, the obitozygomatic fractures constitute a large no. of cases faced by plastic surgeons.
Anatomy of the zygomaticomaxillary complex (ZMC)
The ZMC provides reinforcement to the face and is the foundation of the aesthetic appearance of a person. It sets the midfacial width and also provides prominence to the cheeks. It can be best compared to a tetrapod as it holds the facial structure at four points namely; frontal bone, maxilla, temporal bone and the greater wing of sphenoid. This tetrapod structure leads to complicated fractures as any trauma which occurs on the face does not cause a single fracture only, but causes multiple ones.
The most important point while diagnosing a ZMC fracture is to ensure a thorough ophthalmologic exam as well, as ZMC fractures are often complicated by serious injuries of the eyes. ZMC fractures are a bigger cause of ocular injuries and almost 10% of injuries of eyes are caused by ZMC fractures. A full ophthalmologic exam is not possible by a plastic surgeon in this case, but a full set of tests should be performed by any doctor who is handling such patients.
First of all the gross vision of the patient is tested. A visual acuity exam is not very effective in such a case because a patient may have ointment or tears in the eyes, or he may not be wearing glasses or contact lenses. Therefore the results are not conclusive. A test for red color desaturation is also very important because when the optic nerve is compromised, red color perception is the first to be lost. The movement of the eye should also be tested. If the extra ocular movement is restricted in the upward gaze, it may be an indication of muscle entrapment. To clear the doubt, a CT scan or a forced duction test can be performed under local anesthesia. If during a standard visual field exam, there is a large discrepancy between the vision range of the surgeon and the patient, it is an indication of the compromise of the optic nerve. In some cases surgeon initiate a steroid to minimize swelling as well as arrest any more damage to the optic nerve.
In majority of patients, the correct diagnosis is often interrupted by swelling. A CT scan done in three dimensions is the most accurate diagnostic tool used by the surgeons. It can provide crucial information regarding the extent of the injury.
The type and number of surgical approaches and the sites of the fixation during the surgery will completely depend upon the extent of the surgery and the experience of the surgeon. To ensure adequate and proper healing and to prevent any pot operative complications accurate fixation of the displaced ZMC fractures is absolutely crucial.
Treatment of ZMC fractures in children
This area of treatment requires special attention, as the treatment is complicated by the capacity of child’s skull for growth and remodeling.
Complications and risk factors
Te occurrence of postoperative infections is uncommon after the isolated Zygomatic fractures. The risk after the surgery depends upon various factors like:-
- Extent of the injury
- Duration of surgery
- Experience of the surgeon
- Degree of contamination
- Prosthetic insertion
A research has suggested that even after keeping the aforementioned factors in mind the rate of infection is still very low in the case of isolated fractures. In many such cases, even the antibiotics are not prescribed. Other complications are also very rare, except those that include the lower eyelid.
The right treatment plan for Zygomaticomaxillary fractures begins with the right diagnosis which is succeeded by fabrication of a treatment plan. The treatment plan is aimed at the restoration of facial balance and the proper reduction of the fractured segments. The treatment is highly effective and should be done under experts so that not only the treatment plan is executed finely but also the complications (in case any) can be managed effectively.