Transcript zygomatio-frontal Fracture

Management of Maxillofacial Trauma
Zygomatic complex fractures
1
Contents
Fracture of the zygomatic complex and arch
Orbital floor fractures
Traumatic injury to the frontal sinus
Naso-ethmoial orbital fracture (NEO)
Nasal fractures
2
Zygomatic bone complex
Anatomy
Star-shape like with four processes
Frontal process
Temporal process
Buttress
Orbital floor (Maxilla and GWSB)
Temporal fascia and muscle
Masseter muscle
3
Zygomatic complex and arch
fracture
The malar bone represent
a strong bone on fragile
supports, and it is for
this reason that, though
the body of the bone is
rarely broken, the four
processes- frontal,
orbital, maxillary and
zygomatic are frequent
sites of fracture.
HD Gillies, TP Kilner and D Stone,
1927
Zygomatic bone fractured as a
block near its principle three suture
lines and often displaces inwards to
a greater or lesser extent.
4
Occurrence
•As isolated fracture
•In combination with other middle third fracture
•With internal orbital fracture (blow out)
Observed in (>50%) of middle third
fracture (in developed countries due to assaults)
The zygomatic arch fracture can be
isolated in most of the cases
5
Signs and symptoms
Periorbital ecchymosis and edema
Flattening of the malar prominence
Flattening over the zygomatic arch
Pain and tenderness on palpation
Ecchymosis of the maxillary buccal sulcus
Deformity at the zygomatic buttress of the
maxilla
Deformity at the orbital margin
6
Trismus
Abnormal nerve sensibility
Epistaxis
Subconjunctival ecchymosis
Crepitation from air
emphysema
Displacement of palpebral
fissure (pseudoptosis)
Unequal pupillary levels
Diplopia
enophthalmos
7
Clinical examination
Inspection
Palpation
Visual examination
Eye movement
Diplopia
Pupil reaction
8
Radiographical evaluation
Nothing is more valuable to the surgeon in
determining the extent of injury and the
position of the fragments-both before and
after operation- than a good skiagram
(radiograph)
HD Gillies, TP Kilner and D Stone, 1927
9
Occipitomental view
(Posterioanterior oblique)
(water’s view)
10
submentovertex
Recommended for isolated
zygomatic arch fracture
11
CT scan
Coronal sections
Axial sections
12
Treatment
Timing:
As early as possible unless there are ophthalmic,
cranial or medical complications
Preiorbital edema and ecchymosis obscure the
fine details of the fracture, intervention can be
postponed but not more than a week
Indications:
•Diplopia
•Restriction of mandibular movement
•Restoration of normal contour
•Restoration of normal skeletal protection for the eye
13
Classifications
Displacement
Rotation along the axis of FZ processes
Anterio-posterior displacement
Rotation along the prominence of the bone
Medio-lateral displacement
Extension of the fracture along processes
points of fractures
Combination with other injuries
14
Treatment
The methods of treating a fractured malar bone
recommended by the various writers who have
reported cases include simple digital manipulation
under genre real anesthesia, external manipulation
by means of a cow-horn dental forceps grasping the
edges of the bone, traction and elevation by means
of wire or heavy bone elevators passed through
small local external incisions, and elevation via
incision in the mucosa of the ginigival sulcus at the
canine fossa. Our technique, which has now been
used successfully in a number of cases, differs from
those mentioned.
HD Gillies, TP Kilner and D Stone, 1927
15
Methods of reduction
Temporal approach (Gillies et al
1927)
Suitable for isolated
zygomatic fracture with
good stability afterwards
16
Methods of reduction
Percutaneous approach (malar hook,
Carroll-Girard bone screw)
Suitable for displaced zygomatic
fracture with high
Stability after reduction
17
Methods of reduction
Buccal sulcus
approach (Keen
1909)
Elevation from
eyebrow approach
(the same principle of Gillies
approach)
18
Open reduction and fixation
Transosseous wiring at
–Frontozygomatic suture
–Infraorbial rim
Surgery:
•Lateral eyebrow incision
•Infraorbital approach
19
Open reduction and fixation
Rigid fixation using plate and screws at
Frontozygomatic suture
Infraorbial rim
Inferior buttress of the zygoma
Surgery:
•Lateral eyebrow incision
•Infraorbial approach
•Subciliary (blepharoplasty) incision
•Mid-lower lid incision
•Transconjunctival approach
20
Points of fixation:
Lateral
orbital rim
Buttress of
zygoma
Infraorbital
rim and
buttress 21
Other methods of fixation
Kirschener wire
Pin fixation
Antral pack
22
Internal orbital fractures
In conjunction with other
facial fractures
As isolated type (Blow out
fracture)
23
Anatomy
The floor is made of:
Maxillary bone and
part of zygoma
bounded laterally by
the inferior orbital
fissure and small
part of the ethmoid
bone
24
Clinical and radiographical presentation
Subconjunctival ecchymosis
Crepitation from air emphysema
Displacement of palpebral fissure
Unequal pupillary levels
Diplopia
enophthalmos
25
Diplopia and
enophthalmous
Superior orbital
fissure syndrome
26
Treatment
Rational for intervention:
Small defect with no clinical consequence
may not warrant the surgical intervention.
Large defect with handicapping symptoms
should be operated.
27
Method of reconstruction
Intra-sinus approach
to the orbital floor
External approach to
the internal orbital
floor
28
Materials in orbital reconstruction
Autologous graft
Bone (cranial, rib, iliac)
Cartilage
Allogenic materials
Lyophilized dura
Alloplastic materials
Siliastic and proplast
implants
Teflon
hydroxyapatite
Titanium mish
29
Nasal-orbital ethmoid injuries
They represent a wide spectrum of injuries
Simple nasal fracture with involvement
Of orbital bones
Grossly comminuted and compound
naso-orbital ethmoid fracture involving the base
of skull with significant displacement
30
Diagnosis
Clinical examination:
Obliterating swelling
Canthus detachment
Lacrimal apparatus damage
Deformity of nasal bridge
CSF leak
Radiographical examination:
Occipitomental views
Lateral skull views
CT and 3D CT
31
Fracture classification
Nasal-orbital ethmoid fractures
Type I
Unilateral or bilateral, involves only one portion of the
medial orbital rim with the attached canthal tendon
Type II
Unilateral or bilateral, may be large segments of
comminuted type and the canthus remains attached
to the large central segment
Type III
Unilateral or bilateral, comminution involves the central
segment of the attached tendon results in avulsion
of medial canthus
32
Management of nasal-orbital
ethmoid fractures
Examination for
determination of the extent
of the injury (surgical
exploration)
Nasal bone
Orbital and ethmoidal
Frontal bone
Debridement and closure of
open wounds
Reduction and stabilization
of bone fracture
33
Principles of treatment
Good surgical exposure via:
Existing laceration
Coronal flap
Open sky approach
Reduction and stabilization using:
Transnasal wiring
Osteosynthesis
Prompt treatment as an aid to good
reduction
Immediate bone grafting if this is
indicated
34
Detached canthus
Traumatic telecanthus
Increase in inter-canthal distance
secondary to
canthus displacement or
detachment
Seen in association to:
Nasal bone
NEO
Le Forts fractures
35
Surgical management of detached
canthus
Transnasal wiring
technique (unilateral
type)
Canthopexy
– Identification of the
ligament
– Liberation of the
periorbital tissue
– Liberation of the lacrimal
pathway
– Nasal transfixation
– Contralateral fixation
36
Lacrimal duct system injury
The lacrimal sac can be torn by
fragments of a comminuted fracture
Or
Compressed by a mass of callus
which may block the nasolacrimal canal
EPIPHORA
Dacryocystitis
37
Reconstitution of the lacrimal passages
Done at the same time of canthopexy via
– The original scars
– Lateral nasal incision (Lynch)
– Bi-coronal incision
Dacryocystorhinostomy
If the sac remains intact, drainage of lacrimal fluid by probing
or removing of surrounded bone to allow drainage into the
nose
Conjunctivo-rhinostomy
implantation of a duct-like polythene tube or glass in case of
duct damage
38
Frontal sinus fracture
Frontal sinus
An air filled cavity lined by ciliated respiratory
epithelium encased in the frontal bone
Drains into nasal cavity via fronto-nasal duct
39
Extent of the injury:
Anterior table
Posterior table
Associated injuries:
mid-face or head
injuries e.g.
Le Fort II, III
NOE
Neuralgic insults
Ocular injuries
40
Diagnosis
Clinical examination
Radiographical
evaluation
Occipitomental views
Lateral skull view
CT scan
41
Classification of fractures
Anterior table fracture
– Linear
– Displaced
Posterior table fracture
– Linear
– Displaced
Outflow tract injury (naso-lacrimal duct)
42
Surgical management
Intranasal cannulation
Frontal sinus
trephination
Osteoplastic flap
Sinus ablation
(obliteration)
Cranialization
Reduction and fixation
43
Reduction and fixation
Surgical approaches:
– Site of penetrating injury
– Coronal approach
44
Sinus ablation
(obliteration)
– Bone
– Fat
– Muscle and
fascia
– Alloplastic
materials
45
Fixation
– Wires
– Plating
46
Nasal fractures
Anatomy
Midline central facial
structure that fulfills
both cosmetic and
functional purposes
Formed by union of
rigid and flexible struts
2 rectangle-shaped
nasal bone
ULCs, LLCs and
midline septal
cartilage
47
Classification of injuries
Low energy injuries
Simple injury caused by low velocity trauma (simple
noncomminuted)
High energy injuries
Severe injury with comminution of nasal facial Skelton due to
higher amount of energy
Patterns of injury
•Lateral injury (from the side)
•Sagittal injury (from the front)
•Inferior injury (from below)
48
Treatment
Low energy injuries
Reduction (close
manipulation, open
reduction) and stabilization
Nasal packing
External nasal splint
Adjunct septoplasty
Postoperative care
49
Complex injuries
Immediate measures:
Extra and intranasal examination
Identification of extra and intranasal
lacerations
Identification and control of site
bleeding
Surgical procedures:
Open septal procedures
Open nasal procedures
Open rhinoplasty
Open-sky “H” technique
50