Zygomatic complex fractures in the emergency department: diagnosis and management.

Falls, assaults, road traffic accidents and sporting injuries are some of the common causes of facial bone fractures. Fractures to the zygomatic complex, or cheekbone, are one of the most common fractures to the facial skeleton. These fractures can be easily missed on assessment and examination and thus left undiagnosed. This can lead to aesthetic deformities to the facial region and, rarely, orbital compartment syndrome due to a retrobulbar haemorrhage or other ocular complications. Emergency department advanced nurse practitioners are usually the clinicians responsible for ensuring that patients with zygomatic complex fractures are screened, investigated and escalated appropriately. The aim of this article is to inform readers of the strategies and methods for diagnosing and managing patients with zygomatic complex fractures, including when these types of injuries need to be referred to the oral and maxillofacial team.

Multi-Institutional Regional Otolaryngology Bootcamp.

INTRODUCTION: In order to increase junior resident physician proficiency and improve patient safety, simulation-based procedural training courses, or bootcamps, have been become an emerging educational tool. OBJECTIVES: To compare pre- and post-course confidence levels and to assess station efficacy after completion of our single day bootcamp. METHODS: We developed the University of California (UC) Davis otolaryngology bootcamp, a single day course including six cadaveric task trainer stations and four simulations. The six task trainer stations included (1) Epistaxis, (2) Cricothyrotomy/tracheostomy, (3) Peritonsillar abscess/auricular hematoma, (4) Nasal bone reduction/zygoma reduction/lateral canthotomy/canalicular trauma and probing, (5) Local nerve blocks, and (6) Soft tissue reconstruction. The simulations comprised of airway fire during tracheostomy, pediatric respiratory code during airway evaluation, dislodged pediatric tracheostomy tube in the ICU, and angioedema in the emergency department with inability to intubate or ventilate. Junior residents from multiple locoregional institutions were recruited to participate. Pre- and post-course Likert surveys assessing participant confidence and station efficacy were collected and analyzed. RESULTS: There was a statistically significant increase in resident confidence levels for all task trainer stations. All stations had a station efficacy Likert score average of 4 "very effective" or 5 "most effective." CONCLUSION: A multi-institutional, locoregional, simulation-based bootcamp can be a valuable adjunct to junior resident training. It can promote camaraderie, pool limited resources, and may be cost-effective.

Analysis of Factors Affecting Quality of Life in Patients Treated for Maxillofacial Fractures.

Maxillofacial fractures (MFF) belong to the major modern medicine and public health concerns. The recovery from MFF is associated with a number of social problems. The patient's mood may be affected by the change in self-image and lack of satisfaction with life, in many cases leading to a deepening of mental health disorders, resulting in alcoholism, loss of job or conflicts in the area of family life. The aim of this study was to evaluate the quality of life of patients with MFF, with respect to demographic and medical variables. The mean age of the 227 patients was 36 years. The mandible was the most frequent MFF location (52.9%), followed by the zygomatic bone (30.8%) then the maxilla (16.3%). Bone fracture displacement occurred in 79.3% of patients. A comminuted fracture was found in 71% of patients. The quality of life of patients with MFF was significantly better in all analyzed domains 3 months after the end of hospitalization compared to the initial survey carried out shortly after implementation of the treatment. Among the demographic variables, older age had a statistically significant but weak positive association with the improvement of the quality of life of respondents in General health perception domain.

[Application of 3D printing in the treatment of unilateral comminuted zygomatic bone fracture].

To explore the validity of 3D printing technique in the treatment of unilateral comminuted zygomatic bone fracture. METHODS: Twenty-one patients with unilateral comminuted zygomatic bone fracture were included in the present study, which were treated from hospital January 2014 to April 2017. All patients underwent CT scan and the data were imported in Mimics 10.01 software. The zygomatic bone of healthy side was mirrored to the fracture side to rebuild a "perfect" reduction model. Bone fixation plates were pre-modeled on the model printed by a 3D printing machine and used for bone reduction and fixation during operation. Three dimensional measurements were performed to evaluate the validity of 3D printing based on pre- and post-operative three dimensional CT model. SPSS25.0 software package was used to perform paired t test on the measured data. RESULTS: No significant difference were observed between postoperative CT model and preoperative "perfect" reduction model. All patients were satisfied with their facial appearance. CONCLUSIONS: 3D printing technique is helpful to improve the accuracy of reduction of unilateral comminuted zygomatic bone fracture via preoperative pre-modeling.

Retroseptal transconjunctival approach for fractures of the zygomaticomaxillary complex: a retrospective study.

We designed a retrospective study to evaluate the efficacy of retroseptal transconjunctival approaches in the management of fractures of the zygomaticomaxillary complex (ZMC). The patients were from a single institution, and had had three-point fixation of fractures of the ZMC between 2008 and 2016. A total of 77 patients (56 men and 21 women with a mean (range) age of 28 (18-54) years), were divided into two groups. Group I (n=51) had had reduction and fixation of the infraorbital rim using a retroseptal transconjunctival approach. In group II (n=26) the same approach had been used with lateral canthotomy and inferior canthlolysis for both the infraorbital rim and the zygomaticofrontal region. We analysed the association of both approaches with the outcomes of reduction, fixation, and complications. Suboptimal results were found in 13 patients in group I and one in group II (p=0.017). There were also three patients with trichiasis and two with entropion in group I, and one each of both complications in group II. There was only one patient with a malopposed lateral canthus in group II. All 26 patients in group II had no perceptible scar along the extended line of incision. The risk of a suboptimal outcome was reduced by 20% (relative risk=0.8) in group II. The retroseptal transconjunctival approach with lateral canthotomy and inferior cantholysis is safe, aesthetic, and effective in the management of fractures of the ZMC.

Secuelas en pacientes con fracturas cigomáticas tratados con osteosíntesis semirrígida / Sequelae in patients with zygomatic fractures treated with semirigid osteosynthesis

Se realizó un estudio descriptivo, transversal y aleatorizado de 102 pacientes con fracturas del complejo cigomático, tratados con osteosíntesis semirrígida en el Servicio de Cirugía Maxilofacial del Hospital Provincial Docente Clinicoquirúrgico Saturnino Lora Torres de Santiago de Cuba, desde enero de 2005 hasta diciembre de 2011, con vistas a caracterizarles según variables demográficas y terapéuticas en las fases preoperatoria, intraoperatoria y posoperatoria. En la casuística predominaron los accidentes del tránsito como mecanismos causales de las lesiones (55,8 por ciento), la depresión de la eminencia cigomática y la presencia de escalones óseos palpables en el marco orbitario inferior y/o lateral como síntomas principales (92,1 por ciento, respectivamente), y la exposición escleral como complicación posoperatoria (55,2 por ciento), entre otros; asimismo, el valor del tiempo preoperatorio incrementó el riesgo de secuelas y la vía de acceso subciliar se asoció con un mayor riesgo de exposición escleral para el acceso al marco inferior y/o suelo orbitario. Por otra parte, tanto el enoftalmos como el hipoftalmos son de difícil solución y tienen una tendencia significativa de convertirse en secuelas posoperatorias

A descriptive, cross-sectional and randomized study of 102 patients with fractures of the zygomatic complex, treated with semirigid osteosynthesis in the Maxillofacial Surgery Service of Saturnino Lora Torres Teaching Clinical Surgical Provincial Hospital was carried out in Santiago de Cuba, from January, 2005 to December, 2011, aimed at characterizing them according to demographic and therapeutic variables in the presurgical, intrasurgical and postsurgical phases. In the case material there was a prevalence of traffic accidents as causal mechanisms of the lesions (55.8 percent), depression of the zygomatic eminence and presence of palpable bony steps in the lower and/or lateral orbitary edge as main symptoms (92.1 percent, respectively), and the scleral exhibition as postsurgical complication (55.2 percent), among others; also, the value of the presurgical time increased the risk of sequelae and the subciliary approach was associated with a higher risk of scleral exhibition for approaching to the lower edge and/or orbitary floor. On the other hand, either enophthalmos or hypophthalmos are of difficult solution and have a significant tendency of becoming postsurgical sequelae

Maxillofacial and Mandibular Fractures in Sports.

Sports account for 3% to 29% of facial injuries and 10% to 42% of facial fractures. Fractures of the facial skeleton most commonly occur owing to interpersonal violence or motor vehicle crashes. Facial fractures from sporting activities has clearly decreased over time owing to better preventive measures. However, this decreasing trend is offset by the emergence of more dangerous sports activities, or "pushing the envelope" of traditional sports activities. Fractures can occur from contact between athletes, and between athletes and their surroundings. Football, soccer, hockey, and baseball most frequently are involved in sports-related cases of facial bone fracture.

Equine orbital fractures: a review of 18 cases (2006-2013).

OBJECTIVE: To review the clinical features, treatments, complications, and outcomes of horses with traumatic orbital fractures. STUDY DESIGN: Retrospective study. SAMPLE POPULATION: Eighteen horses with confirmed orbital fractures. PROCEDURES: Medical records of horses presenting with orbital fractures between 2006 and 2013 were reviewed. Signalment, etiology of fracture, clinical signs, fracture descriptions, diagnostic imaging, treatments, complications, and outcomes were evaluated. RESULTS: Eighteen horses presented with orbital fractures resulting from rearing in a confined space (n = 5), being kicked (4), colliding with a stationary object (3), and unknown trauma (6). Radiography and computed tomography were effective at classifying fractures and evaluating sinus/nasal involvement. Epistaxis/sinusitis were associated with fractures of the zygomatic process of the temporal bone (n = 3) and comminuted fractures of multiple bones (5). Seventeen fractures required treatment, with fifteen receiving a combination of medical and surgical therapy. Surgery included reduction of large bony fragments (n = 8), removal of small fragments (12), stabilization with a wire implant (1), and sinus trephination and lavage (5). Factors contributing to a favorable outcome included: globe retention (n = 16), vision (14), comfort (15), cosmesis (9), and return to previous function (13). CONCLUSIONS: Horses sustaining orbital fractures treated promptly with medical and surgical therapy have a favorable prognosis for return to function and cosmesis. Fractures affecting the zygomatic process of the frontal bone are unlikely to involve the sinus/nasal cavities. Epistaxis and sinusitis warrant more aggressive therapy and decrease functional and cosmetic outcome.

The clinical and radiographical characteristics of zygomatic complex fractures: a comparison between the surgically and non-surgically treated patients.

BACKGROUND: In this retrospective study we evaluated the epidemiological data and the clinical and radiographical differences between surgically and non-surgically treated patients with zygomatic complex fractures at their initial assessment in our clinic over a period of 5 years. More knowledge of the clinical similarities and/or differences between the non-surgical and the surgical group will provide us a more complete view and may help physicians to develop any future methods in clinical decision making or even methods in distinguishing patients benefiting from a surgical treatment. METHODS: Surgically and non-surgically treated patients were included in the study, if clinical and radiographical confirmation of zygomatic complex fractures were present at initial assessment. The patient groups were divided into surgically treated zygomatic complex fractures, and non-surgically treated fractures, with and without displacement. The groups were compared according to age, gender, degree of fracture displacement and clinical signs. RESULTS: In total 283 patients were diagnosed with zygomatic complex fractures, with a mean age of 43 years (±20 years) and a domination of male patients. The mean age was higher in the non-surgically treated group and contained more female patients. Overall type C fractures and the majority of the type B fractures were treated surgically. Only 2.1% of the type A fractures were treated surgically. Overall facial swelling and paraesthesia of the infraorbital nerve were found as most common clinical findings. Additionally, malar depression and extraoral steps were frequently found in the surgically treated group, as in the non-surgically treated group only facial swelling was found frequently, whether there was fracture displacement or not. The clinical characteristics 'extraoral steps', 'intraoral steps', and 'malar depression' were found to be significantly related to surgical treatment. CONCLUSION: Extraoral steps, intraoral steps, and malar depression were significantly related to surgical treatment. The group of non-surgically treated zygomatic complex fractures is a valuable group to investigate as this group also consists of patients with displaced fractures (i.e. surgical indication) and thus, could provide us more insight in future clinical decision methods. Therefore, we highly recommend more research of the non-surgically treated group.

Prosthetic rehabilitation of a patient with unilateral dislocated condyle fracture after treatment with a mandibular repositioning splint: a clinical report.

This clinical report describes the use of a mandibular repositioning splint and the subsequent prosthodontic treatment of a unilateral dislocated condyle fracture for a patient whose injury resulted in significant mandibular deviation and malocclusion. The use of a mandibular repositioning splint considerably reduced the mandibular deviation, and a stable mandibular position was maintained with the definitive prosthesis.

Management of facial fractures.

This article presents up-to-date information for the emergency medicine community on several patterns of facial fractures and their associated injuries. The article contains information about the anatomic structure and pathologic injuries that occur in the setting of facial trauma and guides the emergency medicine community in the thorough physical and diagnostic evaluation, emergent treatment, and proper surgical or outpatient treatment.

The prosthetic rehabilitation of a panfacial fracture patient after reduction: a clinical report.

Panfacial fractures involve trauma to the lower, middle, and upper facial bones and often require a team approach for management. Early and complete restoration of preinjury facial contours and function should be the goal of the oral and maxillofacial surgeon and the prosthodontist. When the intraoral landmarks are lost, overall facial anatomic landmarks can be used to restore the oral cavity. A patient with complex clinical panfacial fractures, including a vertically and horizontally malpositioned native alveolar bone and severe facial asymmetry, is presented. A functional and esthetic rehabilitation was successfully accomplished by using a partial removable dental prosthesis retained with telescopic crowns and magnetic attachments in the maxilla and osseointegrated implants to support a definitive dental prosthesis in the mandible.

Incidence and management of zygomatic fractures at a level I trauma center.

PURPOSE: The purpose of this study is to evaluate current treatment of zygomatic fractures presenting at a level I trauma center. METHODS: Radiology records over a 1-year period were retrospectively reviewed to determine all patients diagnosed with fractures through the zygoma. A total of 1049 computed tomography maxillofacial scans were reviewed which identified 243 patients with fractures through the zygoma. Of these, 200 patients were identified as clinically relevant zygomatic fractures defined as having 3 or more major buttress fractures. RESULTS: Among the 200 patients identified with zygomatic fractures, 132 patients were treated nonoperatively and 68 patients required operative management. In the operative group 31% were treated with a limited (one-buttress) approach. CONCLUSIONS: Review of our management of zygomatic fractures at a level I trauma center found a high incidence of zygomatic fractures (66%) that can be managed nonoperatively without significant complications. There is a select group of zygomatic fractures that can be successfully managed by the experienced surgeon with a limited one-buttress approach.

Fracture of the coronoid process, sphenoid bone, zygoma, and zygomatic arch after a firearm injury.

A rare case of fracture of the coronoid process, sphenoid bone, zygoma, and zygomatic arch caused by a firearm is described. A 25-year-old man was hit in the face with a bullet, resulting in restricted mouth opening, difficulty chewing, and pain when opening the mouth. The clinical examination revealed a perforating wound in the right parotid region. A computed tomographic scan revealed a comminuted fracture of the left coronoid process with the bullet stopping in the intact left coronoid process. Treatment was bilateral coronoidectomy associated with speech therapy and was successful. Details of the clinical signs, computed tomography, treatment, and follow-up are presented.

Isolated bilateral zygomatic arch fractures of the facial skeleton are associated with skull base fractures.

BACKGROUND: To date, only limited case reports involving isolated bilateral zygomatic arch fractures exist. This fracture pattern is defined by the presence of bilateral zygomatic arch fractures and the absence of any other facial fractures. The purpose of this study was to systematically review a large trauma database to determine whether this fracture pattern exists and, if so, to elucidate the mechanism of injury and associated concomitant injuries. METHODS: A retrospective review of all patients admitted to the R Adams Cowley Shock Trauma center from February of 1998 to December of 2009 was conducted. International Classification of Diseases, Ninth Revision coding of computed tomographic scans was used to identify patients with zygoma fractures. The facial computed tomographic scans of all patients coded with bilateral zygoma fractures were reviewed to determine whether any had isolated bilateral zygomatic arch fractures. Medical charts were reviewed extensively. RESULTS: Five patients (0.24 percent of all zygoma fractures, 3.18 percent of bilateral zygoma fractures) were found to have isolated bilateral zygomatic arch fractures. All five patients had evidence of skull impact with at least one skull fracture and one skull base fracture. Glasgow Coma Scale scores (range, 6 to 14; average, 8.2) were significantly lower (t test, two-sided, p=0.01) compared with all patients (average, 12.2) with facial trauma during the study period. CONCLUSIONS: Isolated bilateral zygomatic arch fractures do exist. The authors' findings suggest skull impacts as the inciting mechanism of injury and an intimate link with skull base force transmission. The severe nature of this injury warrants a search for concomitant injuries to the head, brain, and spinal cord.

Outcomes in pediatric facial fractures: early follow-up in 177 children and classification scheme.

A comprehensive study of adverse outcomes after pediatric facial fractures has not been published. This study aimed to determine the incidence and classify adverse outcomes after facial fractures in children while reporting our early results. A retrospective chart review was performed on facial fracture patients identified in the Craniofacial Trauma Database of the Children's Hospital of Pittsburgh and seen in follow-up from 2003 to 2007. An Adverse Outcome Classification Scheme was developed: type 1, outcomes resulting from the fracture; type 2, outcomes resulting from fracture treatment; and type 3, outcomes resulting from the interaction between the fracture, its treatment, and subsequent growth and development. Fisher exact or χ analyses were completed. A total of 177 pediatric facial fracture patients were identified with 13.3 months of average follow-up. Mean age was 9.8 years (range, 0.4-18.7 y). Of these patients, 41.8% underwent surgery and 57 patients (32.2%) had adverse outcomes (type 1, 14.1%; type 2, 11.3%; and type 3, 15.8%); 26.3% of these had multiple adverse outcomes. Isolated fractures resulted in fewer adverse outcomes and fewer multiple adverse outcomes compared with combined fractures (26.6% versus 45.3%, P = 0.015; 4% versus 18.9%, P = 0.002). Patients treated operatively exhibited more types 1, 2, and 3 and multiple adverse outcomes compared to those treated conservatively (P < 0.01). In our pediatric cohort, 32.2% of patients had an adverse outcome. With longer follow-up and growth and development studies, we will likely see an increase in the incidence of type 3 adverse outcomes. We recommend, whenever possible, conservative treatment of pediatric facial fractures.

Variables related to surgical and nonsurgical treatment of zygomatic complex fracture.

The aim of this retrospective research was to establish the association between variables for the surgical treatment of zygomatic complex (ZC) fractures. In a 10-year period, 532 patients were examined for ZC fractures. The medical records of patients were analyzed to obtain information related to sociodemographic characteristics, trauma etiology, sign and symptoms of patients, and surgical or nonsurgical treatment. Statistical analysis was performed using χ test with statistical significance of P < 0.05. Most fractures were sustained by subjects between 21 and 40 years of age (55.8%), being principally men (80.1%), and 153 patients underwent surgery (28.8%). Surgical treatment of ZC fractures was statistically associated to the presence of other facial fractures (P = 0.004), alteration of occlusion (P = 0.0001; probably due to jaw fractures), presence of the comminuted fractures (P = 0.0002), and infraorbital nerve sensory disturbances (P = 0.003). A mixture of complex variables can be associated to surgical treatment; however, variables as comminuted fracture and alteration of occlusion were associated to surgical treatment indications.

Pattern of maxillofacial fractures at a tertiary hospital in northern India: a 4-year retrospective study of 718 patients.

PURPOSE: Pattern and aetiology of maxillofacial injuries varies from one country to another and even within the same country depending on prevailing socio-economic, cultural and environmental factors. Various studies have been carried out in various countries to study the epidemiology and demographics of the maxillofacial injuries but the studies from India are few. MATERIAL AND METHODS: Retrospective study was undertaken at Christian Medical College Ludhiana (India) from January 2006 to December 2009. Treatment records of the patients was checked and age, gender, aetiology of injury, associated injuries, maxillofacial fractures and treatment offered were recorded. RESULTS: A total of 1075 fractures were recorded in 718 patients, ranging from 11 months to 85 years of age. Male:female ratio was 6.6:1. Maxillofacial injuries were most common in third decade of life. A total of 517 patients suffered injuries because of road traffic accident, 115 because of accidental fall and 67 because of interpersonal violence. A total of 184 patients had 221 associated injuries of which 56.1% head injuries, 29.0% orthopaedic injuries and 14.9% other injuries were present. Of 596 middle third fractures, 29.8% were managed conservatively; for 21.7% and 48.7% of fractures, closed reduction and open reduction were performed respectively. Of 479 mandibular fractures, 1.8% was managed conservatively; for 16.7% and 81.5% fractures, closed reduction and open reduction were performed respectively. CONCLUSION: Better socio-economic status of people, increased vehicular movements and non-implementation of road safety norms have increased road traffic accidents. Proper education of the people who are most commonly involved in the RTA can be one of the possible ways to reduce the maxillofacial injuries.