CC
An 80-year-old male presents by himself to the emergency department (ED) after a mechanical fall at home the evening earlier with discomfort in the left midface.
HPI
The patient was walking up a carpeted staircase at home and missed a step while ascending. He denies any loss of consciousness, amnesia, nausea, vomiting, or neck tenderness.
PMHX/PDHX/medications/allergies/SH/FH
The patient has hypertension for which he takes indapamide. He does not take any anticoagulants. He has no known drug allergies. He is a lifelong nonsmoker with minimal alcohol intake. He maintains an active lifestyle.
Clinical examination
General assessment. The patient was approached with consideration to primary survey Advanced Trauma Life Support (ATLS) principles. Bedside assessment revealed a healthy-appearing older adult male resting comfortably in an ambulatory assessment area of the ED. The patient is awake, alert, and oriented and in no apparent distress. Introductory conversation with request to examine confirms a Glasgow Coma Scale score of 15 with orientation to person, place, and time. He is hemodynamically stable.
Cervical spine. No midline tenderness; no limitation in cervical rotation, flexion, or extension (Canadian C-spine rule, National Emergency X-Radiography Utilization Study [NEXUS] criteria).
HEENT. No scalp lacerations, contusions, or steps. No Battle’s sign or mastoid tenderness (associated with basilar skull fracture). No otorrhea or rhinorrhea (associated with cerebrospinal fluid leak or dural tear). Extraocular movements are intact. Pupils are equally round and reactive to light with intact accommodation and consensual response. Visual acuity is intact (Snellen chart), and peripheral fields are intact. There is no monocular or binocular diplopia at neutral or extremes of gauze (Goldman chart). There is no enophthalmos, proptosis, or hypoglobus (Hertel or Naugle exophthalmometer). There is mildly increased scleral show on the left (mechanical ectropion) with swelling of the left periorbital region noted. Intraocular pressures are 13 mm Hg in both eyes (tonometer). There are no corneal lacerations, subconjunctival hemorrhage, hyphema, or lens dislocation. Fundoscopy reveals no evidence of traumatic optic neuritis, retinal artery hemorrhage, vitreous hemorrhage, or retinal detachment. There is no dorsal nasal deflection, edema, or crepitation. There is no septal deviation or hematoma and no evidence of anterior (Kiesselbach’s plexus) or posterior (Woodruff’s plexus) nasal hemorrhage. The oropharynx is symmetrical and trachea is midline.
Maxillofacial. There is mild left malar edema and loss of left malar projection (flattening). There is no facial laceration. There is tenderness over the left malar process with subcutaneous crepitation (emphysema). A step defect is palpable along the left inferior orbital rim and along the left zygomatic arch. There is mild left maxillary vestibular ecchymosis (Guerin’s sign). The occlusion is stable and reproducible with no occlusal plane steps, gingival lacerations, or floor-of-mouth elevation. There are no luxated or fractured teeth. Moderate trismus is present with a soft end-feel ( Fig. 51.1 ).
Targeted neurologic examination. Cranial nerves II to XII are intact, but there is hypoesthesia of the left infraorbital (terminal branch of maxillary division of trigeminal nerve entering the orbit via the inferior orbital fissure before entering infraorbital groove and exiting infraorbital foramen 5–7 mm below inferior orbital rim) and zygomatic distribution (another terminal branch of maxillary nerve entering orbital cavity via inferior orbital fissure, traversing laterally along the lateral orbital wall and giving off a communicating branch of postganglionic parasympathetic fibers from the pterygopalatine ganglion to the lacrimal branch of the ophthalmic nerve before exiting the zygomatic bone via the zygomaticofacial and zygomaticotemporal [ZT] foramina as respective terminal nerves).
Labs
Routine laboratory investigations are generally not specific to the workup of isolated facial trauma, though they may be pursued in the workup of a presenting trauma patient if there are concerns for significant blood loss, toxicology, metabolic derangements, acute coronary syndromes, or assessment of renal function before intravenous contrast administration. A complete blood count and electrolytes were ordered and were within normal limits. Point-of-care glucose was normal. An electrocardiogram was ordered given the history of a fall (important if not overtly mechanical in nature to evaluate for potential causative arrythmia), which also revealed normal sinus rhythm.
Imaging
Noncontrast multidetector computed tomography (CT) with bone and soft tissue windowing showed mild cerebral atrophy and patchy low attenuation in the subcortical region consistent with small vessel disease with unremarkable brain parenchyma, ventricular system, and basal cisterns. There is no evidence of intracranial hemorrhage, and no skull fractures were identified. There is emphysema in the left malar and preseptal soft tissue, as well as retroseptal extraconal fat. No retrobulbar hematoma was identified. There are fractures of the left lateral orbital wall and rim, orbital floor, and inferior orbital rim with comminution of the anterior and posterolateral walls of the maxilla. There is no orbital wall blowout fracture, adnexal herniation, or muscular entrapment. The pterygoid plates are intact. The remainder of the image is unremarkable ( Fig. 51.2 ).
Assessment
An 80-year-old male presenting with an isolated left zygomaticomaxillary complex (ZMC), also known as orbitozygomaticomaxillary complex (OZMC) fracture secondary to a low-energy blunt mechanism (Facial Injury Severity Score of 1).
Treatment
Beyond application of ATLS principles in the approach to the injured patient, ophthalmologic emergencies must be ruled out as the first step in the setting of ZMC trauma. The ZMC demarcates the lateral aspect and part of the inferior rim and wall of the osseous orbital cavity, rendering characteristic fracture patterns of the ZMC on the spectrum of orbital trauma. Therefore, orbital compartment syndrome, entrapment of the ocular musculature, and persisting oculocardiac reflex are examples of ocular emergencies warranting urgent intervention that can significantly influence ophthalmologic outcomes. Direct globe, lens, retinal, and optic nerve injuries must be screened for, worked up when suspected, managed, and documented accurately in the posttraumatic, pretreatment setting with ophthalmologic consultation. These baseline data aid in delineation between mechanism-related morbidity and treatment-related morbidity, offers patients the greatest chance for improved ophthalmologic outcomes, and facilitates objective findings to track over time. After these critical findings have been ruled out, OZMC management must consider the functional and esthetic deficits caused by the trauma weighed against the associated risks of surgical intervention. Functional deficits may be in the form of limited temporomandibular joint range of motion caused by coronoid or temporalis muscular impingement; altered eyelid position; altered globe position; altered extraocular muscular range of motion caused by impingement; altered sensorium in the infraorbital, zygomaticofacial, or zygomaticomaxillary (ZM) nerve distribution; or altered lateral canthal ligament positioning. Esthetic considerations are principally caused by changes in facial width, malar projection, contour, eyelid position, and globe position. The patient’s perception of such functional or esthetic deficits also warrants serious consideration in the decision to treat OZMC fractures operatively or nonoperatively.
This patient had no functional limitations but was concerned with the loss of left malar projection after a 2-week observation period to allow resolution of edema and thus opted for operative intervention. He was brought to the operating room for open reduction and internal fixation (ORIF). The left zygoma was approached through a left maxillary vestibular incision. A Seldin retractor was used to perform reduction of the left zygoma. The inferior orbital rim and zygomaticofacial suture were palpated, and malar projection could be visualized from the bird’s eye view quite well clinically because of the delayed timing of operative intervention and resultant minimal perioperative edema. Insufficient postreduction stability of the ZMC was confirmed by easy displacement of the zygoma at the ZM buttress with digital pressure on the zygomatic body; thus, one-point fixation was introduced across the ZM buttress ( Fig. 51.3 ). After internal fixation with a curvilinear titanium miniplate was applied, stability of the anatomically reduced zygoma was verified with digital pressure testing; therefore, no further surgical exposures were deemed necessary. A forced duction test was then performed, which revealed normal ocular motility. The intraoral wound was closed with resorbable sutures, and the procedure was concluded in approximately 30 minutes of operating time.
Discussion
Orbitozygomaticomaxillary complex fractures are among the most common midfacial fractures, most commonly occurring in males between ages 20 and 30 years of age as a result of interpersonal violence (46.6%), falls (22.4%), and motor vehicle accidents (13.3%), though there are regional differences in these distributions. Isolated left-sided fractures are more common than right among patients presenting secondary to assault, which is hypothesized to be because of the higher prevalence of right-handed individuals. The left-sided distribution is not uniform among all OZMC mechanisms. There is no universally agreed on classification system for OZMC fractures, but countless classification systems proposed including but not limited to those proposed by Zingg et al.; Knight and North; Manson, and AOCMF (Arbeitsgemeinschaft für Osteosynthesefragen—Craniomaxillofacial Surgery). The clinical applicability of any given classification system is of less importance than the ability to understand and communicate the extent of involvement of the articulations of the zygoma, degree of displacement, degree of comminution of the associated sutures, status of the internal orbital walls, and status of the zygomatic arch.
Although more displaced fractures ( Figs. 51.4 and 51.5 ) clearly benefit from operative repair, the decision to operate on a mild to moderately displaced fracture (see Figs. 51.1 and 51.2 ) is more challenging. In the shared decision-making process between the patient and practitioner, a decision to treat nonoperatively must be accompanied by the mutual understanding that surgical options for the correction of posttraumatic deformities of the ZMC are markedly different than ORIF in the acute setting and are associated with increased complexity and decreased likelihood of restoration of the ideal pretraumatic facial form and globe positioning. If nonoperative management is elected, several weeks of sinus precautions are advocated, along with a soft diet to minimize further malar displacement from masseteric muscular contraction and the recommendation to avoid further pressure on the affected side such as sleeping in the supine position or with head elevated with analgesics as deemed appropriate. There is no evidence to support routine use of prophylactic antibiotics in the context of nonoperative midface fracture management. Close follow-up for the first several weeks is advocated to allow resolution of soft tissue edema, which may unmask more significant posttraumatic facial asymmetry and motivate the patient to seek surgical correction in the subacute timeframe. Operative intervention for the purpose of decompression of the infraorbital nerve is not supported, though earlier intervention may have a positive impact on neurosensory recovery.
