15018752330
发表时间:2015-12-07 浏览次数:473次
Introduction
The zygoma is a prominent bone in the facial skeleton and contributes to
structural and functional stability of the craniofacial complex. Due to
its location, the zygoma and its associated processes are easily
fractured in a trauma. [1]
As the zygoma is usually associated with adjacent bones, fractures to
this region are termed as zygomatico-maxillary complex (ZMC) fractures.
Fractures of the ZMC may occur alone known as isolated ZMC (iZMC)
fracture or in association with fractures of other bones of the
craniofacial complex. [2]
Since the first description of surgical management of a ZMC fracture,
many authors have proposed a variety of surgical approaches for
reduction of the bone. In addition, after the evolution of bone plating
systems, a large number of recommendations have been made for
stabilization or fixation of these fracture segments. [2] This study presents a retrospective review of iZMC fractures, managed with an individualized approach.
Methods
A retrospective analysis of available records over a 3-year period (from
January 2011 to January 2014) was conducted to assess the treatment
outcomes of iZMC fractures at a multi-specialty hospital in Punjab,
India. Data relevant to the demographic profile of the patients such as
age and gender, cause of injury, other associated injuries
(noncranio-facial), and surgical treatment provided was collected. Only
those patients with iZMC fractures without any other facial bone injury
were included in this study. Patients who presented with displaced iZMC
fractures causing aesthetic or functional problems that needed surgical
intervention underwent standard preoperative investigations. All
patients were given peri-operative antimicrobial prophylaxis, adjunct
analgesics and supportive medication with restricted soft diet for 2
weeks post-treatment. Patients not requiring surgical intervention were
also given antimicrobial prophylaxis, analgesics and were restricted to a
soft diet for a 3-week period. Follow-up period for all patients ranged
from 1 month to 3 months. Based on the clinical presentation and
treatment modality, the fractures were classified into non-displaced or
minimally displaced (low-energy), displaced fractures requiring
reduction and fixation (middle-energy), and comminuted fractures
involving the buttresses requiring orbital reconstruction (high-energy). [3]
Treatment outcomes were considered successful if there was no obvious
facial deformity or asymmetry, no functional limitation and minimal
surgical morbidity, such as scar at the site of the incision where made
extra-orally. Any alteration in these outcome variables was recorded as
either suboptimal treatment outcome or a complication of the procedure.
Results
A total of 25 patients with iZMC fractures were included in the study. The age ranged from 17 years to 56 years, and the sample consisted of 8 females and 17 males. The reporting time after injury varied from 0 day to 6 days and the time to surgical intervention after injury ranged from 1 day to 7 days. Four patients did not require any surgical intervention. Among the patients that required surgical intervention, the following protocols were observed: (1) Reduction of the iZMC fracture segment was performed via buccal sulcus incision (n = 21), (2) reduction of iZMC fracture without bone plate fixation (n = 5), (3) one-point fixation with a bone plate at the zygomatico-maxillary (ZM) buttress (n = 4), (4) two-point fixation with bone plates at the ZM buttress and fronto-zygomatic (FZ) buttress (n = 6), (5) two-point fixation at ZM buttress and infra-orbital margin (IOM) (n = 2) and (6) three-point fixation at ZM buttress, FZ buttress and IOM (n = 4) [Table 1]. The most common cause of injury was road traffic accidents (n = 13). Overall, 17 surgeries were performed under general anesthesia and the remaining under local anesthesia (n = 4). Ten patients were classified as middle-energy group while the remaining were classified into the high-energy (n = 6) and low-energy (n = 6) groups. Surgical access to the FZ buttress and the infra-orbital rim was obtained by standardized lateral eyebrow incision and infra-orbital incision.
The treatment outcome was considered satisfactory in 19 patients that underwent surgical intervention and all patients that did not require surgery. Two patients had complications that required removal of the bone plate from the ZM buttress region. Wound dehiscence was observed on post-operative week 2 in one patient and on post-operative week 3 in another patient. These patients were treated with oral irrigation for local wound care for a total of 5 weeks post-operatively before removal of bone plates, after consolidation of bone healing. Furthermore, 2 other patients developed chronic sinusitis, which was managed by conventional antibiotic protocol, and 3 patients complained of persistent infra-orbital nerve paresthesia until the last follow-up.
Discussion
The zygomatic complex is commonly involved in maxillofacial trauma, but
iZMC fractures are less common. Fractures of the ZMC most commonly occur
due to assault and motor vehicle accidents. [4] The most common cause of iZMC was motor vehicle accidents in our sample. Bogusiak and Arkuszewski [5] found a higher incidence of assaults in their review of ZMC fractures in the Polish population. Ma [6]
reported that 20% of patients in their study in China suffered injury
due to industrial accidents while in our study only 8% of the sample
suffered due to the same reason. The gender distribution of patients in
this study is analogous to those reported by many studies, whereby a
higher number of males suffered from iZMC fractures than females. [7]
Sometimes patients with a facial injury suffer iZMC fractures with
minimal displacement of bone and no functional limitation or cosmetic
derangement or deformity. Such patients need only longitudinal
observation without active surgical intervention. However, displaced
fractures require surgical reduction and stabilization. [3],[4]
In this study, 21 out of 25 patients required surgical intervention.
Majority of the patients in this study had middle-energy fractures which
are similar to those reported by other authors. [8],[9]
Facial edema and peri-orbital swelling may hamper clinical examination
and immediate surgical procedure among these patients. Other factors
that may delay surgical treatment include: preanesthetic review and
investigations, neurological clearance in patients with possible head
injury, or other traumatic injuries of the body. [10]
It is acceptable to wait for the peri-orbital edema to resolve since it
allows for better palpation and manipulation of the fracture segments
intraoperatively. [2]
In this study, all these reasons accounted for the delay in surgical
treatment after injury ranging from 0 day to 6 days. Various surgical
approaches for reduction of iZMC fractures and nonrigid methods of
fixation have been proposed even with the advent of mini-plate
osteosynthesis. [11]
However, recent reviews state that each case must be individualized
because fixation requirements differ greatly from one fracture to
another. [2]
A detailed review of iZMC fractures was performed by Ellis and Kittidumkerng. [8]
They proposed an algorithm to assess the need for fixation of reduced
iZMC fractures and concluded that each case must be individualized for
type of surgical fixation. As per the suggested algorithm, reduction of
the fractured segment is followed by assessment of fracture line
alignment and stability of the bone under controlled pressure. Further
fixation is done after such evaluation. In the management of our
patients with iZMC fractures, we also followed a similar protocol and
primarily used exposure of the ZM buttress in order to reduce and assess
reduction of the iZMC segment. This approach has also been successfully
used for primary reduction by other authors. [4],[12]
Palpation of orbital margins was also performed to confirm the
reduction. Need for surgical fixation was determined by evaluating the
stability of the fracture segments when force was applied judiciously.
In patients with clinical and radiographic features suggestive of
orbital floor involvement, surgical exploration via infra-orbital
incision was performed. In all other patients, infra-orbital reduction
was visually confirmed with exploration via the maxillary sulcus
incision.
It is recommended to use low profile titanium
mini-plates for the management of ZMC fractures as they provide improved
cosmesis and less discomfort to the patients. [8],[9],[13]
In this study, low-profile titanium mini-plates were used in seven
patients while stainless steel plates were used in 14 patients mainly
due to financial constraints of the patients. Different protocols have
been proposed for the site of fixation and points of fixation of iZMC
fragments. These range from no fixation to one-point fixation, [4] two-point fixation [14] and even three-point fixation. [15]
In this study, 7 patients underwent two-point fixation, and 4 patients
underwent three-point fixation. Decision of number and points of
fixation was done as per Ellis and Kittidumkerng's protocol as mentioned
above. [8]
Exploration of the orbital rim and floor is also a controversial topic
in management of ZMC fractures. Most authors recommend that it should be
performed only if necessary. [3]
In this study, exploration and repair of the orbital floor was
performed in only 6 patients when it was indicated on preoperative
evaluation or during surgical exposure of the ZM buttress and reduction
of the fracture fragments.
Many authors have noted complications
in the management of iZMC fractures and they range from malunion,
improper reduction, failure of hardware, aesthetic and functional
impairment. [4],[14],[16]
In this study, bone plates were removed in two patients due to
dehiscence of the oral wounds. No other significant complications were
noted. Two patients complained of persistent infra-orbital nerve
paresthesia, which is an accepted side effect of ZMC fractures and their
treatment. This side effect may or may not be related to actual
surgical manipulation. [17]
Our review of patients with iZMC fractures shows that an individualized
approach to need for surgical reduction and type of fixation provides
optimum outcomes with minimal complications.
Acknowledgement
We would like to thank the faculty and staff of Cheema Medical Complex,
Mohali, Punjab, where the surgical work and patient care was performed.
References
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