Closed Reduction of an Isolated Zygomatic Arch Fracture Under Local Anesthesia: A Case Report.

The zygomatic bone is one of the most prominent bones in the facial region. It forms the most anterolateral projection on each side of the middle face and is articulated with the maxilla, frontal, and temporal bones. Isolated zygomatic arch fractures can occur when a direct force is applied to the zygoma. A variety of intraoral and extraoral techniques have been used as closed reduction techniques for isolated fractures of the zygomatic arch. In this case report, we aim to present our approach for the treatment of a 40-year-old patient with an isolated right zygomatic arch fracture. We used the Keen technique for the closed reduction of the fracture under local anesthesia due to its practicality and effectiveness.

Management of Isolated Zygomatic Arch Fractures and a Review of External Fixation Techniques.

INTRODUCTION: Fractures of the zygomatic bone can present with complicated aesthetic and neurological pathology. Specifically, management of isolated zygomatic fracture has been sparsely discussed in the literature, and most studies are based upon older techniques. Here, we compare the results of 2 critical operative techniques as well as review the available literature in the setting of isolated zygomatic fractures. METHODS: A retrospective chart review was performed at our institution from 2010 to 2018 examining for patients who had sustained an isolated zygomatic fracture confirmed by computed tomography scan. Patients were excluded if they sustained additional maxillofacial fractures. Demographical information, symptoms on presentation, fracture management modality, and postoperative course were all collected and examined. RESULTS: A total of 218 patients were identified for inclusion. The average age of this cohort was 45.5 ± 18 years, with 77.5% being male. Assault (55%) was most the frequent cause of injury with accidents being the least common (17.9%). Most patients (78.8%) underwent nonoperative management. Patients who underwent operation more often presented with zygomatic deformity (97.7% vs 18.4%), paresthesia (29.5% vs 2.9%), and trismus (29.5% vs 6.9%) when compared to their nonoperatively managed counterparts. In all, 44 operatively managed patients underwent open reduction with or without eternal fixation (Gillies Approach vs Keen Approach). There were no significant differences in the presence of zygomatic deformity, paresthesia, and trismus between the 2 operative techniques. CONCLUSIONS: Isolated zygomatic arch fractures can present with discerning symptoms. Unfortunately, the literature on appropriate management is not well described. We find external fixation to provide reestablishment of both form and function with minimal required exposure, although the outcomes may be similar without the use of external fixation.

Management of Zygomatic Arch Fractures by Intraoral Open Reduction and Transbuccal Fixation: A Technical Note.

Fractures of the zygomatic arch are common due to its anatomical prominence. The post-traumatic restoration of the arch form is important to maintain the midfacial symmetry and anteroposterior projection of the face. Open reduction and internal fixation (ORIF) of fractured arch is indicated in specific clinical presentations. The traditional methods of ORIF of zygomatic arch fractures require cutaneous incisions, which are associated with complications such as scarring and facial nerve injury. This article presents a simple technique of "intraoral reduction and transbuccal fixation" of the arch that negates the problems associated with the conventional approaches to ORIF.

Location of the split line of the deep temporal fascia when reducing a zygomatic arch fracture.

BACKGROUND: The deep temporal fascia (DTF) is known to separate into two layers that descend to attach to the zygomatic arch. When surgeons reduce an isolated fracture of the zygomatic arch through a temporal approach, the temporal incision site needs to be superior to the split line of the DTF. MATERIALS AND METHODS: Sixty-seven hemifacial cadavers were investigated after removing the skin, subcutaneous tissue, and superficial temporal fascia. The superficial layer of the DTF was exposed. We cut the superficial layer along the line along, which it adhered to the deep layer inseparably. The heights of the split line of the DTF from the superior border of the zygomatic arch and from the top of the helix were measured at three points: at the jugale, zygion, and 3 cm from the tragus. RESULTS: In all cases there were thick identifiable deep layers of the DTF. The mean heights of the split line of the DTF from the superior border of the zygomatic arch were 49.8, 46.7, and 42.6 mm at the jugale, zygion, and 3 cm from the tragus, respectively; the corresponding mean heights of the split line from the top of the helix were 19.1, 15.6, and 11.4 mm. CONCLUSIONS: Knowledge of the mean height of the split line of the DTF will be helpful for surgeons to determine the temporal incision site for ensuring the safe reduction of a zygomatic arch fracture.

Novel Surgical Technique for Repair of Zygomatic Fractures: Lever Technique.

BACKGROUND: Zygoma is a very crucial component for the anteroposterior positioning of the midface and for the maintenance of facial contours. Zygomatic fractures are considered as the second most common type of facial fractures following nasal fractures. We have developed a new reduction technique called "lever," which is based on the application of lifting force as an alternative to the methods in which the pulling force is applied. PATIENTS: Over a 12-year period, 90 patients were treated with minimal access approach and 130 patients were treated with open reduction internal fixation (ORIF), using the lever technique. RESULTS: In the follow-up period, no complications occurred in any of the patients who underwent minimal access approach. Miniplate removal operation was performed in 3 of the patients. Enophthalmos developed in one patient. Since 4 of the 7 suboptimal reduction patients did not experience any functional or cosmetic problems, no treatment was necessary and the remaining 3 patients underwent fat graft due to the presence of malar depression. CONCLUSION: This minimally invasive surgical procedure we have developed can be successfully used both in the minimal access approach and in ORIF, especially in delayed cases. We recommend this method due to the reasons that it is safe to conduct, easy to learn, fast to apply, simple to perform, and also economical to deploy.

HISTORIQUE: L'os zygomatique est décisif pour le positionnement antéropostérieur de la partie médiane du visage et la préservation des contours du visage. Les fractures zygomatiques sont considérées comme la deuxième cause de fractures du visage en importance, après les fractures du nez. Les auteurs ont créé une nouvelle technique de réduction, la « technique de levier ¼, qui repose sur l'application d'une force de soulèvement plutôt que sur les méthodes reliées à une force de tension. PATIENTS: Sur une période de 12 ans, 90 patients ont subi un abord d'accès minime et 130, une fixation interne par réduction chirurgicale (FIRC) à l'aide de la technique de levier. RÉSULTATS: Pendant la période de suivi, aucun patient ayant subi l'abord d'accès minime n'a souffert de complications. Trois ont dû faire extraire des mini-plaques. Un patient a souffert d'énophtalmie. Puisque quatre des sept patients ayant subi une réduction sous-optimale ne présentaient aucun problème fonctionnel ou esthétique, ils n'ont pas eu besoin de traitement supplémentaire, et les trois autres ont reçu une greffe de tissus adipeux en raison d'un enfoncement malaire. CONCLUSION: Cette intervention peu effractive mise au point par les auteurs peut être utilisée avec succès pour l'abord d'accès minime et la FIRC, surtout dans les cas différés. Ils recommandent cette méthode parce qu'elle est sécuritaire, facile à apprendre, facile à appliquer et à exécuter et peu coûteuse.

"Radiological morphometric analysis of the zygomatic arch: Application of osteosynthesis on the upper arch border for rigid fixation".

BACKGROUND: This study was designed to introduce a novel method of applying osteosynthetic materials to the upper zygomatic arch border for fracture fixation through a temporal incision, and analyze the radiologic morphometric dimensions of the arch to verify its validity. METHODS: Radiological morphometry was analyzed in 51 adult patients with unilateral isolated zygomatic arch fractures. Frequent fracture sites, sites of minimal thickness and height, and their correlation were evaluated, as were the locations and dimensions of fixation vantage points. The novel surgical method based on the results was implemented in 17 clinical cases. RESULTS: Frequent fracture sites, occurring 4.40, 16.47 and 30.48 mm posterior to the arch origin, did not correlate to sites of minimal height and thickness. Arch minimal thickness and height locations were 12.23 and 27.09 mm behind its origin, respectively. Fixation vantage point dimensions varied from point to point, with upper thickness ranging from 1.67 to 4.86 mm and mid-portion thickness ranging from 2.06 to 7.36 mm, and height ranging from 8.99 to 22.53 mm. Arch vertical axis inclination ranged from 6.51° to 16.47°, which increased as the arch stretches posteriorly. These results suggested the use of 1.5 mm-wide plates and 1 mm-diameter screws with 6-8 mm length. Patients received surgery based on these morphometry results for satisfactory stabilization. CONCLUSIONS: This study introduces a new method for open reduction and internal fixation of arch fractures, with morphometric analysis of the arch verifying the validity of tangential plate application to the upper border.

Reduction of Isolated Zygomatic Arch Fractures with Gillies Approach / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The incidence of facial bone fracture is increasing. The zygomatic bone, due to its anatomical prominence, is the second most common site of all facial bone fractures. In this study, we present the clinical experiences of zygomatic arch fracture in a tertiary hospital and introduce the Gillies approach for reduction and its outcome results. SUBJECTS AND METHOD: We collected data from retrospective chart reviews of patients who underwent surgeries from 2010 to 2017 for zygomatic arch fractures at Chungbuk National University Hospital. Data were analyzed according to age, gender, cause of trauma, location of trauma, and clinical symptoms including trismus. All surgery was performed under general anesthesia and via the use of Gillies approach. The result of surgery was evaluated by postoperative facial computed tomography. RESULTS: Sixteen patients underwent surgery for zygomatic arch fracture. The patients had the average age of 41.3 years, a male predominance of 15:1 and physical assault as the most common cause of trauma. The time lag between injury and surgical reduction was 5.5 days. The surgical outcomes were assessed “good” in 14 cases and “moderate” in one case. Patients who had trismus preoperatively were resolved of it in all cases after operation. Postoperative complications were absent. CONCLUSION: The Gillies approach proved to be a relatively easy, safe, and reliable method, and its surgical outcomes was satisfactory in our experiences.

C-arm as intraoperative control in reduction of isolated zygomatic arch fractures: a randomized clinical trial.

PURPOSE: Isolated zygomatic arch fractures (IZAFs) are habitually reduced at a distance, via a temporal approach. Open reductions are not recommended due to the associated morbidity and complications. However, performing closed reductions makes it difficult to determine whether it was done satisfactorily. This study aims to determine whether the acquisition of intraoperative images with a C-arm to evaluate IZAF reductions is a useful technique in treating such fractures. METHODS: Our hypothesis is that acquiring intraoperative images with a C-arm reduces the need for a second surgery. Between 2009 and 2012, 50 patients who were diagnosed with IZAF requiring surgery were randomly distributed into two groups: 25 patients were in the experimental group, where fracture reduction was performed and immediately corroborated intraoperatively for an adequate result using a C-arm, and 25 patients were assigned to a control group where the fracture reduction was controlled with post-surgery imaging. RESULTS: The results did not reveal significant differences between both groups (p = 0.5). Nevertheless, the experimental group had the advantage of being able to immediately reduce the fracture again if the result was unsatisfactory. CONCLUSIONS: Despite the fact that the results are not statistically significant (p = 0.5), the authors recommend undertaking an intraoperative imaging analysis in areas where we are not certain of the reduction.

A comparative study on the diagnostic utility of ultrasonography with conventional radiography and computed tomography scan in detection of zygomatic arch and mandibular fractures.

OBJECTIVES: The objective of the following study is to evaluate the usefulness of ultrasonography (USG) in comparison with conventional radiography and computed tomography (CT) scan in the diagnosis of zygomatic arch and mandibular fractures. MATERIALS AND METHODS: A total of 40 patients with suspected fracture of the zygomatic arch and/or mandibular fractures were included in the study. Two groups (one for zygomatic arch fractures and the other for mandibular fractures) of 20 patients each were designed for the study. Ultrasonographic examinations were performed using small linear probe (LA435, Siemens Acuson Antares) with 10 MHz frequency. Data from CT and conventional radiography were compared with that of USG. RESULTS: Sensitivity and specificity of USG in assessing zygomatic arch fractures were 100% and 100%, respectively; and that of mandibular fractures were 94.74% and 100%, respectively. Overall sensitivity, specificity, positive predictive value, and negative predictive value of USG against CT in diagnosing zygomatic arch and mandibular fractures were found out to be 97.4%, 100%, 100%, and 66.7%, respectively. CONCLUSION: USG is a very reliable tool in detection of fractures involving zygomatic arch and mandible. It can be used for screening of suspected fractures of zygomatic arch and mandible to avoid unnecessary radiation exposure from conventional radiography and CT scans.

Stabilisation of the unstable fractured zygomatic arch with a ballooned foley catheter.

The zygomatic arch fracture is one of the most common facial bone fractures. Especially the isolated zygomatic arch fracture is usually repaired via Gillies' approach. But in the case of unstable zygomatic arch fracture, we need an additional step for stabilising the unstable zygomatic arch segment after repositioning the fractured segment. For the stabilising method we use the ballooned Foley catheter on the medial side of the zygomatic arch in the zygomaticotemporal fossa. This method is of assistance to the patient who has a zygomatic arch fracture with comminution or an old patient with weak and torn periosteum. In this study, we achieved a good result and we will introduce this simple method as one of alternatives of stabilising tool.

Stabilization of the Isolated Zygomatic Arch Fracture Using Foley's Balloon Catheter.

Zygomatic fractures are the most common facial fractures or second in frequency after the nasal fractures. The high incidence of zygomatic fractures probably relates to its prominent position in the facial skeleton hence it is frequently exposed to fractures. This case report presents an isolated zygomatic arch fracture that was been reduced by Gille's temporal approach and stabilized using foley's balloon catheter.

The Avalibility of C-Arm in Reduction of Zygomatic Arch Fracture Intraoperatively: Case Report

The Effective Reduction Method of Unstable Zygomatic Arch Fracture with Thermo-Splint

PURPOSE: The objective of this study is to propose an effective management of unstable zygomatic arch fracture. The reduction methods of arch fracture were relatively simple but the maintenance of reduction state is very troublesome. On this, authors introduce an effective management method of unstable zygomatic arch fracture. METHODS: Authors experienced 23 cases of unstable segmental zygomatic arch fractures and used Thermo- splint in all cases. All the arch fractures were reduced through Gillies' approach under the general anesthesia. After the reduction, the most effective suspension points were marked on the covering skin of the fractured arch. A needle of heavy nonabsorbable suture material was inserted toward the marking site under the reduced zygomatic arch. And then Therm-splint was dipped in the hot water, and we got the splint pattern of patient face. Reshaped Thermo-splint was trimmed and fixated with previous suspension suture materials. More additive suspension was done if necessary. The splint was applied for in two to three weeks postoperatively. RESULTS: In all the cases, good cosmetic and functional results were observed without severe complications. There were 4 cases of incomplete reductions but they also had no specific problems. There were no facial nerve symptom and scar(stitch mark). Postoperative slight tenderness and trismus were completely subsided after removal of the splint. CONCLUSION: The Thermo-splint safely protect and maintain the postoperative reduction state. The application, maintenance and removal were easy and simple. It could be reformed to any contour of face and had enough rigidity for supporting. Above all these things, effective prevention of displacement and easy manipulation were significant merit. Authors experienced good results with Thermo-splint, and would introduce it for another method of management of zygomatic arch fracture.

Fractured zygomatic arch reduction with foley catheter

K-wire Insertion Beneath Zygomatic Arch Under the Fluoroscope for Rigid Fixation of Zygomatic Arch Fracture

The fracture of zygomatic arch is one of the common fracture of the facial bone and commonly reduced by Gillies or Dingman method However, if the reduced bone segments are unstable after reduction, they tend to be displaced by mastication or unintentional external forces. Though many techniques have been introduced for the treatment of the unstable zygomatic arch fracture, all of those techniques have their own shortcomings. We devised a new fixation method to prevent the displacement of the reduced zygomatic arch segments with 0.047 inch K-wire under the fluoroscope. After reduction of zygomatic arch using Gillies method under the fluoroscope, a thin K-ire was inserted along the undersurface of the zygomatic arch through zygoma body for rigid fixation. The inserted K-wire was removed in 4 weeks. In ten cases, good cosmetic and functional results were observed without complications such as infection, facial nerve injury, displacement of fractured segments, and operative scar during the follow up period of 3 months. However, while the pin was being inserted, patients complained discomfort on their cheeks. This technique may be an available method to prevent the displacement of the reduced zygomatic arch and to obtain the rigid fixation.

CLOSED REDUCTION OF ZYGOMATIC ARCH FRACTURE WITH EXTERNAL WIRE TRACTION UNDER FLUOROSCOPY

Recently, facial traumas are increasing due to expansion of motor vehicles and complexity of social life pattern. The zygoma bone is a prominent part of the midface and prone to be traumatized. Numerous approaches for reduction and fixation of zygomatic fractures have been described. Each reduction method has its advantages and disadvantages. The authors employed the external wire traction with fluoroscopy in cases of non-comminuted zygomatic arch fracture. The advantages of this method are a more accurate reduction under direct vision and takes a very short time. This procedure also can reduce the pain and edema after postoperation and possible under local anesthesia. With such method, we obtained satisfactory results cosmetically and functionally.