Treatment of Zygomatic Arch and Lateral Orbit Fractures
The treatment of zygomatic arch and lateral orbit fractures requires a structured approach based on clinical presentation, with immediate surgical repair indicated for muscle entrapment with oculocardiac reflex, while other cases may be managed within 2 weeks or observed depending on severity. 1
Initial Assessment
- CT maxillofacial is the preferred initial imaging modality for suspected midface injuries, providing high-resolution delineation of osseous and soft-tissue structures 2
- A detailed sensorimotor examination should assess versions, ductions, saccades, pursuit, and alignment in multiple gaze positions 1
- Vital signs must be monitored for bradycardia or heart block, which may indicate muscle entrapment causing oculocardiac reflex - a potentially life-threatening condition requiring urgent intervention 1
- Forced duction and forced generation testing help distinguish restriction from paresis of extraocular muscles 1
Treatment Algorithm Based on Clinical Presentation
Immediate Surgical Repair (Emergency)
- Patients with CT evidence of entrapped muscle or periorbital tissue with nonresolving oculocardiac reflex 1
- "White-eyed blow-out fracture" with muscle entrapment and oculocardiac reflex (particularly in children) 1
- Globe subluxation into the maxillary sinus 1
Early Surgical Repair (Within 2 Weeks)
- Symptomatic diplopia with positive forced ductions or entrapment on CT with minimal improvement 1
- Large floor fractures, hypoglobus, and progressive infraorbital hypoesthesia 1
- Early enophthalmos or hypoglobus causing facial asymmetry 1
Delayed Repair (After 2 Weeks)
- Restrictive strabismus and unresolved enophthalmos that persist after initial observation 1
Observation Only
- Minimal diplopia (not affecting primary or downgaze) 1
- Good ocular motility without significant enophthalmos or hypoglobus 1
Surgical Approaches
- Multiple fixation points are commonly used for internal fixation of zygomatic fractures 3
- Approaches may include lateral brow, subciliary, temporal, or intraoral incisions 3
- The lateral orbital approach provides good access for reduction and treatment of zygomatic bone and arch fractures 4
- For fractures not involving the orbital floor, reduction through a temporal incision with fixation of the lateral zygomaticomaxillary buttress may be sufficient 3
Important Considerations
- All life-threatening and vision-threatening conditions must be treated before addressing the strabismus 1
- Serious ocular injury occurs in up to 24% of blowout fractures 1
- Even with proper repair, strabismus and diplopia can persist in up to 37% of patients postoperatively 1
- A short burst of oral steroids can hasten recovery and help identify strabismus that will persist despite resolution of orbital edema/hematoma 1
- In cases without muscle entrapment, waiting 4-6 months after orbital trauma is advised as strabismus may resolve spontaneously 1
Potential Complications to Monitor
- Postoperative scarring and sensory disturbances, particularly with subciliary incisions 3
- Malar asymmetry due to inadequate three-dimensional reduction 5
- Persistent diplopia despite surgical intervention 1
- Enophthalmos due to increased orbital volume 6
Conservative Management Options
- Occlusion, filters, Fresnel prisms, and prism glasses may provide temporary or permanent relief of diplopia in less severe cases 1