Changes of malar ,arch

and bone of nose

By: Dr.Razy Kontar

 Definition

Injuries to the zygoma and the surrounding facial bones are confusingly
referred to by a number of different terms including:
● Malar fracture
● Tripod fracture
● Zygomatic complex fracture
● Zygomaticomaxillary complex fracture
All these terms refer to injuries of the zygoma with, in most cases, involvement
of the maxilla or temporal bone. The sutures connecting the zygoma to
adjacent bones may also be disrupted. Whilst it is important to delineate the
individual components of a facial injury, in most instances this can only be
done accurately by CT scan at a later stage.
Anatomy

The integrity of the zygoma is critical in maintaining normal facial width and
prominence of the cheek. The zygomatic bone is a major contributor to the orbit.
From a frontal view, the zygoma can be seen to articulate with 3 bones: medially
by the maxilla, superiorly by the frontal bone, and posteriorly by the greater wing
of the sphenoid bone within the orbit.
 Classification

In 1961, Knight and North described a classification system of zygoma fractures, hoping to better determine
the prognosis and treatment of these injuries.
Group I encompassed fractures with no significant displacement. While fracture lines may be evident on
imaging, their recommendation was observation and soft diets. Group II fractures include isolated arch
fractures. Fracture is indicated when trismus or aesthetic deformities are present.
Unrotated body fractures, medially rotated body fractures, laterally rotated body fractures, and
complex fractures (defined as the presence of additional fracture lines across the main fragment)
belong to groups III, IV, V, and VI, respectively. Knight and North defined these groups by their
stability after reduction. They found that 100% of group II and group V fractures were stable after a
Gillies reduction, and no fixation was required. However, 100% of group IV, 40% of group III, and
70% of group VI were unstable after reduction and required some form of fixation.
Imaging

Noncontrast computed tomography (CT scan) with three dimensional

reconstruction is most commonly used to confirm the presence of a fracture and
optimize pre surgical planning.

Ultrasonography has been used and found to identify lateral orbital wall fractures
with high sensitivity and specificity. Combining this modality with CT allows for
excellent visualization of fractures, leading to maximal perioperative planning
and repair.
Management and surgical repair

Isolated zygomatic arch fractures

Optimal repair of isolated zygomatic arch fractures is within 72 hours of the
injury. Within this time frame, the arch is easily reduced without the need for
internal fixation or external splints
Zygomatic complex fractures
ZMC fractures are usually repaired with open reduction and internal fixation
within 3 4 weeks following injury. Plating systems are used to fixate the
zygomaticomaxillary buttresses,zygomaticofrontal suture, and zygomatic arch.
Osteotomies are indicated for fractures older than 1 month with onlay bone
grafting for fractures present for 4 months or longer
Complications

1)Infraorbital nerve dysesthesia

2)trismus

3)Diplopia

4)infection

5)Complications with plates and/or screws

Nasal fracture

Nasal fractures account for approximately 40% of all bone injuries. Fights
and sports injuries are the most common causes of nasal fractures in adults,
followed by falls and vehicle crashes. Play and sports account for the
majority of nasal fractures in children.

Although nasal fractures are the most common facial fracture in both adults
and children, they often go unnoticed by physicians and patients. Patients
with nasal fractures usually present with some combination of deformity,
tenderness, hemorrhage, edema, ecchymosis, instability, and crepitation;
however, these features may not be present or may be transient.
Anatomy

The nose is the most prominent and anterior facial feature; as such,
it is also the most readily exposed to trauma. The nose is supported
by cartilage on the dorsum and caudal aspects and by bone
posteriorly and superiorly. The paired nasal bones, the maxillary
crest, and the nasal bones, jutting from the frontal bone, form the
bony framework that supports the underlying nasal cartilages. The
entire lower two thirds of the nose is cartilaginous
Diagnostic method

1) X-ray
2) CT
3) Ultrasound
4) Physical examination
Treatment

Treatment depends on the degree of displacement. If the alignment is

essentially anatomical then no treatment is required. If the displacement is
significant then if untreated they may result both in an unfavorable cosmetic
result and in impaired function (i.e. difficulty in breathing through one or both
nasal passages). Untreated nasal fractures account for a high percentage of
rhinoplasty and septoplasty procedures.

The worst morbidity results from septal hematoma, leading to nasal septal
perforation and necrosis, which causes severe nasal collapse and
deformation