ELEVATING A FRACTURED ZYGOMA

INDICATIONS (1) Inability of the patient to open and close his jaw. (2) Diplopia. If you are inexperienced, and he can move his jaw normally and can see straight, disregard any deformity and don’t operate.

The method described here is for the zygomatic arch. By a slight change in the position of the lever, you can also use it for fractures of the body of his zygoma and the adjacent part of his maxilla.

EQUIPMENT A general set with a Bristowe’s elevator, or a McDonald’s elevator, or a long secrewdriver.

Figure 62.12: ELEVATING A DEPRESSED FRACTURE OF THE ZYGOMATIC-MAXILLARY COMPLEX. A, the initial incision avoiding the superficial temporal vessels. B, dividing the auricularis superior. C, incising the temporalis fascia. D, passing an elevator. E, elevating the arch. F, elevating the body of the zygoma. Kindly contributed by John M Lore Jr.

ANAESTHESIA Give the patient a general anaesthetic and intubate him (13.2).

REDUCTION Be sure to protect the patient’s eyes. Make a 2 cm antero–posterior incision in his temporalfossa, just above his hairline, as in A, Fig. 62-13.

Reflect his skin. Underneath the skin and the superficial fascia you will see his auricularis superior muscle. Cut in the line of Its fibres (B). If his hairline is low, and the incision is lower, you may meet the fibres of auricularis anterior. These run more horizontally, so separate them in a horizontal plane. Underneath them lies his tough deep temporal fascia. Cut this to expose his temporalis muscle (C). The fascia may have two layers. If so, incise them both.

Pass a Bristow’s elevator between his temporalis fascia, and the surface of his temporalis muscle. Push it down until its end lies between his zygomatic bone and his temporalis muscle (D). It should slip easily between the bone and the muscle.

Using a gauze roll as a fulcrum to protect the upper skin edge, gently lever his zygoma into a slightly overcorrected position (E).

If the body of a patient’s zygoma is fractured, pass the elevator forwards, and lever it into position (F).

If the fragment is stable, no wiring is necessary.

If the fragment is unstable, wire its junctions with his frontal or maxillary bones, or with both of them, through separate small incisions.

WIRING A ZYGOMATIC–FRONTAL FRACTURE Expose the fracture line by blunt dissection through an incision in one of the wrinkles at the corner of the patient’s eye. Take care to avoid the branches of his facial nerve supplying his orbicularis muscle. Drill small holes in the bone and fix the fragments in place with soft stainless steel wire.

WIRING A ZYGOMATIC–MAXILLARY FRACTURE Make a 1 cm incision just below the lower rim of the patient’s orbit. Drill small holes and wire the fragments together.

ALTERNATIVELY, in some fractures you may be able to grasp the fragments through his skin with tenaculum forceps.

CLOSING THE WOUND Close his deep temporal fascia with a few monofilament sutures. Put a firm pressure pad over the skin incision.