Zygoma fractures occur in two major patterns: the most serious injury is the tripod fracture, whereas the most common is the arch fracture. The zygoma forms a tripod, which abuts the frontal, maxillary, and temporal bones. The classic tripod fracture involves the infraorbital rim, a diastasis of the zygomatic-frontal suture, and disruption of the zygomatic-temporal junction at the arch. The fragment may drop, and pull the lateral canthus, causing the eye to "tilt." Later, the cheek will flatten, but edema usually obscures this finding in the ED.
Look for lateral subconjunctival hemorrhage and infraorbital anesthesia. A significant percentage of patients with large lateral subconjunctival hematomas have associated zygomatic injury. Either trismus or an open bite will appear if the zygoma impinges on the masseter or coronoid process. Palpate the zygomatic arch from within the mouth to detect arch fractures.
Plain films, consisting of the jug-handle or arch view, are adequate for suspected arch fractures, and the Waters view can screen for tripod injury. Order CT scans for tripod fractures that are diagnosed or suggested by plain films. In those cases where tripod fractures are unmistakable on physical examination, plain films are superfluous and patients should go directly to CT. The scans delineate injury to the orbital floor and guide surgical planning.
Patients with tripod fractures require admission for open reduction and internal fixation of displaced fragments. Those with fractures of the arch may be scheduled for outpatient elevation and repair.
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