SESAP Critique
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**Category 16, Items 11, 12 and 13**

Malar fractures represent the second most frequent midfacial injury after nasal fractures. The prominent position of the malar eminence accounts for the frequency of fracture dislocation. Radiographic evaluation is best accomplished with a computed tomographic (CT) scan where the four articulations of the zygoma with the frontal, sphenoid, temporal, and maxillary bones can be evaluated. Fractures characteristically occur at these four buttress articulations, with varying degrees of displacement of the malar complex. With the fractures of the anterior maxillary wall and the floor of the orbit, blood is seen in the maxillary sinus on the involved side. Fragments of bone from the floor of the orbit and intraorbital soft tissue may also be seen in the maxillary sinus.

The x-ray findings with an orbital floor “blow-out” fracture are limited to fractures of the floor of the orbit, whereas Le Fort II fractures and naso-orbital-ethmoid fractures involve the medial wall of the orbit. Frontal sinus fractures are seen superior to the orbit; the orbital roof and orbital rim may be involved

Clinical examination may show a wide range of findings, including periorbital ecchymosis, edema, and hematoma; subconjunctival hemorrhage; anesthesia in the distribution of the infraorbital nerve (the ipsilateral upper lip, eyelid, medial portion of the cheek, and lateral portion of the nose); posterior displacement of the malar eminence with flattening of the cheek; enophthalmos from enlargement of the bony orbital volume; diplopia; a bony step-off on palpation of the orbital rim; and pain when opening the mouth due to pressure on the mandible. Overall lengthening of the face is not seen with a malar fracture because bilateral fractures are necessary for craniofacial separation.

Nondisplaced zygomatic fractures without functional compromise do not require surgical treatment. Treatment is indicated for any zygomatic fracture, even undisplaced ones, where there is evidence of entrapment of the orbital contents such that there is a limitation of upward gaze. This can occur when a portion of the orbital fat or of the inferior rectus or inferior oblique muscles becomes caught in an orbital floor fracture and herniates into the maxillary sinus. Most displaced zygomatic fractures require surgical treatment. Bony displacement results in a larger orbital volume, which produces enophthalmos with resultant visual impairment and considerable visible deformity.

## References

1.  1.  Jurkiewicz MJ, 
    2.  Krizek TJ, 
    3.  Mathes SH, 
    4.  Ariyan S
    
    Baird WL, Wornom IL III., Jurkiewicz MJ: Maxillofacial trauma, in Jurkiewicz MJ, Krizek TJ, Mathes SH, Ariyan S (eds): Plastic Surgery: Principles and Practice. St. Louis, CV Mosby Co, 1990, pp 241–256
    
    

2.  1.  Ruberg RL, 
    2.  Smith DJ Jr.
    
    Cohen SR: Craniofacial trauma, in Ruberg RL, Smith DJ Jr. (eds): Plastic Surgery: A Core Curriculum. St. Louis, Mosby-Year Book Inc, 1994, pp 318–321