Surgical Anatomy. — Anatomically speaking; the malar is a distinct bone, but from a surgical standpoint it becomes necessary to consider the various processes with which it articulates as a part of that bone, since fractures are rarely limited to the malar alone. The bone is roughly quadrilateral in shape, articulates with the frontal, great wing of the sphenoid, zygomatic process of the temporal and the malar process of the superior maxilla. It also forms part of the wall of the temporal and zygomatic fossae and enters into the formation of the orbit. The bone is composed of heavy compact tissue, its strength being such that blows on the face usually result in impaction of its supports rather than fracture of the bone itself. The fact that the malar enters into the formation of the wall of the orbit and the zygomatic fossa will lead to symptoms peculiar to these cavities when the bone is displaced. From a surgical standpoint the zygomatic arch is to be considered as a whole, and since the zygomatic process of the temporal and the malar both enter into its formation, these two structures are spoken of as one. The space beneath this arch is normally filled by the coronoid process of the inferior maxilla and the temporal muscle, and any inward displacement of the arch must encroach upon these structures and interfere with their function. Interference with the action of the lower jaw may sometimes result from the extravasation of blood or from swelling of the tissues beneath the arch, and we thus have a symptomatic simulation of bony depression. So-called fracture of the malar consists chiefly in impaction of the bone into the processes supporting it, especially that of the superior maxilla. The largest process supporting the bone is the malar process of the superior maxilla, and since the antrum of Highmore projects well up into this process (sometimes even penetrating into the malar) the fracture may open into the cavity of the antrum; when such is the case the manner in which air may be forced from the nasal cavity, through the antrum, into the conjunctiva, is evident. Thus the resulting subconjunctival emphysema, when present, indicates the condition of the underlying bone.<Callout type="important" title="Important">Always check for signs of subconjunctival emphysema as it can indicate a more serious injury.</Callout> Fig. 471. — Relations of the nasal, lachrymal, superior maxilla and malar bones.<Callout type="gear" title="Gear">Use an ophthalmoscope to check for signs of subconjunctival emphysema in cases where direct observation is difficult.</Callout> In fracture of the malar the usual deformity consists in depression of the bone into the superior maxilla with a slight rotary displacement, so that the orbital border may be felt projecting into the orbit while the zygomatic process is displaced inward and downward (see Fig. 471). The malar is sometimes displaced directly backward so that the zygomatic surface encroaches on the space normally occupied by the temporal muscle and coronoid process. The condition is rare but when present may interfere with the function of the lower jaw.<Callout type="risk" title="Risk">Failure to recognize a posterior displacement can lead to improper treatment and potential long-term complications.</Callout> The infraorbital canal runs close to the plane of suture between the superior maxilla and the malar, and when the latter is impacted into the former we may have injury to the nerves contained within the canal; namely the antero-superior dental, the middle superior dental, and the fibres which are later continued into the terminal branches. Accordingly, disturbances in sensation may occur in the upper teeth and gums as far back as the second bicuspid (inclusive) and in the terminal branches of the infraorbital on the face.<Callout type="warning" title="Warning">Nerve injuries can result in permanent numbness or tingling if not properly addressed.</Callout> The subcutaneous tissue covering this region is loosely cellular and devoid of fascia, thus permitting of pronounced and rapid swelling which is so frequently a hindrance to diagnosis. The muscles attached to this bone are three in number; two of them, the zygomaticus major and minor are muscles purely of expression, and hence disturbances in their function will be difficult to recognize; but the masseter, attached to the postero-inferior border, is a muscle of mastication, and disturbance in this function is readily detected. The malar bone is sometimes normally divided into two parts by a horizontal suture, which anomaly should not be mistaken for fracture during operation or while exploring wounds.<Callout type="beginner" title="Beginner">Be aware that the presence of sutures does not always indicate a fracture.</Callout> The postero-superior border of the bone is continuous with the temporal crest of the frontal above, with the upper border of the zygoma below and has the heavy temporal fascia attached to it throughout its extent. The antero-superior border forms the lower and outer margin of the orbit and in this position is easity palpated, as is the postero-inferior border of the bone.<Callout type="tip" title="Tip">Palpating these borders can help confirm the presence or absence of a fracture.</Callout> Etiology. — Fracture of the malar, like fracture of the nasal bones, is the result of direct violence, such as falls and blows on the face. It requires a much greater degree of violence, however, to fracture the malar than it does the nasal bones.<Callout type="risk" title="Risk">Underestimating the force required can lead to misdiagnosis or improper treatment.</Callout> Symptoms. — Pain is a constant element, while mobility and crepitus are more often absent than present. Swelling is usually rapid and pronounced, and ecchymosis about the eye common. The patient will usually give a history of severe trauma and may present a number of variable symptoms according to degree and direction of the displacement. If the anterior and middle dental branches of the superior maxillary nerve have been injured there may be considerable pain, numbness and tingling of the gums and teeth of the affected side as far back as second bicuspid (inclusive). Fractures of the zygomatic arch or a backward displacement of the malar may be accompanied by disturbances in function of the mandible. There may be pain in the affected side on mastication; in severe cases the patient may be totally unable to move the jaw.<Callout type="important" title="Important">Pain during mastication is a key symptom indicating potential displacement or nerve damage.</Callout> The characteristic symptom will consist of a depression of the malar or zygomatic arch with a corresponding flattening of the cheek; this symptom however may be masked by swelling, within a few minutes of the injury, and unless a careful examination is made at the time, the true condition may be overlooked. Conjunctival ecchymosis is usually present and, in some cases, conjunctival emphysema.<Callout type="risk" title="Risk">Ignoring these symptoms can lead to delayed or improper treatment.</Callout> Diagnosis. — If the swelling is not great the examination and diagnosis should be easy. The deformity which results from the depression of the malar or zygomatic arch is masked during the acute stage by the swelling, and unless a careful examination is made to determine the condition and position of the underlying bone we may learn subsequently to our chagrin what the real deformity is, after the swelling has subsided and union has taken place. Inspection alone, in these cases, is valueless since the visible symptoms are the same as seen in ordinary 'black eye' (ecchymosis and swelling). We should therefore carefully palpate the parts to determine the position of the underlying bone.<Callout type="tip" title="Tip">Use a careful examination with palpation to distinguish between a simple bruise and a fracture.</Callout> In most cases, continued pressure with the finger will displace the intracellular inflammatory fluids sufficiently to allow the surgeon to satisfactorily appreciate the conditions present, and to compare them with the facial contour of the uninjured side. The two sides can best be compared by standing behind the patient and palpating both bones simultaneously with the thumb and index finger of each hand (see Fig. 473). The presence of depression can be determined by placing the two index fingers over the prominent portion of the cheeks, and comparing the two sides; sufficient pressure on the injured side should be made to allow the finger to sink in, in order that we may eliminate the swelling which is otherwise misleading. The orbital, temporal and masseteric borders may be palpated and the position of the bone thus determined and compared. The conjunctiva should be examined for the purpose of detecting ecchymosis or emphysema; the former is by no means pathognomonic, but the latter is the result of air having passed from the nasal cavity into the conjunctiva, which is impossible if the bones of the face are intact.<Callout type="important" title="Important">Always check for conjunctival emphysema as it can indicate a more serious underlying injury.</Callout> Treatment. — The first indication in the treatment of these cases is to counteract the local effects of trauma and to relieve pain when severe. The inflammatory reaction can be maintained at the minimum by the use of the ice-bag for the first twelve to twenty-four hours.<Callout type="tip" title="Tip">Using an ice pack early on can help reduce swelling and pain.</Callout> In most cases, an attempt to correct the deformity is purely for cosmetic reasons, and in considering this element we must take into consideration the surroundings of the case. For example: deformity resulting from depression of the malar may be deemed an extremely important matter in the case of the young society woman, while on the other hand, the average laborer would not consider for a moment the trouble, time and expense necessary for the correction of the disfiguration which in no way interferes with his earning capacity. When no attempt is made at correcting the displacement the case resolves itself firstly, into the control of local reaction; secondly, allowing nature to unite the impacted fragments; and thirdly, the treatment of accompanying wounds when present.<Callout type="risk" title="Risk">Ignoring underlying fractures can lead to complications or prolonged healing.</Callout> If the fracture is compound as a result of direct violence the wound should be cleansed and the edges approximated according to general surgical principles as applied to the treatment of wounds and compound fractures. When complications exist, such as interference with the action of the jaw, or extreme and prolonged pain in the region of the superior dental nerves, operation is indicated.<Callout type="important" title="Important">Always assess for potential complications before deciding on a course of action.</Callout> Operative Treatment. — Operation may become necessary for cosmetic reasons or for the alleviation of complications such as the interference with the action of the jaw; the type of operation will depend to some extent on the reasons for which it is undertaken.<Callout type="tip" title="Tip">Operations should be tailored based on the specific needs and circumstances of each case.</Callout> When performed for cosmetic reasons only, open incision should be avoided because of the resultant scar. In these cases, the bone may be approached from the mouth through an incision parallel with the alveolar process and opposite the malar process of the superior maxilla, the thick part of which may be felt opposite the first molar. This incision is carried up under the cheek until the malar is exposed, after which it is pried back into position and the incision closed.<Callout type="gear" title="Gear">Using an intraoral approach can minimize scarring but requires careful technique.</Callout> Another method is that of making a small incision through the skin, drilling a hole in the face of the malar and inserting a screw, by which means the bone may be raised and replaced. Any modification of an intraoral operation should be conducted with due consideration for asepsis and followed by frequent douchings.<Callout type="risk" title="Risk">Improper technique can lead to infection or poor healing.</Callout> Deformity has been successfully corrected by the subcutaneous injection of paraffin, though the method is somewhat questionable. The difficulty with operative treatment is not so much a question of replacing the bone as it is of maintaining it in its original position, and the reason for this difficulty is explained by the loss of bony tissue which takes place in impaction. In other words it is not difficult to reduce the deformity, but we do not have the supporting process intact to maintain reduction after the impaction has been broken up.<Callout type="important" title="Important">Maintaining proper alignment post-reduction is crucial for successful outcomes.</Callout> In Lothrop's operation the bone is approached through the mouth as previously described, the depression corrected and the antrum packed with gauze to maintain the malar in its elevated position. The gauze is left in place for four or five days.<Callout type="warning" title="Warning">Leaving gauze in place too long can lead to infection.</Callout> The cavity is packed a second time — if there is tendency toward a recurrence of the deformity — and left for a second period of four or five days. The danger in this operation consists of infection, which is favored by allowing the packs to remain during the period indicated.<Callout type="risk" title="Risk">Improper packing can lead to complications.</Callout> Some of the more recent work done with bone transplants would suggest the use of bone wedges taken from the tibia to support the malar in its raised position, the wound being closed without drainage. Fracture and depression of the zygomatic arch call for reposition of the fragments; this is most satisfactorily accomplished by means of a direct incision exposing the bone.<Callout type="important" title="Important">Direct visualization during surgery can improve accuracy in repositioning.</Callout> If the incision is made parallel to, and a short distance above the arch we can frequently replace the bone and still have the resultant scar in a position which will be covered by the hair after recovery is complete. Care should be taken to accurately approximate the temporal fascia before closing the wound.<Callout type="tip" title="Tip">Proper approximation of soft tissues can improve cosmetic outcomes.</Callout> Sensory disturbances in the course of the dental nerves will usually clear up, but when severe may call for operative intervention to relieve the pressure. Pain in the terminal branches of the infraorbital nerve can sometimes be controlled by a hypodermatic injection of alcohol into the nerve as it emerges from the infraorbital foramen.<Callout type="important" title="Important">Addressing nerve pain early on can prevent long-term complications.</Callout> After-Treatment. — The after-treatment in the ordinary case consists of the avoidance of additional trauma, and allowing Nature to unite the fragments. No retentive apparatus is necessary and dressings are not called for except in compound cases.<Callout type="tip" title="Tip">Proper wound care can prevent complications without hindering natural healing.</Callout> The mouth and nose should be kept clean by the use of antiseptic douches to avoid the possibility of infection by way of the antrum.<Callout type="important" title="Important">Maintaining hygiene is crucial in preventing post-operative infections.</Callout> Prognosis. — Deformity is a common result of fracture of the malar, and even though operative intervention may reduce the displacement it is rarely possible to return the fragments perfectly to their original positions.<Callout type="risk" title="Risk">Incomplete reduction can lead to long-term deformities.</Callout> Neuralgias may follow the condition, but usually subside within a few months even if allowed to go untreated. Interference with the action of the lower jaw following depression of the arch is a condition which has been followed by recovery of function even in cases where no treatment has been employed.<Callout type="important" title="Important">Early intervention can improve outcomes, but natural healing should not be dismissed.</Callout>
Key Takeaways
- Fractures of the malar and zygomatic arch are often caused by direct violence.
- Palpation is crucial for accurate diagnosis, especially in cases where swelling masks underlying deformities.
- Proper after-treatment involves avoiding additional trauma and allowing natural healing.
Practical Tips
- Always use an ice pack early on to reduce swelling and pain following a suspected fracture.
- Be cautious when performing operations as improper technique can lead to complications such as infection or poor healing.
- Maintain proper alignment of the bone post-reduction to prevent long-term deformities.
Warnings & Risks
- Ignoring underlying fractures can result in delayed treatment and potential complications.
- Leaving gauze in place for too long during surgery increases the risk of infection.
- Improper packing or drainage after surgery can lead to complications such as infection or poor healing.
Modern Application
While the techniques described in this chapter are rooted in historical practices, the principles of accurate diagnosis and proper treatment remain crucial. Modern survival preparedness should include understanding these foundational concepts while also leveraging advanced medical tools and techniques for improved outcomes.
Frequently Asked Questions
Q: How can I tell if a patient has subconjunctival emphysema?
Subconjunctival emphysema is indicated by the presence of air bubbles under the conjunctiva, which may be visible as small white or clear blisters. This condition often indicates a more serious underlying injury and should be carefully evaluated.
Q: What are some signs that a fracture might involve nerve damage?
Nerve damage can manifest as pain, numbness, or tingling in the affected area. In cases involving the malar bone and zygomatic arch, this could include symptoms such as altered sensation in the upper teeth and gums.
Q: How should I approach treating a patient with a suspected fracture of the malar bone?
First, apply an ice pack to reduce swelling and pain. Then, carefully palpate the area to assess for deformities or displacement. If there are signs of nerve damage or severe symptoms, consider seeking professional medical intervention.
Q: What is the importance of proper after-treatment in cases of facial fractures?
Proper after-treatment involves avoiding additional trauma and allowing natural healing processes to take place. This can prevent complications such as infection and ensure better long-term outcomes for the patient.
Q: Why might a patient experience pain during mastication following an injury to the zygomatic arch?
Pain during mastication could indicate interference with the function of the lower jaw. This is a key symptom that should be carefully evaluated, as it may require surgical intervention to correct.