Zygomaticomaxillary (tripod) fracture

Background

• Must distinguish Zygomatic Arch Fracture from Zygomaticomaxillary (Tripod) Fracture
• Definition = fracture through:
  • Inferior orbital rim
  • Lateral orbital wall
  • Zygomatic arch

Clinical Features

• Facial trauma (blunt, medially-directed force or high-energy decceleration)
• Normally depression of tripod (cheekbone) complex
• Lower eyelid/cheek pain, swelling, and ecchymosis
• +/- Diplopia with upward gaze (due to extraocular muscle contusion/entrapment, orbital hematoma)
• +/- Trismus
• +/- Epistaxis
• +/- Paresthesias of lower lid, cheek, nose, upper lip if injury to infraorbital nerve

Differential Diagnosis

Maxillofacial Trauma

• Le Fort fractures
• Skull fracture (peds)
• Auricular hematoma
• Nasal fracture
  • Nasal septal hematoma
• Zygomatic arch fracture
• Zygomaticomaxillary (tripod) fracture
• Dental trauma
• Mandible fracture

Orbital trauma

Acute

• Ruptured Globe^
• Corneal Abrasion
• Ocular foreign body
• Conjunctival laceration
• Caustic Keratoconjunctivitis^^
• Subconjunctival hemorrhage
• Traumatic iritis
• Traumatic hyphema
• Retinal detachment
• Retrobulbar hemorrhage/hematoma
• Traumatic mydriasis
• Orbital fracture
  • Frontal sinus fracture
  • Naso-ethmoid fracture
  • Inferior orbial wall fracture
  • Medial orbital wall fracture

Subacute/Delayed

• Endophthalmitis^
• Corneal Ulcer^

Evaluation

• CT face
• Rule-out associated ocular injuries or other trauma (e.g. retrobulbar hematoma, ruptured globe)

Management

• OMFS/ENT consult
• Optho consult if ocular signs/symptoms
• Analgesia
• Antibiotic prophylaxis if extends into paranasal sinuses (amoxicillin, fluoroquinolone, doxycycline, or clindamycin)
• Usually requires admission and surgical repair

Disposition

• Loss of vision or displacement: admit for IV antibiotics and surgery

See Also

• Maxillofacial trauma

References

Authors

Ross Donaldson, Claire, Neil Young, Daniel Ostermayer