Flattened cheek and diplopia after assault
29-year-old male
§Chief complaint
Depressed cheek and double vision after being punched
§Medical & dental history
- 01Healthy, no ocular history
- 02No dental injury
§Clinical examination
- 01Flattening of the right malar prominence, periorbital ecchymosis and subconjunctival haemorrhage
- 02Step at the infraorbital rim and zygomaticofrontal suture
- 03Infraorbital nerve paraesthesia
- 04Diplopia on upward gaze; visual acuity 6/6 bilaterally
§ figuresFigures (1)
Fig. 1CT brain bone window showing right zygomatic arch and anterior wall of right maxillary sinus fracture. Haemosinus is seen within the right maxillary sinus.
“CT brain bone window showing right zygomatic arch and anterior wall of right maxillary sinus fracture” · Cerevisae · CC BY-SA 4.0 · Wikimedia Commons
Verified open-access images only, reproduced for education under their stated licences · no AI-generated or illustrative artwork · Zygomatic Complex Fracture figures pending faculty review.
§Differential diagnosis
§Final diagnosis
Right zygomaticomaxillary complex fracture with orbital floor involvement
The triad of malar flattening, palpable steps at two or more articulations, and infraorbital nerve paraesthesia distinguishes a ZMC fracture from an isolated floor blowout, where the rims are intact.
§Investigations
- 01CT face axial and coronal — fractures at ZF suture, infraorbital rim, zygomatic arch and orbital floor
- 02Formal ophthalmology review with forced duction test
- 03Visual acuity documented before and after surgery
§Treatment plan
- 01Urgent surgery if globe-threatening; otherwise operate at 5-7 days once oedema settles
- 02Open reduction and internal fixation at two or three points
- 03Orbital floor reconstruction with a titanium mesh or PDS sheet
- 04Nose-blowing avoidance and antibiotic cover
§Surgical procedure
- 01Upper buccal sulcus, lateral brow and transconjunctival approaches
- 02Reduction with a Rowe elevator, fixation at ZF suture and infraorbital rim with 1.5 mm plates
- 03Orbital floor explored, herniated fat reduced, titanium mesh placed
- 04Forced duction repeated at the end of surgery
§Follow-up & outcome
- 01Diplopia resolved by 6 weeks
- 02Infraorbital paraesthesia improving at 3 months
- 03Symmetrical malar projection on review
§Clinical pearls / learning points
- 01Always record visual acuity before and after any orbital surgery — retrobulbar haemorrhage is a sight-threatening emergency.
- 02Malar flattening can be masked by swelling; assess from above and behind the patient.
- 03Two-point fixation is usually enough for a stable ZMC; comminuted arch fractures need more.
§References
- Ellis E, Kittidumkerng W. Analysis of treatment for isolated zygomaticomaxillary complex fractures.
§Similar cases
41 cases in the library