Flattened cheek and diplopia after an assault

§Chief complaint

Facial injury with double vision and numb cheek after being punched

§Medical & dental history

• 01No loss of consciousness, no anticoagulants
• 02Dentition intact, occlusion unchanged

§Clinical examination

• 01Flattening of the left malar prominence with periorbital ecchymosis and subconjunctival haemorrhage
• 02Step deformity at the left infraorbital rim and zygomaticofrontal suture
• 03Paraesthesia in the left infraorbital nerve distribution
• 04Diplopia on upward gaze; mouth opening limited to 25 mm by coronoid impingement
• 05Visual acuity 6/6 bilaterally, pupils equal and reactive

§ figuresFigures (1)

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§Differential diagnosis

§Final diagnosis

Displaced left zygomaticomaxillary complex fracture with orbital floor involvement

Step deformities at three buttresses, malar flattening, infraorbital paraesthesia and gaze-restricted diplopia with CT confirmation of displaced fractures through the ZF suture, infraorbital rim, zygomaticomaxillary buttress and orbital floor define a displaced ZMC fracture requiring reduction and fixation.

§Investigations

• 01Full ophthalmic assessment including visual acuity, pupils and fundoscopy
• 02Forced duction test under anaesthesia to distinguish entrapment from oedema
• 03CT facial bones with axial, coronal and 3D reconstructions

§Radiology

• 01CT — displaced fractures of the ZF suture, infraorbital rim, zygomatic arch and anterior maxillary wall
• 02Coronal CT — orbital floor defect 12 mm with herniation of periorbital fat; inferior rectus not entrapped
• 03Maxillary sinus opacified with blood

§Treatment plan

• 01Open reduction and internal fixation within 7-10 days, before malunion
• 02Orbital floor exploration and reconstruction with a titanium mesh or porous polyethylene implant
• 03Post-operative ophthalmic review; nose-blowing avoidance and antibiotic cover

§Surgical procedure

• 01Lateral brow and upper buccal sulcus approaches plus a transconjunctival incision with lateral canthotomy
• 02Three-point fixation at the ZF suture, infraorbital rim and zygomaticomaxillary buttress with 1.5 mm plates
• 03Orbital floor reconstructed with a 0.4 mm titanium mesh; forced duction repeated and free

§Follow-up & outcome

• 01Day 1 — vision intact, no retrobulbar haemorrhage
• 026 weeks — diplopia resolved, symmetry restored, opening 45 mm
• 036 months — infraorbital sensation nearly normal

Outcome: Symmetrical malar projection with resolution of diplopia and near-complete sensory recovery.

§Discussion

• 01Retrobulbar haemorrhage is the emergency to watch for: proptosis, pain, falling acuity and a fixed pupil require immediate canthotomy and cantholysis.
• 02Non-displaced ZMC fractures without functional deficit may be managed conservatively with observation.
• 03Three-point fixation gives the most reliable control of rotation about the vertical axis.

§Clinical pearls / learning points

• 01Document visual acuity before and after any orbital surgery.
• 02Trismus in mid-face trauma often means the depressed arch is impinging on the coronoid.

§Viva questions

§MCQs

§Related diseases

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