Introduction

The zygomaticomaxillary complex (ZMC) is a prominent component of one’s facial construct, and its convexity poses increased involvement in facial injury [1]. The zygomaticomaxillary buttress is formed via attachment of the zygomatic bone and maxilla by the alveolus and zygomaticomaxillary (ZM) suture. The zygomatic bone connects to the temporal bone’s zygomatic process laterally, establishing the zygomatic arch. Meanwhile, the zygomaticomaxillary suture line extends to the inferior orbital rim. According to the literature, the zygomaticomaxillary region is the third most frequently fractured facial region, with increased predominance in men [2]. Similar facial skeleton traumas are commonly recorded in men in their second to third decades [2]. Frequent etiological factors involved in these injuries include road traffic injuries, sports accidents, falls and violent encounters [1–9].

The zygomatic bone’s anterolateral projection of the corresponding sides of the mid-face and its tendency for varied types and degrees of fracture call for systemic fracture classification. ZMC fractures can manifest as isolated or complex, resulting in the combination of the internal orbit or with the middle third fracture [1, 9].

Limited literature reports on the surgical emergency modality of multi-fragmentary comminuted zygomatic bone fractures. These facial fractures cause complex injuries that often result in significant facial deformities as well as functional impairment [1–9]. The Henderson Classification is an accepted system that describes the severity of such zygomatic fractures [10]. As stated in a paper by Kassam and Messiha (2014) [10], this classification ranges from Henderson I, which represents a not displaced fracture at any site, to Henderson VII, which denotes a comminuted fracture, in this case involving severe multifragmentation of the zygomatic bone. Other anatomic, radiological and clinical classification systems have been utilised. Zingg et al.’ classification is often adopted due to its simplistic characterization, conveniently referenced to plan treatment modalities for patients presented with such fractures. In accordance with Zingg and colleagues’ classification, fractures can be divided into Type A1: isolated zygomatic arch fracture, Type A2: lateral orbital wall fracture, Type A3: infraorbital rim fracture, Type B: complete monofragment zygomatic fracture and Type C: multifragment zygomatic fracture. This patient case description depicts a Type C multifragmentary zygomatic bone fracture, offering insight into the proper treatment approach to minimize the degree of associative complications [1].

A multidisciplinary approach described herein led to a successful outcome for a patient who sustained a Henderson Class VII, Type C fracture of the zygomatic bone after falling into a wheelbarrow. Despite comorbidities, the case showed a favourable result after debridement, foreign body removal, osteosynthesis, and improved facial symmetry and function.

Case report

Herein, we present a male patient aged 54 with controlled type 2 diabetes admitted to the maxillofacial surgery department from a tertiary hospital following a fall into a wheelbarrow. Upon admission, laboratory tests and a computed tomography (CT) scan were ordered. Although there was no loss of consciousness or eye injury, the patient exhibited cheek oedema, a laceration on his right cheek, impaired function of the temporal branch of the facial nerve, and reduced sensation in the V2 branch on the right side. The cheek laceration was stitched, extending from the cheek to the lateral canthus of the eye.

CT scans confirmed a multi-fragmentary Henderson VII zygomatic bone fracture and fractures of the zygomatic arch and the anterior, superior (orbital floor), and lateral walls of the maxillary sinus. Due to the orbital wall fracture, an ophthalmologist was sought for consultation, revealing no eyeball-related injuries diplopia. The patient was subsequently scheduled for surgery. Before surgery, his oral antidiabetic medications were replaced with insulin therapy, and his HbA1c was measured at 7.3%. Additionally, the patient received tetanus prophylaxis.

Surgical intervention at the maxillofacial ward, which included meticulous debridement, removal of a wooden fragment of approximately 1 cm × 1 cm, and osteosynthesis using eight plates and 36 screws, was successfully performed. The old wound was utilised as the access site to the fracture to minimize new scar formation. A follow-up CT confirmed optimal bone positioning, despite the zygomatic arch being displaced by 3 mm. Based on surgeon expertise, additional surgery was deemed unnecessary.

Postoperative recovery was favourable, resulting in improved facial symmetry and ocular function, although minor complications with eyelid closure persisted. The patient was discharged 2 days post-operation with antibiotic prophylaxis and instructions to follow a soft diet and avoid blowing through the nose. At the three-month follow-up appointment, the patient expressed satisfaction with facial symmetry, reported no diplopia, and noted significant improvement in the right eye closure since the surgery. Plastic surgery intervention for the facial scar was offered; however, it was not deemed necessary according to the patient. The patient remains under the care of an ophthalmologist and maxillofacial surgeon.

Discussion

Proper management and classification of multi-fragmentary comminuted zygomatic bone fractures is essential to mitigate associated complications effectively. Henderson Class VII zygomatic fractures are rare compared to the other classes of the Henderson classification system [10]. The rarity of this case is again highlighted in the Type C classification, according to Zingg et al. A Henderson Class VII is a comminuted zygomatic fracture in this case resulting from a fall into a wheelbarrow, as shown in CT scans in Figures 1 and 2. Patients exhibiting similar zygomatic bone and zygomatic arch fractures commonly present with typical symptoms of oedema, tenderness of the facial soft tissues and ecchymosis [1–4, 10]. As described in this case, the patient initially reported to the tertiary hospital with cheek oedema, laceration on his right cheek, and exhibited additional impaired function of the temporal branch of the facial nerve and reduced sensation in the V2 branch on the right side.

The literature reports differentiating symptoms of impingement of mastication, resulting in trismus and pain. Other associated complications include, but are not limited to, infection, diplopia, blindness, facial asymmetry, epiphora, maxillary sinusitis, gaze reduction, scarring, corneal abrasion, oroantral fistula, bone nonunion, and meteorosensitivity [1–10]. To deter the onset or progression of aforementioned complications, the history of the patient’s trauma and medical condition should be noted by surgeons, followed by a thorough physical examination and radiological diagnostics. For instance, the use of insulin therapy in place of oral diabetes medication pre-surgery was a crucial decision in managing the patient’s diabetes and ensuring optimal glycaemic control during the perioperative period. Elevated HbA1c levels in patients with diabetes can impede wound healing and increase the risk of infection; thus, achieving better glucose control was vital. This case illustrates the need for careful preoperative planning and a holistic approach to manage comorbid conditions effectively. The CT scans shown in Figures 1 and 2 confirmed the zygomatic bone fracture and fractures of the zygomatic arch and the anterior, superior (orbital floor), and lateral walls of the maxillary sinus, allowing surgeons to plan the surgical treatment optimally.

The choice of treatment modality for zygomaticomaxillary complex fractures is dictated by the degree of injury, hence establishing the necessity for surgical intervention, such as exposure, open reduction or internal fixation. Patients who present with zygomatic bone fractures should be promptly treated to stabilize fractures, with stable reduction or rigid internal fixation to optimize the functional and cosmetic results [2–9]. The significance of Henderson class VII, as seen in this case, is that it, is the most severe anatomical classification, which indicates the predicted stability upon reduction. This classification confirms the need for fixation, as depicted by osteosynthesis using eight plates and 36 screws (Figure 3). The patient’s presentation, involving significant comminution and multiple fracture sites, required a multidisciplinary approach to ensure optimal outcomes.

ZMC fractures with the involvement of the orbital floor, as seen in this case, pose additional challenges that need to be evaluated preoperatively. The treatment approach of the orbital floor is controversial and depends on the surgeon’s preference. Surgical exploration of the orbital floor and the infraorbital rim carries an increased risk of iatrogenic complications [1–9]. These complications include infraorbital nerve trauma, epiphora, persistent lower eyelid oedema, entropion, worsening diplopia, and potential blindness [1–9]. Extensive facial deformities and CT scan evidence for the necessity of orbital floor reconstruction were clear indications for treatment for this patient despite possible iatrogenic complications [4]. Preoperative ophthalmologist consultation is a vital step due to the orbital wall fracture.

Despite successful surgical intervention (Figure 4), minor complications with eyelid closure persisted, postulated due to the involvement of the orbital floor. Postoperatively, the patient was prescribed oral steroids and vitamin B complex to mitigate nerve paralysis and eyelid closure. Minor issues with eyelid closure were anticipated, given the extent of the trauma and surgical intervention, yet the overall outcome was favourable.

The patient’s postoperative recovery was notably positive, with significant facial symmetry and ocular function improvements. The decision to discharge the patient 2 days post-operation, with clear postoperative care instructions, underscores the importance of comprehensive discharge planning and patient education in ensuring smooth recovery and minimizing complications. The decision whether to have cosmetic elective surgery to address minor facial discrepancies post-operation is varies among patients. The presented 54-year-old male patient decided not to have other elective surgeries considering the associated risk of his type 2 diabetes.

As presented here, emergency cases with complex rare fractures of ZMC warrant preoperative preventive management to mitigate plausible complications of the fractures. A multidisciplinary approach is recommended, with sound preoperative assessment and consultations, adequate intraoperative surgical treatment plan, postoperative care, follow-up appointments, and physiotherapy.

Funding

No external funding.

Ethical approval

No consent of the Bioethics Committee was required. We complied with the policy of the journal on ethical consent.

Conflict of interest

The authors declare no conflict of interest.

References