01Approach to the Critical Patient/attcp21

Airway and Hemodynamic Stabilization

›Initial stabilization priorities for ZMC fracture with concomitant injury

›Airway patency threatened by massive midface edema or bilateral fractures

›Early anesthesia or trauma surgery consultation for anticipated difficult airway

›Cervical spine immobilization until cleared in high-energy mechanisms

Ophthalmologic Emergencies

›Vision-threatening complications requiring immediate recognition

›Retrobulbar hematoma with proptosis, tense orbit, pain with eye movement, and elevated intraocular pressure

›Afferent pupillary defect indicating optic nerve compromise

›Acute vision loss or rapidly decreasing visual acuity in 6% of ZMC fractures requiring surgical repair

›Globe rupture occurring in up to 10% of ZMC fractures requiring surgical repair

›Emergent lateral canthotomy and inferior cantholysis for retrobulbar hematoma with vision threat

Immediate Actions

›Time-critical steps in first 30 minutes

›Visual acuity testing on all patients before any intervention or periorbital manipulation

›Ophthalmology consultation for vision changes, afferent pupillary defect, globe injury, or entrapment

›Control active epistaxis with anterior nasal packing if hemostasis required

›Head of bed elevation to 30 degrees to reduce edema

›Instruction not to blow nose due to risk of orbital emphysema and sinus infection

Consultation Triggers

›Specialist activation criteria

›OMFS or plastic/facial trauma surgery for all displaced ZMC fractures

›Ophthalmology urgently for any visual acuity change, afferent pupillary defect, diplopia, or extraocular muscle entrapment

›Neurosurgery for associated skull base fracture or intracranial injury

›Trauma surgery activation for polytrauma, hemodynamic instability, or high-energy mechanism

02History/hx36

Mechanism of Injury

›Mechanism and force vector characterization

›Direct blow to cheek or malar eminence — assault most common cause in Western populations

›Motor vehicle accident — leading cause in developing countries

›Falls — increasingly common in elderly populations

›Sports injuries — contact sports including boxing, martial arts, rugby, and hockey

›Lateral, anterior, or inferior impact vector

›Timing of injury — delay greater than 2 weeks complicates reduction due to early bony union

Key Symptoms

›Cardinal presenting symptoms

›Facial asymmetry or flattening of the cheek (malar depression)

›Numbness or tingling of ipsilateral cheek, upper lip, upper teeth, or lateral nose (infraorbital nerve V2 distribution)

›Diplopia, especially on upward gaze

›Trismus or difficulty opening the mouth due to arch impingement on coronoid process

›Unilateral epistaxis

›Pain with chewing or mastication

Alarm Symptoms

›High-risk features warranting urgent evaluation

›Acute vision loss or decreasing visual acuity

›Increasing eye pain, proptosis, or inability to open the eye

›Clear rhinorrhea suggesting CSF leak and associated skull base fracture

›Loss of consciousness at time of injury

›Neck pain suggesting cervical spine injury

Past Medical and Social History

›Relevant background information

›Prior facial fractures or facial surgery

›Pre-existing ocular conditions including baseline diplopia, strabismus, or prior orbital surgery

›Bleeding disorders or anticoagulant and antiplatelet use

03Physical Exam/exam32

Inspection

›Visual inspection findings

›Periorbital ecchymosis (raccoon eye) — present in approximately 77% of cases

›Malar flattening or cheek depression — most common sign, present in 73.6%, may be masked by acute edema

›Facial asymmetry on bird's-eye comparison from above

›Lateral subconjunctival hemorrhage with no posterior limit — highly specific finding

›Subcutaneous emphysema indicating sinus communication

›Unilateral epistaxis

Palpation

›Palpation findings

›Bony step-off at infraorbital rim, zygomaticofrontal suture, or zygomatic arch — highly specific

›Tenderness over malar eminence

›Crepitus indicating subcutaneous emphysema

Neurologic Exam

›Infraorbital nerve assessment

›Light touch sensation over ipsilateral cheek, upper lip, upper gingiva, and lateral nose

›Paresthesia or anesthesia in V2 distribution present in 44 to 83% of displaced ZMC fractures

Ophthalmologic Exam

›Ocular examination — mandatory before any intervention

›Visual acuity with Snellen chart

›Pupillary size, reactivity, and afferent pupillary defect testing

›Extraocular movements — restriction in any direction suggests entrapment

›Diplopia assessment, particularly on upward gaze

›Enophthalmos — may be masked by edema acutely; becomes apparent as swelling resolves

›Vertical dystopia — unequal pupil heights indicating orbital floor displacement

›Intraocular pressure measurement if retrobulbar hematoma is suspected

Oral Exam

›Intraoral and dental examination

04Differential Diagnosis/ddx12

Facial Fracture Mimics

›Alternative fracture patterns to distinguish from ZMC fracture

›Isolated zygomatic arch fracture — trismus and cheek flattening without orbital involvement, ICD-10 S02.400

›Orbital blowout fracture (floor or medial wall) — diplopia and enophthalmos without malar flattening, ICD-10 S02.3

›Le Fort II fracture — pyramidal midface fracture with bilateral involvement and midface mobility, ICD-10 S02.411

›Le Fort III fracture — craniofacial disjunction with CSF leak risk, ICD-10 S02.413

›Naso-orbito-ethmoid fracture — telecanthus, CSF leak, medial canthal tendon disruption

Mandibular and Dental Pathology

›Jaw and dental causes of trismus and malocclusion

›Mandibular condyle or subcondylar fracture — trismus and malocclusion without malar findings, ICD-10 S02.61

›Isolated maxillary sinus fracture — epistaxis without cheek deformity

Soft Tissue Injury

›Non-osseous injury patterns

›Soft tissue contusion without fracture — swelling and ecchymosis without bony step-off, no paresthesia

›Periorbital hematoma without fracture — ecchymosis without step-off or neurologic signs

05Laboratory Tests/lt12

Pre-operative Assessment

›Laboratory workup for patients requiring surgical repair

›Complete blood count for baseline hemoglobin and platelet assessment

›Basic metabolic panel for electrolytes and renal function prior to general anesthesia

›Coagulation studies — prothrombin time and partial thromboplastin time for anticoagulant use or bleeding history

›Type and screen for anticipated surgical blood loss

›Pregnancy test for females of reproductive age prior to general anesthesia

Toxicology and Special Circumstances

›Laboratory testing for specific indications

›Blood alcohol level if altered mental status or medicolegal concerns — present in up to 70% of assault-related cases

›Urine drug screen for altered mental status

›Troponin only if concomitant blunt chest trauma or cardiac symptoms

›Routine labs not required for isolated non-operative ZMC fractures

›No specific laboratory abnormalities are diagnostic of ZMC fracture

06Diagnostic Tests/dt34

Scoring Systems

›Zingg classification system for ZMC fractures

›Type A — incomplete fracture at single articulation

›A1 — isolated zygomatic arch fracture

›A2 — isolated lateral orbital wall fracture

›A3 — isolated infraorbital rim fracture

›Type B — complete tetrapod fracture involving all four articulations as a monofragment — most common type requiring ORIF

›Type C — comminuted multifragment fracture with highest complication rate including facial asymmetry, enophthalmos, and persistent nerve injury

›Haworth Clinical Decision Rule (2017)

›Four clinical signs: palpable bony step-off, lateral subconjunctival hemorrhage without posterior limit, infraorbital paresthesia, palpable emphysema

›Sensitivity 100% for displaced ZMC fracture when any one sign is present

›May allow avoidance of CT imaging when all four signs are absent

CT

›Maxillofacial CT — gold standard for diagnosis and surgical planning

›Thin-cut 1 to 2 mm axial slices with coronal and sagittal reconstructions

›3D volumetric reconstruction recommended for surgical planning and assessing displacement

›ACR Appropriateness Criteria support maxillofacial CT as first-line imaging for facial trauma

›Key findings to evaluate on CT

›Fracture line disruption at all four articulations — zygomaticofrontal, zygomaticomaxillary, zygomaticotemporal, and zygomaticosphenoid sutures

›Degree of displacement and rotational deformity

›Lateral orbital wall angulation causing increased orbital volume leading to enophthalmos

›Orbital floor fracture with herniation of orbital fat or inferior rectus muscle

›Hemosinus — maxillary sinus opacification indicating blood

›Posterior displacement 3 mm or greater associated with 40% probability of requiring orbital floor repair

›Plain radiographs (Waters view, submentovertex) largely supplanted by CT; may show arch depression or sinus opacification but miss significant pathology

MRI

›MRI indications in ZMC fracture

›Not first-line for acute fracture diagnosis — CT is preferred

07Disposition/dispo19

Discharge Criteria

›Criteria for safe discharge from emergency department

›Isolated non-displaced or minimally displaced ZMC fracture confirmed on CT

›Normal visual acuity bilaterally

›No extraocular muscle entrapment or restriction

›No evidence of retrobulbar hematoma

›Adequate pain control achieved

›Reliable follow-up with OMFS or plastic surgery within 5 to 7 days arranged

Admission Criteria

›Indications for inpatient admission

›Concomitant intracranial injury, polytrauma, or hemodynamic instability

›Retrobulbar hematoma or acute vision-threatening injury requiring monitoring or urgent intervention

›Inability to protect airway due to severe bilateral fractures or massive edema

›Need for urgent surgical intervention within 24 to 48 hours

›Borderline visual acuity changes requiring serial ophthalmologic examinations

›Significant periorbital edema preventing adequate eye examination

Follow-up Requirements

›Outpatient follow-up schedule

›OMFS or plastic surgery within 5 to 7 days to allow initial edema to subside and for surgical planning

›Ophthalmology within 1 to 2 weeks, or sooner if any visual symptoms develop

›Post-operative follow-up at 1 week, 1 month, 3 months, and 6 months for nerve recovery, symmetry, and ocular function assessment

›Repeat clinical exam after edema resolves to reassess for previously masked malar flattening or enophthalmos

08Treatment/t48

Immediate ED Interventions

›Initial management in emergency department

›Analgesia for pain control

›Ibuprofen 400 to 800 mg orally every 6 to 8 hours for mild to moderate pain

›Ketorolac 15 to 30 mg IV or IM for acute moderate to severe pain

›Acetaminophen 650 to 1000 mg orally or IV every 6 hours as adjunct

›Opioids for severe pain — morphine 2 to 4 mg IV every 4 hours as needed or oxycodone 5 to 10 mg orally

›Antiemetics for nausea or vomiting especially with diplopia or muscle entrapment

›Ondansetron 4 mg IV or orally every 6 hours as needed

›Ice application and head of bed elevation to 30 degrees to reduce edema

›Instruction not to blow nose for minimum 2 to 4 weeks

Emergent Lateral Canthotomy and Cantholysis

›Procedure for retrobulbar hematoma with vision threat

›Indication — acute vision loss, afferent pupillary defect, IOP greater than 40 mmHg, proptosis with tense orbit

›Lateral canthotomy — horizontal incision through lateral canthus to lateral orbital rim

›Inferior cantholysis — division of inferior crus of lateral canthal tendon

›Superior cantholysis added if IOP remains elevated after inferior cantholysis

›Goal — rapid decompression of orbital compartment to restore optic nerve perfusion

›Ophthalmology consultation immediately following procedure

Antibiotic Prophylaxis

›Antibiotic selection based on fracture type and operative status

›Non-operative management — no prophylactic antibiotics indicated (AAST consensus 2023)

›Operative non-contaminated fractures — single preoperative dose cefazolin 2 g IV within 60 minutes of incision

›No postoperative antibiotics beyond 24 hours for non-contaminated fractures (Level I evidence, RCT)

›Open or contaminated fractures — prophylactic antibiotics for 24 hours maximum

›Amoxicillin-clavulanate 875 to 125 mg orally twice daily for oral flora coverage

›Penicillin allergy — clindamycin 600 mg IV every 8 hours or 300 mg orally every 6 hours

09Special Populations/sp33

Pregnancy

›ZMC fracture management in pregnancy

›Fetal radiation exposure — maxillofacial CT delivers approximately 0.004 mGy to 0.01 mGy to fetus, well below 50 mGy threshold for teratogenic risk

›CT imaging indicated when clinical decision rule positive — maternal benefit outweighs fetal risk

›Abdominal shielding recommended when CT obtained

›Teratogenic medication avoidance

›NSAIDs should be avoided after 20 weeks gestation due to premature ductus arteriosus closure risk

›Opioids acceptable for short-term acute analgesia with monitoring

›Acetaminophen preferred analgesic throughout pregnancy

›Surgical timing — delay elective ORIF to second trimester if possible; urgent procedures proceed when clinically indicated

›Multidisciplinary coordination with obstetrics for surgical planning and anesthesia

›Oxymetazoline nasal spray — limited data; use with caution and only short term

Geriatric

›Modified approach in patients aged 65 years and older

›Falls increasingly common mechanism in elderly — low-energy mechanisms can produce significant fractures in setting of osteoporosis

›Higher baseline rate of anticoagulant and antiplatelet use — review and manage perioperatively

›Pre-existing ocular conditions including glaucoma or prior surgery may confound examination

›Frailty and comorbidities increase perioperative risk — careful anesthesia and surgical risk assessment

›Analgesia adjustments in elderly patients

›NSAIDs with caution — increased risk of renal injury, GI bleeding, and cardiovascular events

›Acetaminophen preferred first-line analgesic — 650 mg every 6 hours

›Opioids at reduced doses — increased sedation and fall risk; morphine 1 to 2 mg IV as starting dose

›Cognitive impairment may limit reliable symptom reporting — collateral history from family or caregivers essential

›Lower threshold for admission for monitoring given reduced physiologic reserve

Pediatrics

›ZMC fracture management in children

›ZMC fractures rare in children due to underpneumatized sinuses and prominent forehead providing protection

›Pediatric orbital blowout fractures may present as white-eyed blowout — minimal periorbital signs with significant entrapment and vagal symptoms

10Background/b33

Epidemiology

›ZMC fracture population data

›Second most common facial fracture after nasal fractures

›Accounts for approximately 40% of all facial fractures

›Male predominance with male to female ratio of approximately 3 to 6:1

›Peak incidence in males aged 20 to 40 years

›Leading causes by region

›Western countries — interpersonal violence and assault most common

›Developing countries — motor vehicle accidents predominate

›Alcohol and substance use implicated in up to 70% of assault-related cases

›Bilateral ZMC fractures rare — associated with high-energy mechanisms

Pathophysiology

›Anatomic basis of ZMC fracture

›Zygoma articulates at four points — zygomaticofrontal suture, zygomaticomaxillary buttress, zygomaticotemporal suture, and zygomaticosphenoid suture

›Direct impact disrupts all four articulations producing classic tetrapod fracture pattern

›Infraorbital nerve injury — nerve traverses infraorbital canal and exits via infraorbital foramen; disrupted by zygomaticomaxillary buttress fracture

›Orbital volume increase — lateral wall displacement lateralizes orbital walls, enlarging orbital cavity leading to enophthalmos

›Trismus mechanism — depressed zygomatic arch impinges on coronoid process of mandible limiting mouth opening

›Complications by frequency

›Persistent infraorbital nerve paresthesia — most common long-term sequela at 37 to 45% at 6 months

›Facial asymmetry — 14% of cases

›Enophthalmos — 7% of cases

›Persistent diplopia — 7% of cases

›Surgical site infection — 4% of cases

›Malunion — uncommon with timely surgical repair

Therapeutic Considerations

›Evidence base and clinical decision-making framework

›ACR Appropriateness Criteria support maxillofacial CT as first-line imaging for facial trauma evaluation (Guideline level)

11Patient Discharge Instructions/pdi30

copy discharge instructions

›ZMC fracture discharge instructions for patients

›You have been diagnosed with a cheekbone (zygomaticomaxillary complex) fracture

›Take pain medications as prescribed

›Ibuprofen or acetaminophen as directed for pain control

›Take medications with food to avoid stomach upset

›Activity restrictions

›Do not blow your nose for at least 2 to 4 weeks — this can push air into the orbit causing infection or worsening

›If you need to sneeze, sneeze with your mouth open

›Avoid strenuous activity and heavy lifting for 2 to 4 weeks

›No contact sports for a minimum of 6 to 8 weeks

›Sleep with your head elevated above heart level

›Diet instructions

›Eat soft or liquid foods for 2 to 4 weeks

›Avoid hard, chewy, or crunchy foods requiring forceful chewing

›Maintain adequate hydration and caloric intake

›Expected symptoms during recovery

›Swelling and bruising around the eye will gradually improve over 2 to 4 weeks

›Numbness or tingling over your cheek, upper lip, or teeth may persist for weeks to months and in some cases is permanent

›Double vision, if present, often improves significantly after surgical repair

›Return to emergency department immediately for any of the following

›New or worsening vision changes, blurring, double vision, or loss of vision

›Increasing eye pain, eye swelling, or inability to open the eye

›Proptosis — eye bulging forward or appearing pushed out

›Increasing facial swelling, redness, warmth, tenderness, or fever above 38.0 degrees Celsius

›Clear fluid draining from your nose — this may indicate a CSF leak requiring urgent evaluation

›Worsening difficulty opening your mouth

›Any neurologic symptoms including severe headache, confusion, neck stiffness, or altered level of consciousness

12References/r17

Guidelines and Key Sources

›Primary clinical guidelines

›Expert Panel on Neurological Imaging, Parsons MS, Policeni B, et al. ACR Appropriateness Criteria: Imaging of Facial Trauma Following Primary Survey. Journal of the American College of Radiology. 2022. https://doi.org/10.1016/j.jacr.2022.02.013

›Appelbaum RD, Farrell MS, Gelbard RB, et al. Antibiotic Prophylaxis in Injury: AAST Critical Care Committee Clinical Consensus Document. Trauma Surgery and Acute Care Open. 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11149135/

›Coccolini F, Sartelli M, Sawyer R, et al. Antibiotic Prophylaxis in Trauma: Global Alliance for Infection in Surgery and World Society of Emergency Surgery Guidelines. Journal of Trauma and Acute Care Surgery. 2024. https://doi.org/10.1097/TA.0000000000004233

Key Clinical Studies

›Foundational and recent evidence

›Haworth S, Bates A, Beech A, Knepil G. A Clinical Decision Rule to Predict Zygomaticomaxillary Fractures. Journal of Cranio-Maxillo-Facial Surgery. 2017. https://pubmed.ncbi.nlm.nih.gov/28647160

›Soong PL, Schaller B, Zix J, et al. Role of Postoperative Prophylactic Antibiotics in Treatment of Facial Fractures: RCT. British Journal of Oral and Maxillofacial Surgery. 2014. https://pubmed.ncbi.nlm.nih.gov/24602602

›Birgfeld CB, Mundinger GS, Gruss JS. Evidence-Based Medicine: Evaluation and Treatment of Zygoma Fractures. Plastic and Reconstructive Surgery. 2017. https://pubmed.ncbi.nlm.nih.gov/28027253

›Jamal BT, Pfahler SM, Lane KA, et al. Ophthalmic Injuries in Patients With ZMC Fractures Requiring Surgical Repair. Journal of Oral and Maxillofacial Surgery. 2009. https://pubmed.ncbi.nlm.nih.gov/19375007

›Mueller CK, Zeiß F, Mtsariashvili M, et al. Correlation Between Clinical Findings and CT-measured Displacement in ZMC Fractures. Journal of Cranio-Maxillo-Facial Surgery. 2012. https://pubmed.ncbi.nlm.nih.gov/21733703

›Soliman L, Menville JE, Rhee BS, et al. Refining Indications for Orbital Floor Reconstruction in ZMC Fractures. Journal of Craniofacial Surgery. 2025. https://pubmed.ncbi.nlm.nih.gov/40845370

›Gadkari N, Bawane S, Chopra R, et al. Comparative Evaluation of 2-Point vs 3-Point Fixation in ZMC Fractures: Systematic Review. Journal of Cranio-Maxillo-Facial Surgery. 2019. https://pubmed.ncbi.nlm.nih.gov/31395419

›Winegar BA, Murillo H, Tantiwongkosi B. Spectrum of Critical Imaging Findings in Complex Facial Skeletal Trauma. Radiographics. 2013. https://pubmed.ncbi.nlm.nih.gov/23322824

›Bogusiak K, Arkuszewski P. Characteristics and Epidemiology of Zygomaticomaxillary Complex Fractures. Journal of Craniofacial Surgery. 2010. https://pubmed.ncbi.nlm.nih.gov/20677370

›Brucoli M, Boffano P, Broccardo E, et al. The European Zygomatic Fracture Research Project: Epidemiological Results. Journal of Cranio-Maxillo-Facial Surgery. 2019. https://pubmed.ncbi.nlm.nih.gov/30765246

›Swift WM, Marston AP, Tollefson TT. Advances in Facial Fracture Care in ZMC Fractures. Current Opinion in Otolaryngology and Head and Neck Surgery. 2025. https://pubmed.ncbi.nlm.nih.gov/40298611

›Tong Y, Jie B, Zhang Y, He Y. Treatment Complications Analysis of Zygomatic Complex Fractures. Journal of Craniofacial Surgery. 2026. https://pubmed.ncbi.nlm.nih.gov/41842833

Evidence & Review

Evidence & Review