Previous year question
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The image shows a CT Brain (Plain) report. The key findings are:
- Comminuted fracture of the left zygomatic arch
- Fracture of the angle of mandible on left side
- Soft tissue swelling in the left zygomatic and masticator region
- No intracerebral hemorrhage / extradural / subdural hematoma
- Cerebral hemispheres, midbrain, cerebellum — normal
- Ventricles, sulci, basal cisterns — normal
- No midline shift
- Sella and parasellar structures — normal
This appears to be a previous year exam question based on a CT report. The likely exam question being tested here is:
"A 34-year-old male presents with facial trauma. CT shows comminuted fracture of the left zygomatic arch and fracture of the angle of mandible on left side with soft tissue swelling. No intracranial pathology. Discuss the management."
Key Teaching Points
1. Zygomatic Arch Fracture
Classification (Knight & North for zygomatic complex fractures):
- Type I — undisplaced
- Type II — isolated zygomatic arch fracture
- Type III — unrotated body fracture
- Type IV — medially rotated body fracture
- Type V — laterally rotated body fracture
- Type VI — comminuted
Clinical Features:
- Flattening of cheek (malar eminence depression)
- Trismus (if arch impinges on coronoid process of mandible)
- Restricted mouth opening
- Infraorbital nerve paraesthesia (in zygomatic complex fractures)
- Step deformity at infraorbital rim
Management of Zygomatic Arch Fracture:
- Gillies temporal approach — classic method; elevator inserted through temporal incision deep to temporalis fascia, lifts the arch
- Keen's intraoral approach — elevator passed through buccal sulcus
- Open reduction + internal fixation (ORIF) — for comminuted or unstable fractures (as in this case)
- Timing: ideally within 2 weeks before fibrosis sets in
2. Fracture of the Angle of Mandible
The angle is the most common site of mandibular fracture after the condyle.
Classification (Spiessl for angle fractures):
- Favorable vs. unfavorable (based on muscle pull direction)
- The angle is unfavorable because masseter and medial pterygoid pull fragments apart
Management:
- IMF (Intermaxillary Fixation) — Erich arch bars, 4–6 weeks
- ORIF — preferred; 2.0 mm miniplates along Champy's lines of osteosynthesis
- One plate along the oblique ridge (tension zone) for angle fractures per Champy
- Extraoral approach — submandibular (Hinds) incision for inferior border plating
3. Important Exam Points
| Feature | Zygomatic Arch | Mandibular Angle |
|---|---|---|
| Surgery | Gillies / ORIF | IMF / ORIF (Champy) |
| Complication | Trismus, cosmetic | Malocclusion, trismus |
| Nerve at risk | Facial nerve (temporal branch) | Inferior alveolar nerve |
| Incision | Temporal / Keen's | Intraoral / submandibular |
4. Why CT Rather Than Plain X-ray?
- CT (especially 3D reconstruction) is gold standard for facial fractures
- Better delineates comminution, displacement, and intracranial injury
- OPG (orthopantomogram) is used specifically for mandibular fractures in outpatient settings
Conclusion for this case: 34M with left comminuted zygomatic arch fracture + left angle of mandible fracture, no intracranial injury. Management = ORIF with miniplates for the comminuted arch fracture + ORIF along Champy's lines for the angle fracture, under GA with nasoendotracheal intubation.
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