THE CLASSIFICATION OF MALAR FRACTURES: AN ANALYSIS OF DISPLACEMENT AS A GUIDE TO T R E A T M E N T By J. S. KNIGHT,Ph.D., B.D.S., H.D.D., and J. F. NORTH,M.B., B.Chir., F.R.C.S.

From The Birmingham Regional Plastic Surgery Unit, Wordsley Hospital

INTRODUCTION

MALAR fractures though only occasionally seen in general surgical practice are very common in centres devoted to plastic surgery and facial injuries. If they are displaced and are not correctly treated they result in disfigurement and often also in severe disability due to interference with vision or with mastication. It is our belief that the classification of these fractures has hitherto been unsatisfactory and that an improved classification has proved to be of great assistance in determining the prognosis and treatment. In the standard textbooks of surgery for undergraduates the subject is usually dealt with very briefly. The elevation of the " fractured zygoma" through a temporal incision within the hairline, according to Gillies et al. (1927) is usually described ; and sometimes it is mentioned that if the standard temporalreduction is unstable, a further approach through the antrum may be required in order to provide support by an antral pack. In more specialised accounts by experts various methods are described for supporting the unstable fracture including antral packing, direct wiring, and pinning ; but there is no clear and agreed indication for any particular method m a specific case. Mowlem and Fickling (1948) attach the greatest importance to the presence or absence of gross comminution in determining which cases are likely to prove unstable, and Rowe and KiUey (1955) to the length of time between injury and operation, stating: " In a case of recent injury stability of the fragments following repositioning is assured by the interdigitation of the bone fragments at the sites of fracture, but following surgical refracturing of the bone this locking effect does not exist and, aided by the pull of the contracted fibrous tissue, the bone tends to collapse back into its former position." This appears to imply that, with certain exceptions which they specify later, stability after temporal reduction is to be expected in all cases up to three weeks following injury. In our experience the stability of reduction depends primarily upon neither of these factors, but upon the type of displacement ; and we believe that classification based upon the anatomy of the fracture provides the soundest means of assessing before operation the appropriate method of reduction, whether fixation will be required and what form it should take. DEFINITION The term "malar fracture" is here used to describe a clinical entity, because anatomically these fractures involve more than one bone. To refer to "fractures of the zygoma" is misleading; most commonly, indeed, there is no fracture of the zygoma itself, which is separated from the neighbouring bones either at the suture lines or by fractures of those bones. The separation medially is usually by fracture of the maxilla (floor of the orbit and anterior and lateral walls of the 4c 325

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antrum), laterally by fracture of the zygomatic process of the temporal bone, and above and behind by separation at the suture lines, from the frontal bone and the greater wing of the sphenoid bone. Again, fractures of the zygomatic arch, which

FIG. I

Group I, No significant displacement. form a distinct clinical group, usually involve both the temporal process of the zygoma and the zygomatic process of the temporal bone. THE PRESENT SERIES We have studied 12o cases of "malar fracture" of which records are available and which were seen at The Birmingham Regional Plastic Surgery Centre between 1949 and November 1957. A small number of patients who were treated during the earlier part of this period were referred from other hospitals with radiographs which were subsequently returned to these hospitals so that they are no longer available for reference here ; those patients whose records are therefore incomplete are not included in the series which, however, is otherwise unselected. Malar fractures associated with fractures of the main body of the maxilla have also been excluded. The basis of our classification is the anatomy of the fracture as demonstrated by the occipito-mental radiograph. This projection is unique in its ability to convey the three-dimensional anatomy of the deformity for two reasons: this

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G r o u p II.

FI~. 2 A r c h fracture.

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is the only view which outlines the irregular contour of the malar bone with the minimum of supra-imposition, and its direction is at an angle to the usual direction of displacement.
CLASSIFICATION TABLE I Undisplaced Displaced-Arch Body-Simple-Depression without rotation . Depression with medial rotation Depression with lateral rotation Complex Group I (7 cases) - 6 per cent. Group II (i2 cases) - io per cent.

Group Group Group Group

III (39 cases)-33 per cent. IV (i 3 cases)= I I per cent. V (26 cases) - 2 2 per cent. VI (23 cases) = 18 per cent.

Group I. No Significant Displacement (seven cases, equals 6 per cent.).-This group consists of those cases in which there was no clinical evidence of displacement and in which the radiograph, though confirming the presence of one or more fracture lines, shows no significant displacement (Fig. I). Fracture lines are seen in the infra-orbital margin and in the malar buttress, but although a small gap is visible in the buttress the fragments remain in line. The cases in this group require no treatment. Group II. Arch Fractures (twelve cases, equals IO per cent.).--These fractures are caused by a direct blow over the zygomatic arch which buckles it inwards, without involving the walls of the antrum or of the orbit (Fig. 2, A and B). It will be seen that there are three fracture lines and two fragments, producing the typical angulation deformity. It is not surprising that a high proportion of these cases were associated with trismus but none with diplopia. Group III. Unrotated Body Fractures (thirty-nine cases, equals 33 per cent.).--This is the most numerous group, caused by a straightforward blow on the prominence of the body of the malar which drives it directly into the antrum (Fig. 3, A and B). The model (Fig. 3, B) shows that the body has been driven backwards, inwards, and slightly downwards, producing flattening of the cheek and a " step " at the infra-orbital margin. The diagnostic features of the group on the occipito-mental radiograph are that the displacement appears to be downwards at the infra-orbital margin and inwards at the malar buttress (Fig. 3, A). The displacement at the fronto-malar suture is slight. Group IV. Medially Rotated Body Fractures (thirteen cases, equals i i per cent.).--These injuries appear to be caused by a blow on the prominence of the malar, from above the horizontal axis of the bone. This also drives the bone backwards, inwards, and downwards but with medial rotation (Fig. 4, B and D). When viewed from in front the bone as a whole is seen to be rotated anti-clockwise in the case of the left malar, and clockwise in the case of the right malar. On ,the X-ray (Fig. 4, A and c) the displacement is seen to be downwards at the infra-orbital margin, and either outwards at the malar buttress or inwards at the fronto-malar suture ; these variations provide two subdivisions of the group--A (Fig. 4, A and B) and B (Fig. 4, c and D).

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Group III.

FIG. 3 Unrotated body fracture.

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Group IVA.

FI~. 4 Medially rotated body fracture.

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D Group IVB. FIG. 4 Medially rotated body fracture.

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(iiiii' i /
B

Fro. 5 Group VA. Laterally rotated body fracture,

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D FIG. 5 Group VB. Laterally rotated body fracture.

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FIG. 6 Group VI. Example I.

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D FIG. 6 Group VI. Example 2.

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G r o u p V. Laterally Rotated Body Fractures (twenty-six cases, equal., 22 per cent.).--These fractures appear to be caused by a blow on the prominence of the malar from below the horizontal axis of the bone. The bone is driven inwards, slightly backwards, and rotated laterally, i.e., clockwise in the case of the left malar and anti-clockwise in the case of the right malar when seen from in front (Fig. 5, B and D). On the X-ray (Fig. 5, A and c) the displacement is seen to be inwards at the malar buttress and either upwards at the infra-orbital margin or outwards at the fronto-malar suture : here again we have two subdivisions of the group--A (Fig. 5, A and B) and B (Fig. 5, c and D). G r o u p VI. C o m p l e x Fractures (twenty-three cases, equals r8 per cent.).-This category includes all cases in which additional fracture lines are seen across the main fragment. This does not apply to minor degrees of comminution at the four main fracture sites. In the first example (Fig. 6, A and B) the general form of the fracture is that of an unrotated body fracture (Group III), but it is complicated by a fracture across the middle of the body. In the second example (Fig. 6, c and D) the body of the bone is medially rotated (Group IV) but there are two additional fracture lines, producing separate fragments of the infra-orbital margin and of the fronto-malar process.
TABLE II

Incidence of Diplopia
Group I-o cases out of 7 Group II-o cases out of i2 Group III-6 cases out of 39 Group IV-n. r c a s e o u t o f 6 B. 4 c a s e s o u t o f 7 Group V-A. I c a s e o u t o f IO B. 2 c a s e s o u t o f r 6 Group VI-3 cases out of 23 Total-17 c a s e s o u t o f i 2 o . o-o per cent. o,o per cent. I5o per cent.

I6.7 per cent. 57o per cent. Io.o per cent. I2.5 per cent. 13 .o p e r c e n t . I4'2 per cent.

Comparison
Mansfield (I948)~ 2o cases out of I53 Barclay (I958)-32 c a s e s o u t o f 3 8 3 I3"r per cent. 8,4 per cent.

DIPLOPIA

The incidence of diplopia at any stage is shown in Table II. Diplopia did not occur in the absence of displacement in the orbital region (Groups I and II). Of the rest it is noticeable that the only group in which the incidence of diplopia departs significantly from the overall figure is Group IVB. This is the only sub-group in which both the lateral wall and the floor of the orbit

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are displaced; there is therefore greater disorganisation of the orbit and its contents, and the higher incidence of diplopia is not surprising either according to the older views concerning the mechanism of diplopia or according to those put forward by Barclay (I958). Of the seven cases in our series which fell into this sub-group more than half had diplopia.
TRISMUS

This term is here used to denote difficulty in opening the mouth. occurrence in the various groups of our series is shown in Table III. TABLE III Incidence of Trismus
Group I-o cases out o f 7 Group II-8 cases out o f 12 Group III-I case out o f 33 Group IV~ A. x cases o u t Of B. 3 cases o u t o f Group V-A. 2 cases o u t o f B. 7 cases o u t o f Group VI-2 cases out o f 23 . 6 = 33 .o per cent. 7 =42.8 per c e n t . ~ 5 out o f 13 IO =20.0 per c e n t . \ 16 =44.o per c e n t . f 9 out o f 26 . o.o p e r cent. 66.6 p e r cent. 3 .o p e r cent. 38'5 p e r cent. 34"6 p e r cent. 8 "7 p e r cent. 2o.8 p e r cent.

Its

Total-25 cases out o f I2O

It will be noticed that trismus occurred in two-thirds of the arch fractures and in more than one-third of the rotated body fractures : the incidence in the unrotated group is insignificant. It is hoped to analyse the mechanism of trismus in these cases elsewhere.
STABILITY AND TREATMENT IN RELATION TO G R O U P

TABLE IV
Group. Number of Cases. Treatment.

No

Stable.

Unstable.

Treatment.

I II III . IVA IVB VA .

VB .
IO

7
12 II

(IOO-o per cent.) 39

Temporal' r e d u c t i o n : stable

)i3
I6~
2

22 15 pack I5 (59 "5 per cent.) (40 '5 per cent.) Io pack 13 (IOO .o per cent.~ 2 pack and w i r e r pack and p i n

(lOO.O p l r cent.) I6 (30.0 per cent.) (7o"o per cent.)

VI .

23

Temporal reduction : stable 6 pack o n l y 4 pin o n l y 4 pack and p i n 2 p i n and w i r e

Total

12o

IO

(6o.o per cent.) (40'0 ; 4 cent.) 66

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In Mansfield's (I948) series of cases treated at The Plastic Surgery Centre at St Albans, I94o to I947, ninety-three of I49 treated cases were stable (62 per cent.) ; our overall figure closely approximates to this. It will be seen that in this present series all arch fractures and laterally rotated body fractures were stable, and all medially rotated body fractures unstable. The unrotated body fractures reflected the overall figure of 60 per cent. stable and 40 per cent. unstable : and of the complex fractures only 30 per cent. were stable and 7 per cent. unstable. When the unrotated body fractures were unstable an antral pack was found to provide the appropriate support. In the medially rotated group a pack was always required and in some cases other measures in addition; whereas, in the complex fractures other forms of fixation were found to be required either instead of, or in addition to, a pack in a high proportion of cases.
STABILITY IN RELATION TO OTHER FACTORS

I. L e n g t h of T i m e b e t w e e n Injury a n d T r e a t m e n t . - - T h e average was 6"4 days in the sixty-six stable cases and 6-6 days in the forty-four unstable ones. This difference is clearly not significant. The average time was increased in both groups by a number of cases which were seen very late--for example, unstable cases were treated after thirty-six, nineteen, and eighteen days : but it is noteworthy that other cases proved to be stable after twenty-one, seventeen, sixteen, and fourteen days respectively. 2. C o m m i n u t i o n . - - G r o s s degrees of comminution were seen in the group of complex fractures (Group VI) and instability was twice as common as in the average. Minor degrees of comminution are commonly seen at the four main fracture lines in both stable and unstable cases of all groups.
TABLE V Age.
O tO IO I I to 2O 2 I to 30

Stable. Nil
2 (I8 per

Unstable.
I

Total. I II 39 29 22 5 3 (I per cent.) (lO per cent.) (35 per cent.) (26 per cent.) (2o per cent.) (5 per cent.) (3 per cent.) Nil

cent.)

24 (62 per cent.)

I 8 (62 p e r c e n t . ) 13 (59 p e r cent.)

3I to 4o
41 to 5 5z to 60 61 to 7

9 (82 per cent.) 15 (38 per cent.) n (38 per cent.)

9 (41 p e r cent.)

Over 7

3 (6o per cent.) 2 (67 per cent.) Nil

2 (4o per cent.) I (33 per cent.) Nil

3. S e x . - - O f the treated cases, ninety-seven were in males (88 per cent.) and thirteen in females (I2 per cent.). Of the ninety-seven males, fifty-eight (6o per cent.) were stable, and 4o per cent. unstable, which reflects the overall figure. Of the thirteen females, six (46 per cent.) were stable and seven (54 per cent.) unstable : the figures are small, but seem to suggest a tendency towards reversal of the average trend. 4. A g e . - - T h e distribution of the xIo treated cases is shown in Table V. The average ratio of 6o per cent. stable to 4 per cent. unstable is reflected

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with remarkable accuracy in all adult age groups. In patients under 2I, however, there is a very noticeable reversal of this ratio, as many as ten out of twelve (8 3 per cent.) being unstable. Taken in conjunction with the figures for sex, this would appear to suggest that stability following simple reduction is more likely when the bone is stout and solid than when it is of more delicate structure. These findings were not due to any tendency for the more delicate bone to be more severely comminuted : of the twenty-three complex cases in Group VI only three (I 3 per cent.) were females, which does not depart significantly from the overall figure: and only two (8. 7 per cent.) were under the age of 2I, a proportion which is actually less than the overall figure.
CONCLUSIONS

I. Arch fractures and laterally rotated body fractures were all stable. 2. Medially rotated body fractures were all unstable ; they all required an antral pack and in some cases other measures as well. 3- Unrotated body fractures reflected the overall figure of 6o per cent. stable, 4o per cent. unstable, and those which were unstable were satisfactorily treated by an antral pack. 4. Complex fractures were 3o per cent. stable, 70 per cent. unstable, and in these cases direct wiring or external fixation was often required. 5. Malar fractures in those under 2I years old were much more likely to be unstable. 6. Malar fractures in females were appreciably more likely to be unstable. 7. Diplopia is commonest when there is displacement both in the floor and in the lateral wall of the orbit. 8. Trismus is commonest in arch fractures and to a lesser extent in rotated body fractures. SUMMARY A classification of malar fractures is described, based on the anatomy of the fracture. This has been found to be helpful in predicting the clinical features and necessary treatment.
Our acknowledgments are due to Mr O. T. Mansfield, Surgeon-in-Charge, to our other colleagues at the Birmingham Regional Plastic Surgery Centre who treated many of these cases, and to Miss M. Robertson for the photographs.

REFERENCES

BARCLAY,T. L. (I958). Brit. J. plast. Surg., rI, I47.

GILLIES, H. D., KILNER, T. P., and STONE, D. (I927). Brit. J. Surg., z4, 65I. MANSFIELD, O. T. (I948). Brit..7. plast. Surg., I, I23. MOWLEM, R., and FICKLING, B. W. (I948). Section on "Facio-maxillary Injuries and Deformities" in " British Surgical Practice," vol. iv, p. 29. London : Butterworth & Co. (Publishers) Ltd. ROWE, N. L., and KILLEY, H. C. (I955). " Fractures of the Facial Skeleton," p. 34I. Edinburgh and London : E. & S. Livingstone Ltd.