Transnasal K-wire to stabilise a complex zygomatic fracture: a forgotten method of fixation

Abstract

Zygomatic complex fractures make up approximately 60% of facial fractures. The vast majority treated surgically use titanium miniplates. These require longer operating times and facial incisions to access the fracture. The use of a K-wire was first described 60 years ago. As a new generation of surgeons emerges, it is important to be aware of the various techniques available to increase their surgical armamentarium. One of its benefits is that it has a significantly reduced operative time and does not require any incisions.

Alternative techniques for treating zygomatic complex fractures have been described in the literature but are seldom used these days. The use of transosseous wires for fixation of zygomatic complex fractures was first described in 1968 by Rowe and Killey.¹ This was furthered by Brown and Barnard in 1983.² The technique involved traversing the zygomatic bones with a K-wire. Other methods have been described including the use of packing of the maxillary antrum, suspensory wires and external pin fixation. We present a case using a transnasal wire as described by Brown and Barnard and discuss its advantages over other methods of fixation of an unstable zygomatic complex.

Case history

A 74-year-old man attended our department following a mechanical fall at home. His main complaint was of binocular diplopia in all gazes. Clinical examination revealed obvious orbital dystopia, a flattened right malar, a palpable step along the infraorbital rim and zygomatic arch, and a laceration above the right eyebrow (Fig 1). X-rays showed superior displacement of the right orbital floor, vertical distraction of the frontozygomatic suture, posterior displacement of the lateral orbital rim and buttress, and a fluid level in the maxillary antrum (Fig 2). Medically, he suffered from ischaemic heart disease, hypertension and elevated cholesterol. Given his medical history, we wanted a short general anaesthetic with the addition of minimal morbidity from surgical access scars.

Figure 1.

Pre and post-operative photographs

Figure 2.

Pre-operative x-rays (arrows show fractures)

Technique

Under endotracheal anaesthesia, the zygomatic complex was reduced with an elevator via a temporal incision. The complex is maintained in position by an assistant standing cranial to the patient. A 1.6–1.8mm K-wire is secured in a drill with sufficient length projecting to allow it to traverse the face from the contralateral side of the nose to the inner aspect of the affected zygomatic body. The length of wire required is assessed approximately by laying the wire over the face before insertion. The wire is inserted through a stab incision in the skin of the nose on the contralateral side. It is important that the operator uses the assistant to assist orientation of the passage of the wire in both anterior/posterior (axial) and superior/inferior (coronal) planes. The entry point is approximately midway between medial canthus and alar base. The wire is aimed at the inner aspect of the zygomatic body.

Points of resistance are felt as the wire passes through the unaffected side frontal process of the maxilla, the nasal septum, the affected side lateral nasal wall and, finally, the zygoma. Once the point of the wire enters the body of the zygoma, the assistant can release any support provided to assess stability. If the wire is inserted too far into the fractured zygomatic body, it can be felt protruding by the operator’s other hand and can simply be withdrawn appropriately. The wire is then cut short with 5mm projecting, which is covered with a rubber bung or Elastoplast^® tape (Beiersdorf, Birmingham, UK). Post-operative x-rays can be taken to check reduction and the position of the wire (Fig 3). The patient can be discharged the following day. We follow up the patient weekly and after 4–6 weeks the wire can be removed in the outpatient clinic with minimal pain and trauma.

Figure 3.

Post-operative x-rays

Discussion

Zygomatic complex fractures make up close to 60% of all facial fractures. Falls account for approximately 15% of these injuries.³ K-wire fixation was first described for fixation of zygomatic complex fractures over 60 years ago.⁴ As a new generation of surgeons emerges, it is important to be aware of the various techniques available to increase their surgical armamentarium. One of the benefits of the technique described here is that it has a significantly reduced operative time and does not require any incisions. This case took approximately 15–20 minutes. If this had been managed using miniplates, it could have taken up to two hours to open, reduce and plate the zygomaticofrontal suture, infraorbital rim and zygomatic buttress.

Conclusions

The technique can be very useful, especially when treating elderly patients, who may have poor quality bone unsuitable for miniplate osteosynthesis. In addition, patients in this age group may have complicated medical histories that would benefit from a shorter general anaesthetic. There is a risk of damage to the nasolacrimal duct and infraorbital nerve but knowledge of anatomy and careful positioning can avoid this complication. Scarring is minimal. Techniques using antral packs are no longer recommended due to prolonged paraesthesia of the infraorbital nerve.⁵ In this case, it was found to be useful in managing a ‘blow in’ fracture of the orbit that has not been described previously.