broken faces

Monday, March 2, 2015

“You can’t put anything on the internet if it isn’t true.”

It’s a funny commercial for State Farm Insurance but when it comes to medicine, everything must be taken with a grain of salt. Just because the website is reputable or the speaker is well credentialed, does not mean that the information is correct. When it comes to analyzing medicine in the news, fact checking can be difficult since the information source may or may not be reliable. And that’s how I came to yell at my computer screen when reading about the facial injury sustained by Oklahoma Thunder’s Russell Westbrook.

The play was accidental, within seconds of the end of the game, and Mr. Westbrook’s face collided with a teammate’s knee. His face lost and a visible dent could be seen. A quick trip for x-rays, perhaps a face CT, and the diagnosis of zygomatic arch fracture was made. The surgery to repair it has already been completed. My frustration began and increased as I read descriptions of the fractured bone and the complications associated with the injury. Unfortunately, the commentary confused zygomatic arch with the zygoma. Two totally different structures within the face and their injuries are cared for in different ways.

The zygoma or zygomatic bone forms the lateral part of the face and the prominence of the cheek. It also forms the lateral wall and floor of the orbit, where the eye is located. This is a different bone than the zygomatic arch, which is formed by a prominence of the zygomatic bone in combination with the frontal bone.

Zygomatic_bone_anterior Zygomatic_bone_lateral

Zygomatic bone

The zygomatic bone helps form the structure of the face and orbit. It supports the eye socket and the muscles located within. There are also foramens (tunnels or holes) that allow arteries, veins and nerves to enter and exit the face and the orbit.

zygomatic arch

The arch, which Russell Westbrook broke is the prominent part of the cheekbone and part of its job to form protect the face against strong blows.It extends behind or poserior from the zygomatic bone and is rather strong because of its arch design. However, its most import responsibility is its location where the muscles of chewing and facial expression attach. And as a bonus, it allows the temporalis muscle to pass under the arch to allow the jaw to move appropriately.

When injured, the face can break in many ways but isolated injuries to the orbital bones including the zygoma and maxilla can occur. By the way, the orbit is also made up of the frontal, sphenoid, ethmoid, palatine, and lacrimal bones. The worry is all about the eye and its function, the sinuses that are located adjacent to those bones and the nerves that enter and exit through the bones. No matter what prominent websites report, the zygomatic arch has no relationship to these structures.

The zygomatic arch can break in association with other bones or it can be an isolated injury. When the arch is broken, the muscles that attach to it go into spasm and make be difficult to open the mouth (trismus). There is asymmetry and flattening of the face but usually no other major disasters. Its purpose is to protect more important facial structures and by collapsing the arch, it has performed its duty.

Treatment of the zygomatic bone fracture is meant to restore the symmetry of the face, make certain that the eye moves normally in the orbit and address any potential nerve damage. Up to 50% of these fractures will heal with no surgery required.

Treating the zygomatic arch fracture depends upon whether it is displace or caved in. If the bone is in the appropriate alignment, not much else is required. But in cases like Mr. Westbrook, where the arch is caved in, surgery is required to restore facial symmetry and to allow the temporalis muscle to pass under the arch unimpeded so jaw movement and chewing can be normalized.

Medicine isn’t that hard once you know anatomy and physiology and can match the two. It might be acceptable for the press to confuse one bone with another…or not. Fact checking is part of the job, just as it is in medicine. By knowing the structures of the body and their purpose, it is easier to look for potential complications. It is also easier to explain to the patient and family what options for treatment are reasonable. Sometimes the discussion gets confusing when the patient has done some research and the information that they read on the internet wasn’t necessarily true and may conflict with the bedside opinion they have just heard. That said, perhaps the best advice is not to rely of reporters for their medical knowledge, or you can just scream at your compute like I did.

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