# Quadramalar cheek fracture



## awest (Dec 30, 2009)

What code would you use? The doctors office says 21365...


PREOPERATIVE DIAGNOSIS:  Comminuted displaced right quadramalar cheek fracture.

POSTOPERATIVE DIAGNOSIS:  Displaced comminuted right quadramalar fracture with the right infraorbital nerve compression.

PROCEDURES
1.	Repair of orbital floor fracture.
2.	Repair of inferior orbital rim fracture.
3.	Repair of lateral orbital rim fracture.
4.	Repair of maxillary buttress fracture.
5.	Right infraorbital nerve decompression.


HISTORY OF PRESENT ILLNESS:  The patient is a 38-year-old female who sustained a syncopal episode hitting her face on a piece of equipment at a mammography suite.  The patient was transferred to the emergency room where a CAT scan showed a right malar fracture.  The patient came to my office the day following the injury and was examined by me.  Physical exam in the office showed significant right cheek soft tissue ecchymosis and edema as well as right cheek hypoesthesia along the gums, the cheek, and the upper lip.  There was some flattening of the right malar eminence and some significant displacement of the right temporal zygomatic arch laterally.  There was some diplopia and pain with upward gaze on the right eye.  However, extraocular movements were only mildly restricted on the right side with upward gaze.  The remainder of the cranial nerve evaluation as well as the physical examination was within normal limits.

PROCEDURE:  On the date of procedure, the patient was identified in the holding area.  She was taken to the operating room where she was laid in the supine position.  General endotracheal anesthesia was successfully administered.  The table was then turned and the right gingival buccal sulcus, the right inferior conjunctiva, and the right malar eminence soft tissues were injected with 1% lidocaine with 1:100,000 epinephrine.  At this point, a transconjunctival incision was made in the right lower eyelid with a Colorado Bovie.  The orbital septum was identified and using the Colorado needle, the periosteum of the right infraorbital rim was identified and incised.  Using a periosteal elevator, the periosteum was elevated from the anterior face of the orbital rim as well as from the orbital floor, releasing and decompressing any orbital contents within the medial orbital floor fracture.  At this point, there were several spicules and remnants of comminuted orbital floor as well as orbital rim that were compressing the right infraorbital nerve.  The larger pieces of bone were savaged.  However, multiple pieces of comminuted bone had to be removed in order to aid in reduction.  The nerve was decompressed and cleaned of all remnants of bone at this point.  All fractured segments along the orbital floor and orbital rim were identified and isolated from the periosteum.  Attention was now directed to the right gingival buccal sulcus where an incision was made with Colorado needle tip Bovie.  The soft tissues of the sulcus were transected down to the face of the maxilla.  The periosteum was elevated through these incisions from an inferior to superolateral direction, communicating this incision with the transconjunctival incision.  At this point, multiple comminuted portions of bone from the face of the maxillary sinus were identified.  A #15 scalpel was used to make an incision in the soft tissues over the right malar eminence and this was followed down to the periosteum of the malar eminence.  Using a Freer elevator, the periosteum was freed from the bone from over this incision.  A Carol-Gerard screw was then inserted into the malar eminence in order to aid in movement of the free segment of maxilla.  Using the Carol-Gerard screw to obtain reduction of all segments, the segment was manipulated and held in place while the fractures were plated.  Through the gingival buccal sulcus incision in L-shaped, 2.0 mm plate was secured from the anterior face of the maxilla across the fracture and onto the free-floating segment of maxilla.  Two screws were used on either side of the fracture in order to secure this L plate.  Adequate reduction was achieved with this L plate along the anterior face of the maxilla.  At this point, the transconjunctival incision was used to approach the orbital floor again with the aid of malleable retractors and a Desmarres retractor.  An orbital floor plate was customized and inserted over the orbital floor fractured, paying close and meticulous attention to keeping all contents of the orbit above the plate.  The plate was left and using four points of fixation, 4-mm screws were used to secure the anterior face of the palate to the orbital rim, paying close attention to using the plate to reduce the orbital rim fracture.

At this point, the decision was made to adequately reduce the right lateral orbital rim fracture.  An incision was made along the lateral canthal area with a #15 scalpel, and the periosteum was identified.  A Freer elevator was used to identify the fractured lateral orbital rim segment and separate the periosteum from the bone.  A three-hole 2-mm plate was used to secure either side of this fracture.  This was done with 4 mm screws.  The skin incisions were closed with a 5-0 plain suture in an interrupted fashion and a 5-0 Prolene suture in a running subcuticular fashion.  The transconjunctival incision was closed with a 3-0 Vicryl for the orbital septum and the periosteum as well as to displace as much orbital fat as possible over the rim of orbital floor plate in order to minimize palpation of the plate.  The conjunctiva was closed with a 6-0 fast gut in a buried interrupted fashion.  The right gingival buccal sulcus incision was closed with a 4-0 chromic interrupted deep and then the mucosa was closed with an interrupted 4-0 chromic complemented by a running locking 4-0 chromic for the mucosa.  The patient was successfully extubated.  The patient was taken to recovery in a stable satisfactory condition.  The patient tolerated the procedure well.


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