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Facial Trauma After Assault: Zygomaticomaxillary Fracture Case [ Case Discussion ](https://mdster.com/blog?category=case-discussion) Facial Trauma After Assault: Zygomaticomaxillary Fracture Case ================================================================ How to localize the fracture pattern, avoid missed associated injuries, and handle the forensic and longitudinal care issues that matter in Family Medicine [ MDster Editorial Team ](https://mdster.com/about) · Mar 14, 2026 · 7 min read · 132 [ Reviewed by Dr. Ali Ragab, MBBCH, MSc, MCAI ](https://mdster.com/medical-reviewers/dr-ali-ragab) [Editorial Policy](https://mdster.com/editorial-policy) | [Corrections Policy](https://mdster.com/corrections) [ Board Review ](https://mdster.com/blog?tag=board-review) [ Family Medicine ](https://mdster.com/blog?tag=family-medicine) [ Case Discussion ](https://mdster.com/blog?tag=case-discussion) [ Emergency Care ](https://mdster.com/blog?tag=emergency-care) [ Facial Trauma ](https://mdster.com/blog?tag=facial-trauma) [ Intimate Partner Violence ](https://mdster.com/blog?tag=intimate-partner-violence) Share this article Share this post On this page 1. [ Reading the vignette in real time ](#reading-the-vignette-in-real-time) 2. [ Differential diagnosis and why it matters ](#differential-diagnosis-and-why-it-matters) 3. [ Investigations and early management ](#investigations-and-early-management) 4. [ IPV, documentation, and longitudinal follow-up ](#ipv-documentation-and-longitudinal-follow-up) 5. [ Clinical Application ](#clinical-application) 6. [ Key Points for Board Exams ](#key-points-for-board-exams) 7. [ Conclusion ](#conclusion) 8. [ References ](#references-heading) On this page 1. [ Reading the vignette in real time ](#reading-the-vignette-in-real-time) 2. [ Differential diagnosis and why it matters ](#differential-diagnosis-and-why-it-matters) 3. [ Investigations and early management ](#investigations-and-early-management) 4. [ IPV, documentation, and longitudinal follow-up ](#ipv-documentation-and-longitudinal-follow-up) 5. [ Clinical Application ](#clinical-application) 6. [ Key Points for Board Exams ](#key-points-for-board-exams) 7. [ Conclusion ](#conclusion) 8. [ References ](#references-heading) The trap in assault-related facial trauma is anchoring on the bruise and missing the fracture pattern, the cervical spine, the mandible, the orbit, and the violence behind the injury. A 28-year-old woman arrives after repeated blows to the right face, with malar swelling, periorbital ecchymosis, subconjunctival hemorrhage, an infraorbital rim step-off, trismus, and numbness from the lower lid to the upper lip. She is talking, oxygenating, and hemodynamically stable. That stability should not lull you: the next decisions determine whether you miss a zygomaticomaxillary complex (ZMC) fracture, a second mandibular fracture, a mild TBI, or an unsafe discharge back into an abusive environment. [\[1\]](#cite-1 "Reference [1]") Reading the vignette in real time --------------------------------- After airway, the immediate trauma priority is **cervical spine protection**. NICE still frames early trauma care as a prioritizing sequence with airway managed **with in-line spinal immobilization**, and recommends maintaining protection until the neck is clinically cleared or imaged when indicated. In facial trauma, pain and swelling are classic distracting injuries, so a normal conversation does not clear the neck. [\[2\]](#cite-2 "Reference [2]") The fracture pattern here is doing most of the talking. **Pain over the zygoma, infraorbital rim step deformity, malocclusion, and infraorbital paresthesia** fit ACR’s midface-injury pattern and make a **ZMC fracture** the leading diagnosis. The sensory deficit maps to the **infraorbital nerve**, a terminal branch of V2. Limited mouth opening may be pain-limited, but in zygomatic arch injury it can also be mechanical: a depressed arch can impede temporalis excursion and produce trismus. Meanwhile, failure of the tongue-blade bite test should raise suspicion for a **concurrent mandibular fracture**, not just "jaw pain." [\[1\]](#cite-1 "Reference [1]") FindingWhat it should make you thinkInfraorbital rim step-off + V2 numbness**ZMC/midface fracture**; **CT maxillofacial without IV contrast** is usually appropriate. [\[1\]](#cite-1 "Reference [1]")Trismus or failed tongue-blade test**Mandibular fracture** and/or **arch impingement**; CT maxillofacial is usually appropriate, mandibular radiography may still be used selectively. [\[1\]](#cite-1 "Reference [1]")Headache and feeling "shaken"**mTBI/concussion** remains on the differential; do not image reflexively, use decision rules and give explicit return precautions. [\[3\]](#cite-3 "Reference [3]") > **Clinical Pearl:** In facial trauma, numbness is anatomy talking. Lower lid and upper lip paresthesia after a malar blow is V2 until proven otherwise; marked trismus after an arch injury is mechanical until proven otherwise. [\[4\]](#cite-4 "Reference [4]") Differential diagnosis and why it matters ----------------------------------------- The sensible differential is not broad for broadness’ sake. **ZMC fracture** is first because it explains the malar swelling, infraorbital step, periorbital findings, and sensory loss. **Orbital floor or lateral wall involvement** must be assumed until imaging and ocular examination say otherwise. **Mandibular fracture** remains plausible because trismus and a positive tongue-blade test are not well explained by soft-tissue bruising alone. **TMJ injury** and isolated zygomatic arch fracture are alternatives, but the infraorbital findings push you back toward a ZMC pattern. Finally, headache without LOC does not exclude **mild TBI**; the board question is usually whether you will recognize concussion while avoiding indiscriminate CT use. [\[1\]](#cite-1 "Reference [1]") Investigations and early management ----------------------------------- Once life threats are excluded, **noncontrast CT maxillofacial** is the study that answers most of this case. ACR rates it as usually appropriate both for suspected **midface injury** and for suspected **mandibular injury**. In other words, one well-chosen scan evaluates the ZMC buttresses, orbital walls, zygomatic arch, and mandible in a way plain films often cannot. If the cervical spine cannot be cleared clinically, maintain protection and image the neck as indicated. [\[1\]](#cite-1 "Reference [1]") The eye exam cannot be abbreviated. Before swelling worsens, document **visual acuity, pupils, ocular motility, diplopia, and gross globe integrity**. Severe pain on eye movement, restricted supraduction, or other concern for entrapment or serious ocular injury should lower the threshold for urgent ophthalmology involvement. At the same time, keep the head injury lane open: CDC’s 2025 adult mTBI summary, reflecting the 2023 ACEP policy, advises **not** routinely imaging every mild TBI, but instead using validated decision rules, providing discharge advice about delayed hemorrhage symptoms, and arranging follow-up within a few days. [\[5\]](#cite-5 "Reference [5]") The cheek laceration is the easy part, but even easy parts matter. CDC’s June 10, 2025 tetanus guidance states that for a **clean minor wound**, no tetanus vaccine is needed if the patient completed the primary series and the last tetanus dose was **less than 10 years** ago. Her booster 8 years earlier is therefore adequate, and **TIG is not indicated**. For facial wound closure, **suture removal in 3 to 5 days** remains the practical standard to balance dehiscence against track marks. [\[6\]](#cite-6 "Reference [6]") IPV, documentation, and longitudinal follow-up ---------------------------------------------- This is not only a fracture case; it is a possible **intimate partner violence** case. The USPSTF final recommendation dated **June 24, 2025** continues to give a **Grade B** recommendation to screen **women of reproductive age** for IPV and to connect those who screen positive with **multicomponent interventions and ongoing support**. In practice, screen **privately**, without partners, family members, or police in the room. **HARK** and **HITS** are acceptable brief tools. [\[7\]](#cite-7 "Reference [7]") Once disclosure occurs, the chart becomes a medical and potentially forensic document. ACOG emphasizes using the patient’s words when possible, documenting injuries precisely rather than vaguely, and including **measurements, body maps, and photographs with consent** because the record may later matter in legal proceedings. For this patient, that means writing what you saw—"3 cm linear cheek laceration," "infraorbital rim step-off," "right circumorbital ecchymosis"—and what she said happened, without editorializing. [\[8\]](#cite-8 "Reference [8]") Family Medicine also owns the aftermath. If she later develops **intrusive recollections, avoidance, sleep disturbance, hypervigilance, or concentration problems**, think PTSD rather than "stress." NICE advises **active monitoring** for subthreshold symptoms within the first month, recommends **against psychologically focused debriefing** and against drug treatment such as benzodiazepines for prevention, and recommends **trauma-focused CBT** for adults with clinically important symptoms persisting beyond 1 month. [\[9\]](#cite-9 "Reference [9]") Clinical Application -------------------- 1. **Do not let a dramatic face exam distract you from the neck.** Protect the cervical spine until you have cleared it properly. [\[2\]](#cite-2 "Reference [2]") 2. **Use the exam to choose imaging, not to avoid imaging.** Infraorbital paresthesia points to midface injury; trismus and a positive tongue-blade test keep the mandible in play. [\[1\]](#cite-1 "Reference [1]") 3. **Treat the laceration, but do not stop at the laceration.** Tetanus status, ocular injury, concussion counseling, and specialty referral all sit alongside wound closure. [\[6\]](#cite-6 "Reference [6]") 4. **A safe discharge plan includes social context.** IPV screening, objective documentation, and mental health follow-up are not optional add-ons in assault care. [\[7\]](#cite-7 "Reference [7]") Key Points for Board Exams -------------------------- - **Infraorbital rim step-off plus infraorbital numbness** is a high-yield clue for **ZMC/midface fracture**. [\[1\]](#cite-1 "Reference [1]") - **Trismus** after facial trauma should trigger concern for **mandibular fracture** or **zygomatic arch impingement**. [\[1\]](#cite-1 "Reference [1]") - For suspected **midface or mandibular injury**, **CT maxillofacial without IV contrast** is the preferred initial study. [\[1\]](#cite-1 "Reference [1]") - For a **clean minor wound** with complete tetanus series and last booster **<10 years**, give **no Td/Tdap and no TIG**. [\[6\]](#cite-6 "Reference [6]") - USPSTF recommends screening **women of reproductive age** for IPV; **HARK** and **HITS** are acceptable tools. [\[7\]](#cite-7 "Reference [7]") - Early PTSD care is not debrief-everyone medicine: **active monitoring early, trauma-focused CBT if symptoms persist, and no benzodiazepines for prevention**. [\[9\]](#cite-9 "Reference [9]") Conclusion ---------- The expert move in this case is parallel processing: stabilize, protect the neck, localize the fracture pattern, interrogate occlusion and ocular function, and never separate the injury from the circumstances in which it occurred. In Family Medicine, the case is not over when the CT is read; it continues through wound follow-up, concussion counseling, IPV response, and trauma-informed mental health care. [\[2\]](#cite-2 "Reference [2]") References (17) ------------------- 1. 1. [ acsearch.acr.org/docs/3179912/Narrative ](https://acsearch.acr.org/docs/3179912/Narrative/) [↩](#cite-ref-1-1 "Back to text") 2. 2. [ www.nice.org.uk/guidance/ng41/chapter/recommendations ](https://www.nice.org.uk/guidance/ng41/chapter/recommendations) [↩](#cite-ref-2-1 "Back to text") 3. 3. [ www.cdc.gov/traumaticbraininjury/pdf/key\_recommendations\_adult\_mTBI-508.pdf ](https://www.cdc.gov/traumaticbraininjury/pdf/key_recommendations_adult_mTBI-508.pdf) [↩](#cite-ref-3-1 "Back to text") 4. 4. [ www.ncbi.nlm.nih.gov/books/NBK499881 ](https://www.ncbi.nlm.nih.gov/books/NBK499881/) [↩](#cite-ref-4-1 "Back to text") 5. 5. [ eyewiki.aao.org/Orbital\_Floor\_Fractures ](https://eyewiki.aao.org/Orbital_Floor_Fractures) [↩](#cite-ref-5-1 "Back to text") 6. 6. [ www.cdc.gov/tetanus/hcp/clinical-guidance/index.html ](https://www.cdc.gov/tetanus/hcp/clinical-guidance/index.html) [↩](#cite-ref-6-1 "Back to text") 7. 7. [ www.uspreventiveservicestaskforce.org/uspstf/recommendation/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening1 ](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening1) [↩](#cite-ref-7-1 "Back to text") 8. 8. [ www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2012/02/intimate-partner-violence ](https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2012/02/intimate-partner-violence) [↩](#cite-ref-8-1 "Back to text") 9. 9. [ www.nice.org.uk/guidance/ng116/chapter/recommendations ](https://www.nice.org.uk/guidance/ng116/chapter/recommendations) [↩](#cite-ref-9-1 "Back to text") 10. 10. American College of Radiology. ACR Appropriateness Criteria® Imaging of Facial Trauma Following Primary Survey. J Am Coll Radiol. 2022;19(5S):S67-S86. 11. 11. National Institute for Health and Care Excellence. Spinal injury: assessment and initial management (NG41). 12. 12. Centers for Disease Control and Prevention. Clinical Guidance for Wound Management to Prevent Tetanus. June 10, 2025. 13. 13. Centers for Disease Control and Prevention. Key Recommendations for the Care of Adult Patients with Mild Traumatic Brain Injury. July 29, 2025. 14. 14. U.S. Preventive Services Task Force. Intimate Partner Violence and Caregiver Abuse of Older or Vulnerable Adults: Screening. Final Recommendation Statement. June 24, 2025. 15. 15. National Institute for Health and Care Excellence. Post-traumatic stress disorder (NG116), last reviewed April 8, 2025. 16. 16. American College of Obstetricians and Gynecologists. Committee Opinion No. 518: Intimate Partner Violence. Obstet Gynecol. 2012;119(2 Pt 1):412-417. 17. 17. Alonso LL, Purcell TB. Accuracy of the tongue blade test in patients with suspected mandibular fracture. Ann Emerg Med. 1995;26(2):175-179. 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