Le Fort Fractures

Le Fort fractures are a group midface fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures patterns classified into 3 types: Le Fort I, II, and III. Le Fort fractures represent 10%–20% of all facial fractures and can be caused by any significant blunt trauma to the face, most commonly from motor vehicle accidents. Clinical presentation includes severe facial bleeding and edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema and mobility of different bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones segments, depending on the type in question. Diagnosis is clinical, supported by imaging techniques. Initial management centers around stabilization of the individual and control of bleeding. Definitive management is surgical. Long-term management concerns preservation and rehabilitation of facial function.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition

  • A group of midface fractures typically brought on by trauma
  • Described by Dr. Rene Le Fort in 1901

Classification

  • Le Fort I (most inferior):
    • Trans-maxillary fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures (also known as Guerin fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures)
    • Bony disruption involves:
      • Superior to the maxillary alveolar process
      • Spans the body of the nasal septum
      • May involve pterygoid plates of the sphenoid bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones
  • Le Fort II: 
    • Pyramidal fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
    • Bony disruption involves:
      • Posterolateral portions of the maxillary sinuses
      • Typically passes through the infraorbital foramina
      • Lacrimal and/or ethmoid bones may be involved.
  • Le Fort III (most superior): 
    • Craniofacial disjunction: Face is separated from the skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull.
    • Also known as horizontal fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures 
    • Bony disruption involves:
      • Superior orbital fissures
      • Lacrimal bones
      • Ethmoid bones
      • Nasal bones
      • Greater wings of the sphenoid bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones
      • Frontozygomatic sutures
    • Eyes are held in place by the optic nerves.
  • Le Fort IV:
    • Characteristics of type III + involvement of the frontal bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones

Epidemiology

  • 10%–20% of all facial fractures
  • Usually seen in the context of polytrauma
  • Associated with substance use
  • Decreased incidence related to motor vehicle crashes owing to better restraint systems

Etiology

  • Any trauma to the face that transfers a significant amount of kinetic energy:
    • Motor vehicle accidents
    • Sports injuries
    • Physical assault (e.g., child abuse Child abuse Child abuse is an act or failure to act that results in harm to a child's health or development. The abuse encompasses neglect as well as physical, sexual, and emotional harm. Seen in all subsets of society, child abuse is a cause of significant morbidity and mortality in the pediatric population. Child Abuse, domestic violence, elder abuse)
    • Falls
  • Velocity of trauma is associated with severity of Le Fort fractures.
Le fort fracture types

Le Fort fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures types:
These fractures follow the “lines of weakness” proposed by Rene Le Fort in 1901.

Image by Lecturio.

Pathophysiology

  • Blunt trauma: a significant amount of kinetic energy is directly transferred to the midface.
    • Motor vehicle accidents: Unrestrained individual’s face strikes the dashboard.
    • Sports (e.g., football, baseball, and hockey): contact injuries or projectile (e.g., ball or puck) strikes the face 
    • Physical assault: severely battered individuals
    • Falls from significant heights 
    • May also include:
      • Penetrating injury
      • Laceration injury
  • Le Fort I: Force is directed downward on the maxillary rim.
  • Le Fort II: Force is directed to the lower or mid maxilla.
  • Le Fort III: Force impacts the nasal bridge or upper maxilla.

Clinical Presentation

History

  • Remember: Because of the nature of the fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures, the individual most likely won’t be able to articulate any details about the incident. 
  • First responders or companions will report recent high-energy blunt trauma. 
    • Motor vehicle accident
    • Fall from a great height
    • Attack with a blunt object
  • The clinician must determine:
    • The mechanism of trauma
    • Further details if possible

Physical examination

  • Airway:
    • Assess for patency. 
    • Determine the need for an emergency airway.
  • Oral cavity assessment: 
    • To determine the presence of hard palate Palate The palate is the structure that forms the roof of the mouth and floor of the nasal cavity. This structure is divided into soft and hard palates. Oral Cavity: Palate fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
    • To determine the presence/source of oropharyngeal hemorrhage
  • Nasal cavity assessment:
    • To determine the presence of nasal fractures
    • To determine the presence/source of nasopharyngeal hemorrhage
    • Assess for leakage of CSF.
  • Cervical spine/neck assessment:
    • Keep cervical spine immobilized during the examination.
    • Cervical spinal fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures should always be suspected until proven otherwise.
  • Facial assessment:
    • Significant facial hemorrhage and edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema are likely to be present.
    • Possible development of early ecchymosis
    • Dish-face deformity: flattening of the face (type III)
  • Determine mobile bony segments (with forehead stabilized):
    • Le Fort I: hard palate Palate The palate is the structure that forms the roof of the mouth and floor of the nasal cavity. This structure is divided into soft and hard palates. Oral Cavity: Palate
    • Le Fort II: maxilla and nose Nose The nose is the human body's primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Anatomy of the Nose 
    • Le Fort III: maxilla, nose Nose The nose is the human body's primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Anatomy of the Nose, and zygomas
    • Anterior open bite malocclusion:
      • May be associated with fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures and posterior displacement of the maxilla
      • May be associated with accompanying fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures and anterior displacement of the maxilla
  • Orbital/ocular assessment:
    • Bilateral orbital ecchymosis (also known as raccoon eyes)
    • Widening of the intercanthal space
    • Orbital involvement commonly occurs with types II and III fractures (requires emergent ophthalmologic consultation).
  • Neurologic assessment:
    • Determine mental status and level of consciousness.
    • If level of consciousness is impaired, determine baseline Glasgow Coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma Scale score.
    • Assess for cranial nerve function and the presence of focal neurologic injury.
    • Assess for symptoms/signs of increased intracranial pressure Increased Intracranial Pressure Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP).
    • Assess for symptoms/signs of intracranial hemorrhage/traumatic brain injury.
Le fort iii fracture

Individual with a Le Fort III fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures:
Note the widening of the intercanthal space and pronounced facial edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema. The ED physicians opted for a secure airway through the nose Nose The nose is the human body's primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Anatomy of the Nose.

Image: “Preoperative” by Santosh Kumar Yadav et al. License: CC0 1.0

Diagnosis

Clinical diagnosis

  • Prior to assessment for findings specific to Le Fort fractures, the following should be assessed, diagnosed, and appropriately triaged:
    • Airway patency
    • Cervical spine stability
    • Life-threatening trauma
    • Life-threatening hemorrhage
    • Hemodynamic status
  • The diagnosis of a Le Fort fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures should be considered and ruled out in any individual with the following:
    • History of significant cranial, facial, or cervical trauma
    • Facial hemorrhage
    • Facial edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
    • Facial ecchymosis
  • History and physical examination should be sufficient for initial triage if the individual is stable and clinical suspicion for Le Fort fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures is low.

Imaging

  • Should be obtained only after the individual has been stabilized.
  • Plain films of the face/cervical spine:
    • May be useful in the absence of CT to identify superficial fractures
    • Limited utility in identifying deeper fractures and associated soft tissue/vascular injury
    • May be useful in the absence of CT to assess cervical spine stability and/or the presence of fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • CT scan:
    • Useful for identification of superficial and deep facial fractures
    • Useful for identification of associated soft tissue/vascular injury
    • Useful in assessment of associated penetrating injury
    • Useful in assessment of associated traumatic brain injury and/or intracranial hemorrhage 
Ct image of le fort iii fracture

Craniofacial CT (A) and 3-dimensional reconstruction (B) of an individual with a Le Fort III fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures

Image: “Craniofacial computed tomography scan obtained on arrival.” by Momoko Mishima, Tetsuya Yumoto, Hiroaki Hashimoto et al. License: CC BY 4.0

Management

Goals of management

  • Restore nasal and orbital integrity, along with height and projection of the midface
  • Regain proper occlusion of the jaw Jaw The jaw is made up of the mandible, which comprises the lower jaw, and the maxilla, which comprises the upper jaw. The mandible articulates with the temporal bone via the temporomandibular joint (TMJ). The 4 muscles of mastication produce the movements of the TMJ to ensure the efficient chewing of food. Jaw and Temporomandibular Joint
  • Evaluate for and appropriately manage associated injuries:
    • Head injury/traumatic brain injury
    • Intracranial hemorrhage
    • Increased intracranial pressure
    • CSF leakage
    • Associated soft tissue/vascular injury
    • Cervical spine fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures/ spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord injury
    • Ocular injuries/loss of vision
    • Dental injuries 

Initial triage

  • Secure the airway.
    • Blind nasotracheal intubation is not preferred.
    • Endotracheal intubation with direct visualization is preferred.
    • Epistaxis/orofacial hemorrhage may complicate airway patency and/or visualization for intubation.
  • Follow advanced cardiac life support (ACLS)/advanced trauma life support (ATLS) protocols for management of:
    • Hemodynamic instability
    • Respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure
    • Associated nonfacial trauma
    • Hemorrhage

Initial management

  • In parallel with assessment of airway, breathing, and circulation (ABCs):
  • Airway protection: 
    • Orotracheal intubation or surgical airway
    • Ventilatory support if indicated
  • Fluid resuscitation 
  • Cervical spine stabilization (e.g., cervical collar)
  • Nasal packing

Surgical management

  • After stabilization and management of life-threatening injuries
  • Maxillofacial surgery: 
    • Fracture reduction with plate-and-screws osteosynthesis
    • Proper occlusion ensures adequate repair.
  • Neurosurgery Neurosurgery Neurosurgery is a specialized field focused on the surgical management of pathologies of the brain, spine, spinal cord, and peripheral nerves. General neurosurgery includes cases of trauma and emergencies. There are a number of specialized neurosurgical practices, including oncologic neurosurgery, spinal neurosurgery, and pediatric neurosurgery. Neurosurgery consultation: cases with CSF leaks

Complications

  • Life-threatening exsanguination
  • Intracranial hemorrhage
  • Traumatic brain injury
  • CSF leak
  • Severe epistaxis
  • Permanent disfigurement

Prognosis

  • Depends on mechanism, severity, and location of injury
  • Potentially life-threatening if not managed promptly 
  • Common morbidities after injury include: 
    • Visual problems
    • Difficulty with mastication
    • Cranial nerve palsies
    • Taste/smell abnormalities

Differential Diagnosis

  • Frontal fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures: disruption in the cortex of the frontal bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones, usually due to direct blunt or penetrating trauma to the forehead. Clinical presentation includes active bleeding and edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema, crepitus in the area of fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures and/or mobility of bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones segments, and altered mental status associated with accompanying traumatic brain injury. Diagnosis is clinical, supported by imaging, and definitive management can be conservative or surgical. 
  • Mandible luxation: describes the unilateral or bilateral uncoupling of the components of the temporomandibular joint. Causes can be traumatic or atraumatic, such as forceful over-opening of the jaw Jaw The jaw is made up of the mandible, which comprises the lower jaw, and the maxilla, which comprises the upper jaw. The mandible articulates with the temporal bone via the temporomandibular joint (TMJ). The 4 muscles of mastication produce the movements of the TMJ to ensure the efficient chewing of food. Jaw and Temporomandibular Joint. Diagnosis is clinical. Management consists of bimanual reduction.
  • Mandible fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures: disruption in the cortex of the mandible, usually due to blunt trauma seen in vehicle accidents or worksite injuries. Clinical presentation includes maxillofacial deformity and edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema and ecchymosis in the site of injury. Diagnosis is clinical, supported by imaging, and definitive management is surgical.

References

  1. Phillips, B. J., Turco, L. M. (2017). Le Fort fractures: a collective review. Bulletin of Emergency & Trauma, 5:221.
  2. Rodriguez, E. D., Dorafshar, A. H., Manson, P. N. (2018). Facial injuries. In: Rodriguez, E. D., Losee, J. E., P. C. Neligan, P. C. (Eds.), Plastic Surgery. Volume 3: Craniofacial, Head and Neck Surgery and Pediatric Plastic Surgery, 4th ed. pp. 47–81. Elsevier.
  3. Hedayati, T., Amin, D. P. (2020). Trauma to the face. Chapter 259 of Tintinalli, J. E., Ma, O. J., Yealy, D. M., Meckler, G. D., Stapczynski, J. S., Cline, D. M., Thomas, S. H. (Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed. McGraw-Hill Education. http://accessmedicine.mhmedical.com/content.aspx?aid=1167028185
  4. Patel, B. C., Wright, T., Waseem, M. (2021). Le fort fractures. StatPearls. Retrieved October 15, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK526060/

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