Fracture, Le Fort

By admin Last updated Dec 16, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Fracture, Le Fort

Amy Leu

Basics

Pediatric Considerations

Maxillofacial fractures occur less frequently in children.
- Because of the smaller facial skeleton, there is a higher incidence of skull fractures and head trauma compared with midface injuries.
- Le Fort fractures are particularly uncommon in young children. By ages 10–12 yrs, as facial morphology becomes adult-like, more mid- and lower facial fractures are seen.
- Be suspicious of child abuse or family violence as possible causes of midfacial injuries, especially in children under age 6.
Cautions:
- Airway management:
  - Airway compromise is common.
  - Bag valve mask (BVM) ventilation may be difficult.
  - Avoid nasotracheal intubation.
- Strict cervical spine precautions
- Multisystem injury is likely with high-energy trauma.

Description

Maxillofacial fractures caused by high-energy blunt trauma to the midface: The most common causes include motor vehicle accidents, physical assault, sports injuries, and domestic violence.
On traction of the maxillary arch/hard palate, you should find:
- Le Fort I (horizontal): Movement of the hard palate and maxillary dentition only; can arise from a blow low on the maxillary alveolar rim
- Le Fort II (pyramidal): Movement of the hard palate, maxillary dentition, and the nose; can arise from a blow to the lower to middle maxilla
- Le Fort III (transverse): Movement of the entire midface including orbital rims (inferior and lateral aspects); can arise from a blow to the nasal bridge or upper maxilla

Epidemiology

Prevalence

Midface fractures have been reported to make up ∼30% of all facial fractures.

Commonly Associated Conditions

Le Fort III fractures are commonly associated with lateral rim and zygomatic breaks.
Visual changes may signify a disturbance of the optic canal, problems within the globe or retina, or other neurologic lesions.
Disturbances of extraocular motion or enophthalmos may signify a blowout in the orbital floor.
Consultation with an ophthalmologist is appropriate when extensive involvement of the orbit or globe is suspected.
Le Fort III fractures also can extend to the base of the sphenoid and can result in a CSF leak.

Diagnosis

Pediatric Considerations

Young children are often frightened and in pain. Through kindness, patience, and distraction, cooperation can be gained.
Sedation may be required to perform a thorough exam after ruling out head injury.
Incomplete (greenstick) fractures with minimal or no displacement can occur.
Be cognizant of possible child abuse, and evaluate for prior nonaccidental trauma, if appropriate.
Evaluate the patency of the airway and need for immediate airway control.
There is a high incidence of cervical spine injuries associated with facial trauma; thus cervical spine precautions always must be taken (1).
Le Fort fractures can be diagnosed by careful intraoral examination and the pattern of facial movement.
- If fracture fragments are impacted, there may be little or no midface mobility.
- Carefully evaluate the patient for CSF rhinorrhea and malocclusion.
- If any disturbance of vision or extraocular motion is suspected, consider the presence of a blowout fracture and/or ophthalmologic involvement.

Pre Hospital

Establishing airway patency is of utmost importance.
In severe Le Fort II and III cases, the maxillary plate can be displaced posteriorly and inferiorly, possibly occluding the airway.
There is a high incidence of cervical spine injuries associated with facial trauma; thus, cervical spine precautions always must be taken (1).

History

History may be difficult to obtain directly from the patient, but these types of fractures typically arise from a high-energy force directed at different aspects of the face. Situations can include motor vehicle accidents, altercations, sports injuries, and falls.

Physical Exam

Facial injury with massive swelling and ecchymosis
Facial hemorrhage/epistaxis
Airway obstruction may be present.
Dyspnea (especially when supine)
Malocclusion
Vision disturbance (diplopia)
Facial lengthening or flattening, periorbital ecchymosis (raccoon's eyes), periorbital swelling
CSF rhinorrhea
Facial anesthesia, midface mobility on traction, open bite
Frequently associated with multisystem injury (especially head and cervical spine)

Diagnostic Tests & Interpretation

Imaging

Facial imaging may be delayed for 24–72 hr in patients requiring care of other life-threatening conditions.
CT scanning is the diagnostic standard for defining midface fractures with thin (2-mm) cuts in the coronal and axial planes.
Conventional radiographs may be used as a screening test. The occipitomental (Waters') and lateral views of the skull may reveal bony fracture/asymmetry, subcutaneous emphysema, or layering of blood in the maxillary sinuses. Sinus films and cervical spine films usually are included as part of the screening examination.

Differential Diagnosis

Le Fort fracture classification:
- Le Fort I: Transverse (horizontal) through the maxilla above the roots of the teeth
- Le Fort II: Pyramidal dysjunction including the nasal bridge, maxilla, lacrimal bones, and orbital floor and rim
- Le Fort III: Craniofacial dysjunction
- Le Fort IV: Involves the frontal bone in addition to a Le Fort III maxillary fracture
Different-grade Le Fort fractures may be found on opposite sides of the face.

Treatment

Pediatric Considerations

Surgical cricothyroidotomy should not be considered in children under age 10.
Needle cricothyroidotomy with jet ventilation may be attempted if intubation attempts fail.
There is a higher incidence of multiple injuries in children, especially head trauma, skull fractures, and orthopedic injuries.

P.211

Cervical spine injuries tend to involve upper levels more commonly in children. Also, spinal cord injury without radiographic abnormality (SCIWORA) syndrome may be seen.
Definitive repair of pediatric facial fractures should not be delayed for more than 3–4 days. The facial bones heal rapidly, and delayed repair may result in malunion and cosmetic deformity.

ED Treatment

Cervical spine: Owing to the risk of cervical spine injury in patients with head and maxillofacial trauma, it is imperative that radiographic clearance of the cervical spine is obtained.
Hemorrhage control: Direct pressure should be applied to areas of bleeding, and nasal packing (anterior and posterior) may be necessary for epistaxis. In some cases, manual reduction of the midface may be required to control intractable hemorrhage. Although blood loss from facial bleeding may be significant, it is rarely a primary cause of hemorrhagic shock.
Early consultation with oral maxillofacial or plastic surgeon
Analgesics, antibiotics, and tetanus prophylaxis
Medications:

	Adult Dose (mg/kg IV)	Pediatric Dose (mg/kg IV)
Sedative/analgesics*
Diazepam	0.1–0.2	0.1–0.2
Droperidol	2.5-mg aliquots	1- to 1.5-mg aliquots
Etomidate	0.2–0.3	0.2–0.3
Fentanyl	2–10 µg	2–3 µg
Ketamine	2	1–2
Meperidine	1–2	1–2
Midazolam	0.1	0.15
Morphine sulfate	0.1–0.2	0.1–0.2
Defasciculating drug
Vecuronium	0.01	0.01
Paralytic agents
Pancuronium	0.1–0.15	0.1–0.15
Rocuronium	0.6	0.6
Succinylcholine	1.5	1.5–2
Vecuronium	0.1–0.3	0.1–0.3
*All these sedatives/analgesics should be titrated to effect.

Surgery/Other Procedures

Often, maxillomandibular fixation (MMF) is used in conjunction with open reduction and internal fixation (ORIF) of maxillofacial injuries to maintain optimal immobilization.
In the pediatric population, several considerations are taken into account, including duration of MMF, use of smaller hardware, and avoiding injury to developing teeth.

In-Patient Considerations

Initial Stabilization

Aggressive airway control is paramount.
Orally suction patients to minimize aspiration of blood, saliva, and stomach contents.
Remove any foreign matter or teeth from the airway.
After cervical spine clearance, stable and alert patients may be allowed to sit up and suction themselves.
When airway management is needed, rapid-sequence induction is recommended to maximize airway control and minimize rise of intracranial pressure (ICP) in patients with head injuries (2).
If there is concern that paralysis will result in loss of airway tone and inability to intubate because of subsequent distortion of airway anatomy in patients with severe facial injuries, oral intubation under sedation with midazolam, etomidate, droperidol, or ketamine is an option.
Emergency cricothyroidotomy may be necessary if orotracheal intubation is unsuccessful. Recall that BVM ventilation may be difficult owing to loss of bony support and altered anatomy.
Nasotracheal intubation is not recommended in patients with midface trauma because of the lack of success and danger of intracranial placement (2,3,4).

Admission Criteria

All patients are admitted for ORIF of maxillofacial injuries.
Patients should be admitted to an ICU setting.

Ongoing Care

Complications

Infection can emerge from multiple stages during the treatment process, particularly if there is extensive soft tissue involvement.
Scarring can occur depending on the suturing technique used, as well as the patient's ability to keep the repaired area immobilized.
Nerve damage can arise from the original trauma as well as a result of the type of surgery used to repair the fractures.
Malunion and, less commonly, nonunion also can result if adequate immobilization is not achieved.

References

1. Mithani SK, St-Hilaire H, Brooke BS, et al. Predictable patterns of intracranial and cervical spine injury in craniomaxillofacial trauma: analysis of 4786 patients. Plast Reconstr Surg. 2009;123:1293–1301.

2. Porras LF, Cabezudo JM, Lorenzana L, et al. Inadvertent intraspinal placement of a Foley catheter in severe craniofacial injury with associated atlanto-occipital dislocation: case report. Neurosurgery. 1993;33:310–311; discussion 311–312.

3. Pawar SJ, Sharma RR, Lad SD. Intracranial migration of Foley catheter–an unusual complication. J Clin Neurosci. 2003;10:248–249.

4. Engel M, Reif J, Moncrief E. Inadvertent intracranial placement of a Foley catheter. A rare iatrogenic complication of severe frontomaxillary trauma. Rev Stomatol Chir Maxillofac. 1992;93:333–336.

Additional Reading

Colucciello SA, Sternbach G, Walker SB. The treacherous and complex spectrum of maxillofacial trauma: etiologies, evaluation, and emergency stabilization. Emerg Med Rep. 1995;16;7:59–69.

Hehmann RJ, Sargent LA. Maxillary fractures. Trauma Q. 1992;9:67–75.

Hunter JG. Pediatric maxillofacial trauma. Pediatr Clin North Am. 1992;39:1127–1143.

Le Fort R. Experimental study of fractures of the upper jaw. Rev Chir de Paris. 1901;23:208, 360, 479. Reprinted in Plast Reconstr Surg. 1972;50:497, 600.

Moe KS, Byrne P, Kim DW, et al. Facial Trauma, Maxillary and Le Fort fractures. 2008 Dec http://emedicine.medscape.com/article/1283568-overview

Shimoyama T, Kaneko T, Horie N. Initial management of massive oral bleeding after midfacial fracture. J Trauma. 2003;54:332–336; discussion 336.

Subhashraj K, Nandakumar N, Ravindran C. Review of maxillofacial injuries in Chennai, India: a study of 2748 cases. Br J Oral Maxillofac Surg. 2007.

Codes

ICD9

802.4 Closed fracture of malar and maxillary bones
802.5 Open fracture of malar and maxillary bones