Fracture, Le Fort

Ovid: 5-Minute Sports Medicine Consult, The

Fracture, Le Fort
Amy Leu
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.
  • 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
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.
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 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
  • 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.
Ongoing Care
  • 802.4 Closed fracture of malar and maxillary bones
  • 802.5 Open fracture of malar and maxillary bones

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