Le Fort Fractures

Introduction

Le fort fractures are complex facial injuries which occur due to blunt force trauma. The most common mechanisms of these injuries are use of intoxicants, assaults, falls and motor vehicle collisions. The fractures are separated into three types: Le fort I, II and III and this is based on the direction of the fracture. Note the pterygoid plate is involved in all le fort fractures

Le Fort I

This is a horizontal fracture of the anterior maxilla which occurs above the palate and extends through the lateral nasal wall and pterygoid plates. It separates the teeth from the upper face and can be unilateral/bilateral. Therefore, on examination there is mobility of the tooth-bearing maxilla. Le Fort I fractures result from a downward directed force on the maxilla.
Common signs on presentation:
• Mobility of maxilla
• Malocclusion
• Ecchymosis of maxillary buccal sulcus and palate
• "Cracked pot" percussion of teeth
[1]

Le Fort II

This is a pyramidal fracture involving zygomaticomaxillary suture, nasofrontal suture, pterygoid process of sphenoid and the frontal sinus. The damage to the maxillary buttress causes discontinuity of the inferior orbital rim. There will be mobility of the maxilla and the nose.
Common signs on presentation:
• Mobility of midface
• Gross facial swelling
• Raccoon eyes
• Epistaxis
• Malocclusion
• Subconjunctival haemorrhage
• Ecchymosis of maxillary buccal sulcus and palate
• Numbness/paraesthesia in V2 region
[1]

Le Fort III

This will result in complete separation of the midface from the cranium. The fracture involves the nasal bones, medial, inferior and lateral orbital walls, pterygoid processes and zygomatic arches. This type of fracture is usually the result of an impact to the nasal bridge/upper maxilla. A mobile bony segment can be observed including maxilla, nose and zygoma.
Common signs on presentation:
• Raccoon eyes
• Enophthalmos
• Battle’s sign – ecchymosis over mastoid region
• Increased facial height and flattening of facial profile
• Mobility of midface to include maxilla, nose and zygoma
• Posterior gagging/anterior open bite
[1]

Figure 1. Classification of Le Fort Fractures [2]

Figure 2. Examination of Le Fort Fractures [3]

Airway

It is crucial to ensure that when these patients arrive in hospital, they have a stable airway. Airway obstruction is not uncommon with Le fort fractures as often there is intranasal damage and altered airway anatomy due to the trauma. In addition to this, there may be bleeds into the airway compromising its patency.
It is also important to remember patients with Le Fort fractures are likely to have other bodily injuries therefore always ensure when taking a referral you are checking if the patient has been cleared from a head injury point of view and whether their spine is stable especially at the cervical level. If the airway is compromised, the patient may require intubation or a tracheostomy.

Special Investigations

A CT scan of the facial bones is the imaging modality of choice. Also, ensure this includes the full extent of the mandible. Plain film radiographs will seldom be of any value and it is not possible to determine the extent of soft tissue damage. Ensure that you have the coronal, axial and sagittal cuts prior to treatment planning.

Figure 3. Anterior & posterior maxillary wall fractures [3]

Treatment

Le Fort fractures do not always need to be dealt with immediately especially if there are other life-threatening injuries. Once the patient has been stabilised fixation of the le Fort fractures can be performed. If surgical intervention is required, the aims are:
• Restore facial contour
• Re-establish occlusion
The most common method of fixating midface fractures is with miniplates and screws. The general principles of fracture fixation in le Fort fractures are:
1) Occlusion is stabilised and restored using intermaxillary fixation (IMF)
2) Exposure of the fracture via intra/extra-oral approach
3) Fixation is achieved by plating the mobile segment to the most superior stable bone
4) Additional fixation is performed if required e.g. orbital rim fractures

Red flags

In general, involve your registrar early when managing complex facial fractures. Other considerations include:
• Orbital +/- globe concerns – involve the ophthalmologist on-call
• Airway concerns – involve the on-call anaesthetist
• Suspected base of skull fracture – involve on-call neurosurgery SpR

References

[1] Phillips, Bradley J, and Lauren M Turco. “Le Fort Fractures: A Collective Review.” Bulletin of emergency and trauma vol. 5,4 (2017): 221-230. doi:10.18869/acadpub.beat.5.4.499.
[2] Archives of Craniofacial Surgery [Internet]. E-acfs.org. 2020. Available from: https://e-acfs.org/journal/Figure.php?xn=acfs-18-5.xml&id=
[3] Themes U. Maxillary Fractures [Internet]. Ento Key. 2020. Available from: https://entokey.com/maxillary-fractures/
[4] Cornelius C, Gellrich N, Hillerup S, Kusumoto K, Schubert W, III E et al. Midface [Internet]. Surgeryreference.aofoundation.org. 2020. Available from: https://surgeryreference.aofoundation.org/cmf/trauma/midface