Hi everyone,
Welcome to the first of many POTDs this month and what better way to start then to continue Trauma Tuesdays! I decided to focus on Le Fort Fractures because I have noticed these questions come up a lot when going through ROSH Review. So lets dive in!
Le Fort fractures are broken down into three types (I, II, and III) based on the injury plane. They are caused by blunt trauma to the midface and involve a break in the pterygoid plates. A way to think about it is the higher in #, the worse the injury.
You have all probably heard of the mnemonic below but if not, here it is: "Speak no evil, see no evil and hear no evil" this should hopefully make sense as you keep reading.
Breakdown of Le Fort Fractures:
Le Fort I (Horizontal) → Horizontal fracture along the maxilla and usually from lower-velocity trauma
These fractures separate the maxilla (upper jaw) from the rest of the skull, giving you what’s called a “floating palate.”
Fun tip: gently pulling on the upper incisors might reveal the whole dental arch moving
Exam: Swelling of the upper lip, dental malocclusion, difficulty biting properly, and mobility of the dental arch when gently manipulated
Pathognomonic Test: Mobility when pulling on upper incisors
Le Fort II (Pyramidal) → Le Fort II is a pyramidal fracture involving the nasal bones, maxilla, and infraorbital rims. These patients often have a widened nasal bridge and flat midface appearance.
Watch out for CSF rhinorrhea, which suggests the fracture may be deeper than it looks.
Symptoms: Nasal flattening, widened intercanthal distance, periorbital swelling, and potential CSF rhinorrhea. This commonly involves the infraorbital nerve!!
Buzzword: “Floating maxilla.”
Le Fort III (Transverse) → Le Fort III fractures are the most severe, involving craniofacial disjunction. Look for loss of sensation in the midface from nerve involvement. These are associated with additional complications such as CSF leak and trigeminal nerve damage.
Injury: Transverse fracture through orbits and zygomatic arches. Craniofacial disjunction is the hallmark.
Symptoms: Flattened face, enophthalmos, mastoid bruising, and severe deformity.
Buzzword: “Floating face”
So how do we diagnose this? CT Face!
So our patient has a Le Fort fracture... now what?
Management:
Airway: Be vigilant for airway obstruction from swelling or blood. Intubate early if needed
C-Spine: Maintain spinal precautions until cleared, may need to obtain a CT C-spine
Bleeding: Control with nasal packing or direct pressure.
Antibiotics may be indicated: Start IV antibiotics to prevent sinus and intracranial infections; these are considered open fractures
Tetanus as indicated
Maxillofacial Surgery: Essential for surgical repair.
Neurosurgery: Involvement for CSF leaks or brain injury.
Pain Control
Key Teaching Points:
Always check the airway and C-spine.
Use the mnemonic “Speak, See, Hear No Evil” for quick recall of fracture types
I: transverse fracture separating maxilla from pterygoid and nasal septum
II: maxilla and palate fractured
III: craniofacial dissociation
II and III: CSF rhinorrhea (due to cribriform plate involvement)
Involve specialists early for definitive care.
Remember CT face to help determine the type of fracture
Resources:
UpToDate: Le Fort Fractures (https://www.uptodate.com)
Osmosis: Le Fort Overview (https://www.osmosis.org)
Radiopaedia: Facial Fracture Imaging (https://radiopaedia.org)
WikiEM: Le Fort fractures
ROSH Review
https://www.emrap.org/corependium/chapter/recGrF99hDMuLNdcD/Midfacial-Trauma#h.sfzflara7koe
Thanks friends and talk to you all soon,
Caro