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Le Fort III Fracture

Case Introduction

A 52 year old male presented to the emergency department with a chief complaint of seizure earlier in the day. He was amnestic to events prior to reported seizure and his primary survey supported trauma. Initial Glasgow Coma Score was 14 and patient was hypertensive to 145/78 but vitals otherwise stable. Physical exam revealed left sided orbital edema with upward gaze entrapment of the left eye as well as left sided hemotympanum without battle sign. There was a noted left afferent pupillary defect. Dentition was intact without mobility of hard palate segments or injury to soft palate and a maximum mouth opening of 25mm. The patient did not have any sign of airway compromise.
Lateral orbital wall and skull fractures (arrows)
Lateral orbital wall and skull fractures (arrows)
Right Zygomaticomaxillary complex fracture (arrow)
Right Zygomaticomaxillary complex fracture (arrow)
Given the presentation, CT imaging was obtained. This revealed a right sided Le Fort type III fracture, left zygomaticomaxillary complex fracture and orbital blowout fracture involving the lateral orbital wall and floor on the left. There was herniation of orbital fat and the inferior rectus through the orbital floor. Additional findings included a cribriform plate fracture, bilateral fractures through the orbital apex, and pneumocephalus in the bilateral temporal and left frontal subdural spaces were also noted. The patient was loaded with 1500 mg of levetiracetam, the patient was admitted to the surgical intensive care unit with neurosurgery, maxillofacial surgery and ophthalmology consultation.

Discussion

Le Fort Fractures, originally described by Rene Le Fort in 1901, are a specific facial bone fracture pattern that occur in the setting of blunt trauma such as motor vehicle collisions, assaults and falls.1Noffze MJ, Tubbs RS. Rene le fort 1869-1951. Clin Anat. 2011;24(3):278–81. Le Fort fractures are classified as type I, II or III depending on the involvement of the maxillary, nasal and zygomatic bones however all of them involve the pterygoid process of the sphenoid bones and disrupt the intrinsic buttress system of the midface. In isolation, these fractures are associated with a low mortality rate however they often involve significant trauma which can include serious injuries to the head, neck and torso. 2Bagheri SC, Holmgren E, Kademani D, Hommer L, Bell RB, Potter BE, et al. Comparison of the severity of bilateral le fort injuries in isolated midface trauma. J Oral Maxillofac Surg. 2005;63(8):1123–9
By involving the maxilla, inferolateral orbital rims, sphenoids, ethmoids and zygomas, Le Fort fractures inherently represent some form of midface discontinuity. The facial skeleton contains four paired vertical buttresses: the lateral, medial, and posterior maxillary, and posterior vertical mandibular buttresses and four paired transverse buttresses: the upper maxillary, lower transverse maxillary, upper mandibular, and lower transverse mandibular buttresses.3Brown D, Borschel G. Michigan manual of plastic surgery. Philadelphia: Lippincott Williams and Wilkins; 2004.
Illustration of Le Fort Fracture types
Illustration of Le Fort Fracture types
Le Fort I fractures are characterized by a horizontal fracture of the anterior maxilla above the palate and alveolus and extends through the lateral nasal wall and pterygoid plates. Subsequently, there is instability of the dental maxilla and hard palate from the midface. This injury pattern is associated with jaw malocclusion and dental fractures.
Le Fort II fractures are characterized by a pyramidal fracture involving the zygomaticomaxillary suture, nasofrontal suture, pterygoid process of the sphenoid and frontal sinus. This type is accompanied by disruption of the inferomedial orbital rim and subsequently these patients can develop complications of entrapment including extraocular muscle injury, orbital hematoma, globe rupture or impingement as well as damage to the optic nerve. Less commonly, epistaxis, CSF rhinorrhea, lacrimal duct injuries, and others can be seen.4Fraioli RE, Branstetter BF, Deleyiannis FW. Facial fractures: Beyond le fort. Otolaryngol Clin North Am. 2008;41(1):51–76.
Le Fort III fractures are the most serious fracture type and involve the medial, inferior and lateral orbital walls, pterygoid process and zygomatic arch. These patients have complete separation of the midface from the cranium. Their complication patterns are similar to Le Fort II.
le fort fracture clinical with CT and 3D reconstruction
A: Clinical characteristics of sinking of the middle third of his face, edema and bilateral periorbital ecchymosis. B: The characteristics of imaging exam tomography. C and D: The imaging exam showed a line of fracture compatible with a high Le Fort I fracture.1https://www.redalyc.org/journal/3786/378662239017/html/
About half (56%) of Le Fort fractures are from low velocity mechanisms such as a fall from standing position or blunt assault as opposed to high velocity mechanisms such as high speed motor vehicle crash or fall from one story or higher. Higher grade Le Fort fractures are associated with increased risk of skull fracture (40%), closed head injury (5%) and cervical spine injury (5%).5Chen WJ, Yang YJ, Fang YM, Xu FH, Zhang L, Cao GQ. Identification and classification in le fort type fractures by using 2D and 3D computed tomography. Chin J Traumatol. 2006;9(1):59–64. Sports-related facial trauma has a greater frequency in high-speed sports such as mountain biking and skiing.6Maladiere E, Bado F, Meningaud JP, Guilbert F, Bertrand JC. Aetiology and incidence of facial fractures sustained during sports: A prospective study of 140 patients. Int J Oral Maxillofac Surg. 2001;30(4):291–5. Drug and alcohol use is seen in between 28% and 45% of traumas and is associated with more severe Le Fort fractures.
Clinical suspicion for Le Fort fractures is made through history and physical exam and diagnosis is confirmed by imaging. Racoon eyes and midface mobility, although not specific, should increase the suspicion for Le Fort fractures. Radiographic findings that should increase suspicion of Le Fort fractures include pterygoid fracture, fractures of the lateral nasal wall, inferior orbital rim, lateral orbital rim and zygomatic arch. Computed Tomography (CT) is the imaging modality of choice and is far more sensitive than standard radiographic findings.
The so called dish face deformity with dropped upper jaw (A)
The so called dish face deformity with dropped upper jaw (A)2Ghabach, Maroun B., et al. "Airway management in a patient with Le Fort III Fracture." Saudi Journal of Anaesthesia 8.1 (2014): 128-130.
Surgeon reducing the maxillary fracture by pulling the maxilla forward with the index finger
Surgeon reducing the maxillary fracture by pulling the maxilla forward with the index finger3Ghabach, Maroun B., et al. "Airway management in a patient with Le Fort III Fracture." Saudi Journal of Anaesthesia 8.1 (2014): 128-130.
Management of Le Fort fractures requires a comprehensive approach and the vast majority of patients are hospitalized. On initial arrival, ATLS algorithm should be followed including airway management and evaluation for other injuries. Endotracheal intubation, tracheostomy or cricothyroidotomy may be required.
The vast majority of Le Fort Fractures will be managed surgically. Goals for management of Le Fort fractures includes restoration of facial projection, height and proper occlusion.7McRae M, Frodel J. Midface fractures. Facial Plast Surg. 2000;16(2):107–13. One review found that 60% of cases required open reduction and internal fixation, 30% were managed conservatively and 10% of cases required not treatment.8Phillips, Bradley J., and Lauren M. Turco. “Le Fort fractures: a collective review.” Bulletin of Emergency & Trauma 5.4 (2017): 221. Le Fort fractures are frequently associated with fractures of the hard palate, dentition and mandible which create further surgical challenges.
Depending on the mechanism of injury, patients should be evaluated for concomitant injuries for the head and cervical spine. Approximately 1% of patients have a spinal fracture, dislocation or spinal cord injuries. Ocular injuries such as retrobulbar hemorrhage or retinal detachment are seen in 6% to 8% of Le Fort II and III fractures.9Garri JI, Perlyn CA, Johnson MJ, Mobley SR, Shatz DV, Kirton OC, et al. Patterns of maxillofacial injuries in powered watercraft collisions. Plast Reconstr Surg. 1999;104(4):922–7. Dental injuries have a much higher incidence of around 48%.
3D reconstruction showing right Lateral view ZMC and skull fracture (arrow)
Complex facial fractures, including Le Fort fractures, have a mortality rate of 11.6% compared to 5.1% seen in simple facial fractures. Le Fort I, II, and III fractures had mortality rates of 0%, 4.5%, and 8.7%. Symptoms associated with increased morbidity include development of visual problems (47%), diplopia (21%), epiphora (37%), difficulty with breathing (31%), and difficulty with mastication (40%). Patients with Le Fort III injuries are less likely to return to work than Le Fort I fractures. Approximately 89% of patients have satisfactory outcomes while about 11% of patients have continued issues including long term infection, temporary TMJ stiffness, or facial deformity.

Case Conclusion

The patient never endorses a mechanism other than possible seizure. On admission day two the patient underwent open reduction and internal fixation of the left orbital floor by oral and maxillofacial surgery which he tolerated well. Interval CT head was performed and no further intracranial hemorrhage was noted. The patient was discharged after a four day stay in the surgical intensive care unit. He was seen by oral and maxillofacial surgery in clinic a week post-op with improvement in pain and facial edema. Initial evaluation by Ophthalmology on the night of the injury suggested that the patient had a poor prognosis for visual recovery given the degree of traumatic optic neuropathy sustained. Follow up five weeks post incident reveals that the patient has persistent loss of light perception in the left eye with low chances for recovery.

3 Key Points

  1. Le Fort Fractures are a spectrum of facial fractures seen in the setting of blunt trauma
  2. They require consultation with an ENT or maxillofacial surgeon and many require surgical fixation
  3. They are associated with other injuries such as orbital lesions, cervical injuries and intracranial insults

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