Le Fort Fracture are complex fractures of the midface, named after Rene Le Fort who studied cadaver skulls that were subjected to blunt force trauma. His experiments determined the areas of structural weakness of the maxilla designated as “lines of weakness” where fractures occurred. These fractures are classified into 3 distinct groups based on the direction of the fracture: horizontal, pyramidal or transverse. The pterygoid plate is involved in all types of Le Fort fractures. This may result in a pterygomaxillary separation. The absence of a pterygoid fracture rules out a Le Fort fracture. However, the presence of a pterygoid fracture does not specifically indicate whether a Le Fort fracture exists. Up to one-third of pterygoid plate fractures do not result from a Le Fort fracture pattern.[rx][rx][rx]
Type of Fractures of Le Fort Fracture
Le Fort Type I
These fractures (trans-maxillary fracture) result from a force directed low on the maxillary rim in a downward direction. This occurs in the horizontal plane at the level of the base of the nose. A direct blow to the lower face causes fractures that involve all 3 walls of the maxillary sinus and pterygoid processes. The fracture extends around both maxillary antra, through the nasal septum and the pterygoid plates. This causes palate-facial separation. However, this fracture does not involve the glabella or zygoma.
Le Fort Type II
This pyramidal fracture occurs due to trauma to the midface. The fracture line begins in the region of the bridge of the nose (nasion) and extends obliquely through the medial aspect of the orbits and inferior orbital rims. It then continues posteriorly in a horizontal fashion above the hard palate to involve the pterygomaxillary buttresses, resulting in a disarticulation of the pyramid-shaped facial skeleton from the remainder of the skull. Note that the zygoma remains attached to the cranium.
Le Fort Type III
Also called cranial-facial separation, the fracture line in this injury passes from the nasofrontal area across the medial, posterior, and lateral orbital walls, the zygomatic arch, and through the upper portion of pterygoid plates.
Anatomic Level Classification
Le Fort Type I
Transverse fracture through the maxilla above the roots of the teeth, separating teeth from the upper face. These can be unilateral or bilateral.
Le Fort Type II
These fractures extend superiorly in the midface to include the nasal bridge, maxilla, lacrimal bones, orbital floor, and rim. They are pyramidal fractures with teeth at the base and nasal bone at the apex. These fractures are typically bilateral.
Le Fort Type III
This type of fracture starts at the bridge of the nose and extends posteriorly along the medial wall of the orbit and the floor of the orbit, and then through the lateral orbital wall and the zygomatic arch. The fractures run parallel with the base of the skull, separating the entire midfacial skeleton from the cranial base. This discontinuity between the skull and the face is termed craniofacial dissociation. This may be associated with a cerebrospinal fluid (CSF) leak.
Causes of Le Fort Fracture
A high percentage of facial injuries occur secondary to injuries, from sports such as football, baseball, and hockey. Le Fort fractures can also occur secondary to motor vehicle collisions, assault, and fall from a substantial height. Patients with Le Fort fractures often have associated head and cervical spine injuries.[rx][rx][rx]
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Le Fort type I fractures may result from a force directed in a downward direction against the upper teeth.
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Le Fort type II fractures result from a force to lower or mid maxilla.
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Le Fort type III fractures are caused by impact to the nasal bridge and upper part of the maxilla
Le Fort Type I
These fractures result from a force directed low on the maxillary rim in a downward direction. Fractures extend from the nasal septum to lateral pyriform rims, and extend horizontally above the teeth, crossing below the zygomaxillary junction, then traversing the pterygomaxillary junction interrupting the pterygoid plates.
Le Fort Type II
These fractures result from a force to the lower or mid maxilla. This fracture has a pyramidal shape and extends from the nasal bridge at the nasofrontal suture through the maxilla. Inferolaterally, the fracture extends through the lacrimal bone and inferior orbital floor near the inferior orbital foramen and inferiorly through the anterior wall of the maxillary sinus. On the lateral aspect, it travels under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plate.
Le Fort Type III
These fractures result from an impact to the nasal bridge or upper maxilla. This results in complete craniofacial dysjunction.
Symptoms of Le Le Fort Fracture
- Le Fort I — Slight swelling of the upper lip, ecchymosis is present in the buccal sulcus beneath each zygomatic arch, malocclusion, mobility of teeth. Impacted type of fractures may be almost immobile and it is only by grasping the maxillary teeth and applying a little firm pressure that a characteristic grate can be felt which is diagnostic of the fracture. Percussion of upper teeth results in cracked pot sound. Guérin’s sign is present characterised by ecchymosis in the region of greater palatine vessels.
- Le Fort II and Le Fort III (common) — Gross edema of soft tissue over the middle third of the face, bilateral circumorbital ecchymosis, bilateral subconjunctival hemorrhage, epistaxis, CSF rhinorrhoea, dish face deformity, diplopia, enophthalmos, cracked pot sound.
- Le Fort II — Step deformity at the infraorbital margin, mobile mid-face, anesthesia or paresthesia of cheek.
- Le Fort III — Tenderness and separation at the frontozygomatic suture, lengthening of face, depression of ocular levels (enophthalmos), hooding of eyes, and tilting of occlusal plane, an imaginary curved plane between the edges of the incisors and the tips of the posterior teeth. As a result, there is gagging on the side of injury.
Diagnosis of Le Fort Fracture
History
Your doctor in the emergency department may ask the following questions
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How – How was the fracture created, and, if chronic, why is it still open? (underlying etiology)
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When – How long has this fracture been present? (e.g., chronic less than 1 month or acute, more than 6 months)
- Where – Where on the body parts is it located? Is it in an area that is difficult to offload, complicated, or keep clean? Is it in an area of high skin tension? Is it near any vital organ and structures such as a major artery?
- What is your Past – Has your previous medical history of fracture? Are you suffering from any chronic disease, such as hypertension, blood pressure, diabetes mellitus, previous major surgery? What kind of medicine did you take? What is your food habits, geographic location, Alcohol, tea, coffee consumption habit, anabolic steroid uses for athletes, etc?
Physical Examination
Physical examination is done by your doctor, consisting of palpation of the fracture site, eliciting boney tenderness, edema, swelling. If the fracture is in the dept of a joint, the joint motion, normal movement will aggravate the pain.
- Inspection – Your doctor also check superficial tissue, skin color, involving or not only the epidermal layer or Partial-thickness affects the epidermis and extend into the dermis, but full-thickness also extends through the dermis and into the adipose tissues or full-thickness extends through the dermis, and adipose exposes muscle, bone, evaluate and measure the depth, length, and width of the fracture. Access surrounding skin tissue, fracture margins for tunneling, rolled, undermining fibrotic changes, and if unattached and evaluate for signs and symptoms of infect warm, pain, delayed healing.
- Palpation – Physical examination may reveal tenderness to palpation, swelling, edema, tenderness, worm, temperature, open fracture, closed fracture, microtrauma, and ecchymosis at the site of fracture.
- Motor function – Your doctor may ask the patient to move the injured area to assist in assessing muscle, ligament, and tendon function. The ability to move the joint means only that the muscles and tendons work properly, and does not guarantee bone integrity or stability. The concept that “it can’t be fractured because you can move it” is not correct. The jerk test and manual test are also performed to investigate the motor function.
- Sensory examination – assesses sensations such as light touch, worm, paresthesia, itching, numbness, and pinprick sensations, in its fracture side.
- Range of motion – A range of motion examination of the fracture associate joint and it’s surrounding joint may be helpful in assessing the muscle, tendon, ligament, cartilage stability. Active assisted, actively resisted exercises are performed around the injured area joint.
- Blood pressure and pulse check – Blood pressure is the term used to describe the strength of blood with which your blood pushes on the sides of your arteries as it’s pumped around your body. An examination of the circulatory system, feeling for pulses, blood pressure, and assessing how quickly blood returns to the tip of a toe to heart and it is pressed the toe turns white (capillary refill).
Fracture specefic test
Le Fort Type I
Le Fort type I presents as a swollen upper lip, anterior open bite malocclusion, ecchymosis of the maxillary buccal vestibule and palate, and mobility of the maxilla.
Le Fort Type II
With a Le Fort type II fracture, there is significant deformity and swelling, widening of the intercanthal space (nasal septum fracture), mobility of the maxilla and nose as a combined segment, as well as bilateral periorbital edema and ecchymosis (raccoon eyes), epistaxis, anterior open bite malocclusion, ecchymosis of the maxillary buccal vestibule and palate, and possible CSF rhinorrhea. Since the fracture involves the inferior orbital rim and floor, there may be sensory deficits in the infraorbital region extending inferiorly to the upper lip.
Le Fort Type III
The most significant clinical findings are demonstrated by bilateral periorbital edema and ecchymosis (raccoon eyes), ecchymosis of the maxillary buccal vestibule and palate, lengthening of facial height- elongation and flattening of the face (dish-face deformity), orbital hooding, enophthalmos, ecchymosis over the mastoid region (Battle’s sign), CSF rhinorrhea, CSF otorrhea, and hemotympanum.
Evaluation
The initial evaluation of patients with maxillofacial trauma should follow advanced trauma life Support (ATLS) protocols. The primary survey includes airway and cervical spine stabilization, breathing and ventilatory support, attention to circulation and hemorrhage control, disability and neurologic evaluation, and exposure and environment control.
Airway obstruction associated with fractures of the midfacial skeleton can be life-threatening if not recognized promptly and treated appropriately. Orotracheal intubation is required when intranasal damage is a possibility. Airway obstruction in Le Fort injuries mainly occurs due to multiple sources bleeding into the upper airway, as well as midface altered airway anatomy. Beware that the risk of life-threatening hemorrhage in Le Fort II and III injuries is higher than that associated with other facial injuries.
Maxillofacial trauma is an obvious threat to the patient’s airway; therefore, a rapid evaluation must be performed to determine the need for a definitive airway. The concept of the definitive airway in cases of maxillofacial trauma is probably much more critical as compared to trauma to other body parts; therefore, an emergency airway may be required.
In a patient with complex maxillofacial trauma, cervical spine fracture should always be considered unless proven otherwise. Therefore, the cervical spine must be protected while providing airway management.
During the secondary survey, the assessment of maxillofacial fractures is performed after initial stabilization and resuscitation of the multisystem trauma patient. An ophthalmologic evaluation is required in Le Fort II and III fractures with orbital involvement. This should be completed before surgery to ensure there is no globe injury.
The mobility of the face should be tested on both sides as well as in the midline. The type of Le Fort fracture is determined by which regions are mobile.
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Le Fort I: Mobility of the maxilla; maxilla is free from the rest of the facial bones (floating palate)
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Le Fort II: Mobility of the maxilla and nose as a combined segment
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Le Fort III: Mobilized segment to include the maxilla, nose, and zygomas
A CT scan of facial bones is required to fully and adequately assess the extent of bone and soft tissue involvement. Plain radiographs are not sufficient for evaluation. Beware that penetrating trauma to the midface may involve injury to the brain and major vascular structures. Therefore, a CT scan of the head and diagnostic angiography should also be considered.
Treatment of Le Le Fort Fracture
Do no HARM for 72 hours after injury
- Heat—hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
- Alcohol stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
- Running, and walking may cause further damage, and causes healing delay.
- Massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.
Medication
The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment
- Antibiotic – Cefuroxime or Azithromycin, or Flucloxacillin or any other cephalosporin/quinolone, meropenem antibiotic must be used to prevent infection or clotted blood removal to prevent further swelling, inflammation, and edema.
- NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include first choice NSAIDs is Ketorolac, then Etoricoxib, then Aceclofenac, naproxen.
- Muscle Relaxants – These medications provide relief from spinal muscle spasms, spasticity. Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control postoperative muscle spasms, spasticity, stiffness, contracture.
- Calcium & vitamin D3 – To improve bone health, blood clotting, helping muscles to contract, regulating heart rhythms, nerve functions, and healing fractures. As a general rule, too absorbed more minerals for men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day to heal back pain, fractures, osteoarthritis.
- Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, tingling sensation, and paresthesia.
- Glucosamine & Diacerein, Chondroitin sulfate – can be used to tighten the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. The dosage of glucosamine is 15oo mg per day in divided dosage and chondroitin sulfate approximately 500mg per day in different dosages, and diacerein minimum of 50 mg per day may be taken if the patient suffers from osteoarthritis, rheumatoid arthritis, and any degenerative joint disease.[rx]
- Topical Medications and essential oil – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation in acute trauma, pain, swelling, tenderness through the skin. If the fracture is closed and not open fracture then you can use this item.
- Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins in your body’s natural painkillers. It also helps in neuropathic pain, anxiety, tension, and proper sleep.
- Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To heal the nerve inflammation and clotted blood in the joints.
- Dietary supplement – To eradicate the healing process from fracture your body needs a huge amount of vitamin C, and vitamin E. From your dietary supplement, you can get it, and also need to remove general weaknesses & improved health.
- Cough Syrup – If your doctor finds any chest congestion or fracture-related injury in your chest, dyspnoea, post-surgical breathing problem, then advice you to take bronchodilator cough syrup.
What To Eat and What to avoid
Eat Nutritiously During Your Recovery
All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.
- Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
- Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
- Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
- Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.
The initial evaluation and stabilization should be performed in conjunction with a trauma surgeon. Definitive surgery should be performed after stabilization when life-threatening injuries are addressed. Le Fort fractures require fixation of unstable fracture segments to stable structures. [rx][rx][rx]The goals of fracture management are to:
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Restore the facial projection and the involved sinus cavities
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Reestablish proper occlusion of teeth; note that proper repair cannot be performed without good occlusion
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Restore the integrity of the nose and orbit
Le Fort fractures may be associated with other injuries such as dental or alveolar ridge fractures (alveolar and palatal fractures are commonly associated with all types of Le Fort fractures and make the repair more difficult and complex), cerebrospinal fluid leaks, and severe epistaxis.
In type III, significant facial swelling, deformity, and orbital ecchymosis are almost always present.
Antibiotic prophylaxis in patients with CSF leak remains controversial and should be considered at the discretion of the treating neurosurgeon.
References
