Background:
In 1901, Dr. Rene Le Fort performed various experiments with the skulls of cadavers. He did this by imposing varying amounts of force in varying angles on the skulls of cadavers. Through his experimentation, he was able to conclude that there are 3 main types of mid face fractures, thus ultimately leading to the discovery of the three main types of Le Fort fractures.
Le Fort I
Horizontal: maxillary fracture immediately above the teeth and palate. Le Fort II
Pyramidal: maxillary fracture transects the nasal bones, orbital wall, orbital floor, inferior orbital rim, and pterygoid plate
Le Fort III
Transverse (craniofacial) disjunction essentially separates the maxilla from the skull base.
It is common for the fractures to not follow the commonly described paths detailed above. In the event that there are more than one type of Le Fort fracture, the classification follows a descending nomenclature. For example, if an individual were to have both a Le Fort I and Le Fort III fracture, then it would be classified as a Le Fort III-I fracture.
Typically, Le Fort fractures occur after high speed deceleration injuries, such as a motor vehicle accident, pedestrian struck, or a fall onto pavement. Trauma from other objects, such as bats, may also cause Le Fort fractures.
Le Fort fractures account for approximately 10-20% of all facial fractures, therefore it is important to include it in your differential diagnosis for any patient with facial trauma.
Evaluation:
When a patient comes in with significant facial trauma, it is important not to get too distracted by the degree of facial trauma. Initial evaluation should adhere to ATLS guidelines with a primary survey that focuses on the airway, breathing, circulation, disability, and exposure/environment control. In cases of Le Fort fractures, it is imperative to assess for airway patency immediately. If the airway is compromised and there is a need for assisted ventilation, then consider a nasotracheal intubation over a flexible bronchoscope or a tracheostomy. It is important to keep in mind that the patient may also have sustained serious cervical spine injury and that cervical spine stabilization is necessary.
Once the patient has been stabilized, a secondary survey can be performed. An ophthalmologic evaluation should be performed at this step to assess for globe injury. It is during this time that you can test the mobility of the maxilla to quickly assess for the degree of the Le Fort Fracture: In Type I, the maxilla is the only part of the face that is mobile. In type II, the maxilla and the nose are mobile together. Lastly, Type III will show mobility of the maxilla, nose, and the zygomas.
Imaging: CT is diagnostic of Le Fort fractures. X ray films offer very little detail. Patients presenting after such a trauma will most likely be getting CT scans, therefore it is reasonable to defer on x ray imaging. It is also reasonable to add a CTA of the Head and Neck as there may also be concurrent damage to the vascular structures in the head.
Management
It is imperative to get facial trauma involved as early as possible. In addition, if there is suspicion of a CSF leak or globe rupture, then neurosurgery and ophthalmology should also be involved, respectively.
In the ED, the patient should be started on antibiotics. Although there is no literature to prove the effectiveness of antibiotics in Le Fort Fractures, it is better to err on the side of caution here. Oral Maxillofacial Surgeons tend to prefer Augmentin (Clindamycin if there is a penicillin allergy)
Management centers around surgical repair with restoration of functional occlusion and re-alignment of the facial contour.
Prognosis
A meta-analysis performed by Dr. Phillips and Dr. Turco outlined the prognoses of patients with Le Fort Fractures. Their meta-analysis found that Le Fort I, II, and III fractures had a mortality of 0%, 4.5%, and 8.7%, respectively. Therefore, mortality is typically low, however these fractures are associated with significant morbidity. Patients with Le Fort fractures often experience vision changes, diplopia, difficulty with chewing, and difficulty breathing even after proper treatment of the fractures. 58% of patients with Le Fort III fractures were able to return to work compared to the 70% of patients with Le Fort I and II fractures who were able to return to work.
Resources:
Funk, G. (n.d.). Iowa head and Neck Protocols. Facial Fracture Management Handbook - LeFort Fractures | Iowa Head and Neck Protocols. Retrieved March 23, 2022.
Patel BC, Wright T, Waseem M. Le Fort Fractures. [Updated 2021 Nov 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
Phillips BJ, Turco LM. Le Fort Fractures: A Collective Review. Bull Emerg Trauma. 2017;5(4):221-230. doi:10.18869/acadpub.beat.5.4.499.
Darshak Vekaria, M.D. is a PGY-1 at Stony Brook University Hospital.