Hello everyone!
For trauma Tuesday, let's discuss Le Fort fractures.
Le Fort fractures are complex facial fractures involving the maxilla, zygoma, and orbital rims. They were discovered by Dr. Rene Le Fort who discovered these "lines of weakness" in skulls of patients with blunt facial traumas. These fractures by nature include the pterygoid structures of the sphenoid bone, which provide stability and support for the mid face. Most commonly seen in MVC, the velocity determines the severity of the fractures, of which there are three categories:
Le Fort I: "floating palate"
- a transverse fracture of the maxillae above the teeth, leaving the body of the maxilla separated from the pterygoid plate and nasal septum. This leads to a "floating palate", where the maxilla and hard palate may be mobile.
- associated with malocclusion and dental fractures
- generally considered a stable fracture
Le Fort II: "floating maxilla"
- fracture that extends superiorly to include the nasal bridge, maxilla, and orbital rim and floors. fractures are typically bilateral and appear triangular in shape
- The maxilla and nose are mobile, the eyes/orbits are not
- can be stable or unstable
Le Fort III: "floating face"
- the rarest and most severe, this fracture involves the bridge of the nose, medial and lateral orbital wall, zygomatic arch, and maxilla.
- the entire face is mobile, can present as a "dish face" deformity (essentially the face is caved in)
- this is an unstable fracture
Presentation and Evaluation:
Le Fort fractures can present with many features, including facial deformity and emphysema, CSF rhinorrhea, conjunctival hemorrhage, raccoon eyes, hemotympanum and auricular hematoma, and anosmia
Questions to ask:
Can you smell? Can you bite?
How is your vision?
Is there numbness or tingling in you face?
Exam:
- palpate for signs of crepitus, areas of tenderness, or instability
- visual acuity test - very important considering high risk of ophthalmologic damage
- check mobility by stabilizing the forehead and grabbing the upper teeth/hard palate, and attempt to move the hard palate
-evaluate to c-spine injuries - approximately 1.4% have concomitant c-spine injuries or dislocations
Management:
- Stabilize ABCs. If airway is at risk - understand that it will be a difficult airway, and consider awake intubation. These patients are particularly difficult as oral injury may prevent appropriate jaw displacement for oral intubation. Nasal intubations are contraindicated due to nasal injuries. These are patients where if a definitive airway is needed, cricothyroidotomy should be considered.
- significant nasal bleeding can occur and may present an airway risk. Consider anterior packing and elevation of head of bed to 40-60 degrees. Posterior packing should be avoided due to risk of skull base injuries.
- IV antibiotics should be given in sinus fractures or CSF leaks, which will be the majority of these fractures
- CT with dedicated facial view should be obtained.
Disposition:
- All Le Fort fractures should be seen by OMFS
- consider Ophtho or NSG consult if there is concern for eye or brain damage/CSF leak
- some stable Le Fort I and II are stable for discharge with follow up, however most will require ICU (for airway management) or direct OR
http://www.emdocs.net/em3am-le-fort-fractures/
https://www.ncbi.nlm.nih.gov/books/NBK526060/
https://coreem.net/core/le-fort-fractures/