Le Fort Fracture

Le Fort fractures are classic patterns of horizontal and pyramidal midface fractures involving the maxilla and its articulation with the pterygoid plates of the sphenoid bone. They typically follow high energy blunt trauma: road traffic crashes, motorcycle accidents, falls from height, and assaults. Le Fort type fractures all extend through the pterygoid plates, which is an essential feature.

Types:

• Le Fort I (transverse or floating palate): passes above the tooth roots through the lower nasal septum, lateral nasal aperture and maxillary sinus walls to the pterygoid plates.
• Le Fort II (pyramidal fracture): through the nasofrontal suture, medial orbital wall, infraorbital rim and zygomaticomaxillary suture, to the pterygoid plates.
• Le Fort III (craniofacial dysjunction): through the nasofrontal suture, medial and lateral orbital walls, zygomatic arch and pterygoid plates, separating the face from the skull.

Combinations and unilateral variants are common, and real fractures are often comminuted. Complications include airway obstruction, haemorrhage (maxillary artery branches), cerebrospinal fluid leak, ocular injury, malocclusion, nasolacrimal obstruction, and associated brain injury.

• Facial swelling, bruising (raccoon eyes in type II and III), subconjunctival haemorrhage, epistaxis, bleeding in the mouth.
• Elongation of the midface ("donkey face" or dish face), flattened midface, malocclusion with anterior open bite, gagging of the posterior teeth.
• Mobility of the midface: type I (the palate alone moves when grasped), type II (the nose and maxilla move as a pyramid), type III (the entire midface moves relative to skull base, with mobility at the nasofrontal area).
• Cerebrospinal fluid rhinorrhoea (clear fluid with halo sign on tissue), anosmia, step deformity of the infraorbital rim, infraorbital numbness, diplopia, enophthalmos, telecanthus (type II and III).
• Airway compromise from posterior displacement of the maxilla and swelling; trismus.
• Red flags: airway obstruction, massive haemorrhage, loss of consciousness, CSF leak, visual loss, cervical spine injury, and polytrauma.

• Trauma assessment with advanced life support principles; cervical spine and head injury evaluation; document visual acuity, pupils, eye movements, and cranial nerves.
• Facial examination: palpation of orbital rims, nasal bones, zygomatic arches and maxillary buttresses, bimanual midface mobility test (grasp the anterior maxillary teeth and rock), occlusion, intraoral examination, sensation in V2 distribution; check for CSF leak.
• CT of the facial bones with axial, coronal and 3D reconstructions (essential), and CT head and cervical spine in blunt high energy trauma.
• Ophthalmology review for orbital involvement; formal visual field and forced duction test when suspected.
• Blood tests: full blood count, group and cross match, coagulation profile.
• Exclude zygomaticomaxillary complex fracture, naso-orbito-ethmoid fracture, orbital blow out, skull base fracture, and mandibular fracture.

• Airway: early securing of airway (nasotracheal intubation is contraindicated with CSF leak or skull base fracture; use orotracheal route, or tracheostomy or submental intubation for extensive fracture); position patient upright or lateral when safe; suction; avoid nasopharyngeal airways.
• Haemorrhage control: nasal packing (anterior and posterior balloon catheter or Foley catheter inflated with 10 to 15 mL saline), manual reduction of the maxilla and temporary intermaxillary fixation to reduce bleeding.
• Also for haemorrhage: intravenous tranexamic acid 1 g over 10 minutes within 3 hours then 1 g over 8 hours, fluid and blood resuscitation, and angioembolisation if arterial bleeding persists.
• Analgesia: paracetamol 1 g every 6 hours, morphine 0.05 to 0.1 mg/kg intravenously every 4 hours as needed; avoid NSAIDs until bleeding stops.
• Antibiotics: amoxicillin clavulanate 1.2 g intravenously every 8 hours for 24 to 48 hours perioperatively for open or sinus involved fractures.
• Ceftriaxone 2 g intravenously once daily for CSF leak or neurosurgical involvement, according to local policy.
• Tetanus toxoid 0.5 mL intramuscularly if not immunised in the last 5 years; avoid nasal instrumentation.
• Definitive treatment: open reduction and internal fixation (ORIF) once swelling settles (usually 5 to 10 days) and the patient is stable.
• Restore occlusion first with maxillomandibular fixation, then reduce and fix buttresses (nasomaxillary, zygomaticomaxillary, pterygomaxillary) with titanium miniplates (1.5 to 2.0 mm) through gingivobuccal, subciliary or transconjunctival, and coronal incisions.
• Bone grafts for comminution; Le Fort III needs fixation of the frontozygomatic suture, zygomatic arch, and nasofrontal region.
• CSF leak: head elevation 30 degrees, avoid nose blowing, acetazolamide 250 mg orally three times daily for 5 to 7 days; most resolve within 7 days; persistent leak needs repair by neurosurgery.
• Eye injury: urgent ophthalmology review; orbital decompression for traumatic optic neuropathy only in selected cases.
• Remove intermaxillary fixation after 2 to 4 weeks and start physiotherapy and soft diet.
• Complications: malocclusion, malunion, nonunion, infection, sinusitis, nasolacrimal duct obstruction, enophthalmos, diplopia, anosmia, CSF leak, and meningitis; treated by revision, orthognathic surgery, dacryocystorhinostomy.
• Follow up: review at 1, 2, 6 and 12 weeks, then at 6 and 12 months with CT if needed; ophthalmology review at 1 and 3 months.
• Counselling: road safety, helmet use, seat belts, and no nose blowing for 2 weeks.