Le Fort II Fracture

Le Fort II fracture is a pyramidal fracture of the midface that separates the central maxilla and nose from the facial skeleton. The fracture line crosses the nasal bridge, the medial orbital wall, the orbital floor and infraorbital rim, the zygomaticomaxillary suture, and the lateral maxillary wall to the pterygoid plates.

It follows a blow to the central midface, for example in road traffic collisions, falls or assault, and is often associated with fractures of the nasoethmoidal region and skull base.

Pathophysiology. The pyramid shaped central segment is detached, and the muscles of mastication and gravity pull it downward and backward, producing elongation and an open bite.

Involvement of the infraorbital rim and orbital floor can injure the infraorbital nerve and entrap orbital contents. Extension through the ethmoid and cribriform plate can cause a cerebrospinal fluid leak.

Mobile maxilla with movement felt at the nasal bridge when the teeth are rocked, face lengthened and flattened, periorbital swelling and bruising, bilateral subconjunctival haemorrhage, epistaxis, infraorbital numbness, step deformity at the infraorbital rim, malocclusion with an anterior open bite, and possible diplopia.

Clear fluid from the nose (cerebrospinal fluid leak), reduced vision, altered consciousness and airway compromise are serious signs. A tramline sign (halo) on a tissue suggests cerebrospinal fluid.

Visual loss, cerebrospinal fluid leak, airway compromise, signs of raised intracranial pressure and associated head injury need immediate escalation.

• CT of the facial bones and head with 3D reconstruction, the investigation of choice, to identify the fracture pattern and skull base injury.
• Ophthalmic assessment: visual acuity, pupils, colour vision, eye movements and diplopia, with orbital and optic nerve assessment.
• Testing of fluid for beta-2 transferrin when a cerebrospinal fluid leak is suspected.
• Cervical spine assessment and head injury evaluation depending on the mechanism.
• Tetanus status.

Differential diagnosis.

• Le Fort I and III fractures
• Nasoorbitoethmoid fracture
• Zygomatic complex fracture
• Isolated orbital floor fracture
• Skull base fracture with cerebrospinal fluid leak
• Mandibular fracture with open bite
• Retrobulbar haemorrhage

• Resuscitate and secure the airway, avoiding nasal intubation and nasopharyngeal tubes because of the risk of skull base fracture. Oral intubation or tracheostomy as needed. Control haemorrhage with packing, and reduce the fracture.
• Ophthalmic emergency: retrobulbar haemorrhage or traumatic optic neuropathy needs urgent lateral canthotomy and cantholysis for orbital compartment syndrome, with ophthalmology. Corticosteroids are not advised for traumatic optic neuropathy.
• Cerebrospinal fluid leak: head elevation to 30 degrees, no nose blowing, avoidance of straining, and neurosurgical review. Most leaks stop within 7 days. Routine prophylactic antibiotics are not supported by good evidence.
• Definitive treatment: open reduction and internal fixation through subciliary or transconjunctival, intraoral and nasal approaches, with miniplates at the nasofrontal, infraorbital rim and zygomaticomaxillary buttresses, orbital floor reconstruction, and intermaxillary fixation to set the occlusion. Surgery is performed when swelling allows, usually within 7 to 14 days, if the condition is stable.
• Antibiotics: amoxicillin with clavulanic acid 1.2 g intravenously every 8 hours for 24 hours perioperatively, with no routine extension unless infection exists. Clindamycin 600 mg intravenously every 8 hours in penicillin allergy. Reduce the dose of amoxicillin with clavulanic acid when eGFR is under 30.
• Tetanus toxoid 0.5 mL intramuscularly if vaccination is incomplete or the last dose was over 10 years ago, with tetanus immunoglobulin 250 IU intramuscularly (500 IU after 24 hours or heavy contamination) when status is unknown or incomplete.
• Analgesia: paracetamol 1 g every 6 hours (maximum 4 g daily) with ibuprofen 400 mg every 8 hours with food when appropriate.
• Nasal and sinus care: no nose blowing for 2 weeks, saline irrigation and chlorhexidine 0.2% mouthwash.
• Complications: malocclusion, enophthalmos, diplopia, infraorbital numbness, nasolacrimal duct obstruction, sinusitis, meningitis and malunion.

Monitoring. Review at 1 week, 2 weeks, 6 weeks and 3 months for occlusion, vision, eye movement, sensation and wound, with CT at 6 weeks. Repeated visual checks in the first 48 hours.

Referral and escalation. Refer to oral and maxillofacial surgery with ophthalmology and neurosurgery. Emergency referral for visual loss, cerebrospinal fluid leak, airway compromise or head injury.