Le Fort III Fracture

Le Fort III fracture is a craniofacial disjunction in which the whole midface is separated from the skull base. The fracture line runs through the nasofrontal suture, the medial and lateral orbital walls (zygomaticofrontal suture), the orbital floor, the zygomatic arch and the pterygoid plates.

It follows high energy trauma to the upper face and is nearly always accompanied by a skull base fracture, and often by head injury and other facial fractures. It may be bilateral or combined with other Le Fort patterns.

Pathophysiology. The midface is detached from the cranium and displaced downward and backward by the pull of the pterygoid muscles and gravity, with elongation and flattening of the face.

Involvement of the ethmoid roof and anterior cranial fossa causes cerebrospinal fluid leak, and orbital fracture can damage the optic nerve, extraocular muscles and the nasolacrimal system.

Gross facial swelling and elongation with a dish face deformity, a mobile midface with the whole face moving on palpation of the nasal bridge, periorbital ecchymosis, subconjunctival haemorrhage, enophthalmos or proptosis, diplopia, telecanthus, epistaxis, cerebrospinal fluid rhinorrhoea or otorrhoea, and malocclusion with an anterior open bite.

Altered consciousness and visual loss are common. Raccoon eyes and mastoid ecchymosis (Battle sign) suggest skull base fracture.

Airway compromise, visual loss, cerebrospinal fluid leak, signs of intracranial injury and haemorrhage need immediate escalation.

• CT of the head, facial bones and cervical spine with 3D reconstruction as the primary imaging.
• Ophthalmic assessment: visual acuity, pupils, colour vision, eye movements, and fundus, with orbital imaging for optic canal fracture and retrobulbar haematoma.
• Beta-2 transferrin in nasal or ear fluid when cerebrospinal fluid leak is suspected.
• Neurological assessment and Glasgow Coma Scale, with neurosurgical review.
• Tetanus status.

Differential diagnosis.

• Le Fort I and II fractures
• Nasoorbitoethmoid fracture
• Zygomatic complex fracture
• Frontal sinus and anterior skull base fracture
• Orbital apex fracture with optic neuropathy
• Mandibular fracture with open bite
• Retrobulbar haemorrhage

• Trauma resuscitation and airway control (oral intubation or tracheostomy, with no nasal tubes), cervical spine protection, and treatment of life threatening injuries first. Reduce haemorrhage with packing and reduction.
• Neurosurgical care for intracranial injury and cerebrospinal fluid leak. Head elevation to 30 degrees, no nose blowing, and surgical repair for a persistent leak beyond 7 to 10 days. Routine prophylactic antibiotics for cerebrospinal fluid leak are not supported by good evidence.
• Ophthalmic emergencies: lateral canthotomy and cantholysis for retrobulbar haemorrhage with visual loss. Corticosteroids are not advised for traumatic optic neuropathy. Surgical decompression of the optic canal is considered only by specialists.
• Definitive treatment once stable and swelling has allowed, usually within 7 to 14 days: open reduction and internal fixation using coronal, lower eyelid and intraoral approaches. Reconstruct from the stable cranium downward and from the outside inward, with miniplates at the frontozygomatic suture, zygomatic arch, nasofrontal region, orbital rim and maxillary buttresses, bone grafts for defects, and intermaxillary fixation to set the occlusion.
• 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 careful use of ibuprofen when bleeding risk allows. Chlorhexidine 0.2% mouthwash.
• Complications: malocclusion, enophthalmos, diplopia, blindness, nasolacrimal obstruction, meningitis, brain abscess, malunion and facial deformity.

Monitoring. Neurological and visual checks every 1 to 2 hours in the first 48 hours, then review at 1, 2, 6 and 12 weeks, with CT at 6 to 12 weeks for union and position.

Referral and escalation. Refer to oral and maxillofacial surgery, neurosurgery, ophthalmology and critical care. Emergency escalation for visual loss, cerebrospinal fluid leak, intracranial injury or airway compromise.