Makindo Medical Notes.com

Le Fort I is a floating palate (horizontal), Le Fort II is a floating maxilla (pyramidal), Le Fort III is a floating face (transverse)

About

• Le Fort fractures are fractures of the midface due to blunt trauma
• Good airway protection and bleeding management is paramount
• Due to Road traffic accidents, assault, and falls

Historical

• Rene Le Fort, French surgeon described in 1901.
• He dropped cannon balls on dead corpses faces
• He boiled the heads to remove soft tissue and to see the damage caused

Le Fort fractures of the Maxilla

• I - Transverse fracture above teeth. Primarily involve the maxilla. There is the separation of the hard palate from surrounding bone. Remember with "speak no evil". Pulling on the central incisors can lead to a "floating palate" due to mobility of the dental arch. Usually due to a low-velocity injury such as a simple fall.
• II - Involve the maxilla, nasal bridge, lacrimal bones, orbital floors, and orbital rims. Remember with "See No Evil". The shape of this fracture has a pyramidal appearance.The entire nasal complex is mobile when the central incisors are pulled. May be due to High-velocity trauma mechanisms
• III - Fractures involve the nasal bridge, medial orbital walls, lateral orbital walls, maxilla, and zygomatic arch. The facial skeleton is freed from the cranial bones. Remember with "hear no evil". This results in complete or near-complete craniofacial dislocation.A CSF leak may be present as the intranasal portion of the fracture extends posteriorly through the sphenoid. Pulling on the central incisors will result in an entire anterior displacement of the face. It May be due to High-velocity trauma mechanisms

Clinical

• Assess coma scale and pupils and ABC and other injuries
• Facial trauma, epistaxis, rhinorrhea, bruising, bleeding
• Malocclusion, loose teeth, periorbital bleeding, blood in ear canal

Investigations

• A computerized tomography (CT) scan of the facial bones is often required to fully assess the extent of the injury.

Management

• ABC, Facial trauma can become life-threatening, especially if there is a risk of airway compromise. Rapidly assess the patient's airway, breathing, and circulation, and take action as deemed necessary. Tracheostomy is an effective and safe way of securing airway management in the setting of severe. Nasotracheal intubation in the setting of facial fracture is contraindicated as it can result in sinus infection, mediastinal emphysema, and most importantly, accidental intracranial intubation facial trauma.
• Once the primary survey is complete, the secondary survey can help evaluate the extent of the injury. Midface fractures are typically due to blunt trauma and are differentiated using the Le Fort classification system.
• During the secondary survey, the central incisors can be pulled anteriorly to assess what parts of the face are mobile. This can help determine which type of Le Fort fracture is present.
• Manage and pack any bleeding of the nasopharynx and/or oropharynx may be necessary. Consider prophylactic IV antibiotics should be considered. Oral maxillofacial surgery should also be involved. If there is a CSF leak then discuss with neurosurgery.
• The review below found that Le Fort fractures required open reduction and internal fixation in 60% of cases, 30% of cases were managed conservatively, and the remaining 10% of cases required no treatment.
• Today's simple tactic will be using the "see no evil, hear no evil, speak no evil" saying to understand the different types of Le Fort midface fractures.

References

• Le Fort Fractures: A Collective Review