What is Le Fort Fractures?
Le Fort injuries are complicated fractures that occur in the middle of the face. They are named after Rene Le Fort, who studied how human skulls reacted to strong impacts. His research identified the weaker parts of the upper jaw, called the maxilla, where fractures tend to happen. These fractures are grouped into three categories based on the fracture direction: horizontal, pyramidal or transverse.
All types of Le Fort fractures involve a part of the skull called the pterygoid plate, which can lead to a separation between it and the upper jaw. If there isn’t a pterygoid fracture, then it can’t be a Le Fort fracture. But the presence of a pterygoid fracture doesn’t necessarily mean there’s a Le Fort fracture. It’s noted that up to one-third of pterygoid plate fractures don’t fall into the pattern of a Le Fort fracture.
What Causes Le Fort Fractures?
A lot of facial injuries happen due to sporting accidents from sports like football, baseball, and hockey. In addition, car crashes, physical assaults, and falls from great heights can cause what are known as Le Fort fractures. People with these types of fractures often have related injuries to the head and neck area.
There are three types of Le Fort fractures, which are caused by different kinds of impact:
– Le Fort type I fractures can happen when a force hits downward against the upper teeth.
– Le Fort type II fractures occur when a force impacts the lower or middle part of the upper jaw.
– Le Fort type III fractures are caused by an impact to the bridge of the nose and the upper part of the upper jaw.
Risk Factors and Frequency for Le Fort Fractures
Le Fort fractures, which represent between 10% and 20% of all facial fractures, can be potentially life-threatening and disfiguring, especially in patients with a severe injury.
Signs and Symptoms of Le Fort Fractures
Le Fort fractures are severe facial injuries, categorized into three types, each with distinct signs:
- Le Fort Type I: This type often results in a swollen upper lip, mobility of the upper jaw, and darkening of the skin or bruising in the mouth and palate.
- Le Fort Type II: People with this type of fracture often show major swelling and distortion of the face, a widened space between the corners of the eyes due to a broken nose, and mobility of the upper jaw and nose. Other signs can include both eyes appearing blackened or bruised (also known as “raccoon eyes”), nosebleeds, and potential leakage of cerebrospinal fluid (CSF) from the nose. There might also be numbness in the lower eye and upper lip region due to the involvement of the lower part of the eye socket.
- Le Fort Type III: This type shows severe signs like “raccoon eyes”, lengthening and flattening of the face, deep-set eyes, darkening or bruising in areas of the jaw and around the ear (known as Battle’s sign), and leakage of cerebrospinal fluid (CSF) from the nose and ears. There may also be blood in the middle ear region.
Testing for Le Fort Fractures
When treating a patient with facial trauma, health care providers must follow advanced trauma life support protocols. The first steps involve making sure the patient can breathe and is stable. Then, the medical team focuses on helping the patient to breathe, controlling any bleeding, checking brain function, and making sure the patient is comfortable.
One common facial injury involves fractures of the middle facial bones. These injuries can block the airway, which can be life-threatening if not quickly and properly managed. A tube may be inserted via the mouth to aid in breathing if the nasal passage is damaged. This kind of injury, known as Le Fort injury, can sometimes cause severe bleeding and change the anatomy of the nasal passage. Remember that Le Fort II and III injuries pose a more significant risk of severe bleeding compared to other facial injuries.
The airway is strongly affected in cases of facial trauma. Health care professionals need to evaluate quickly if there’s a need for an emergency airway since it might be more crucial than for injuries in other body areas.
For patients with complicated facial trauma, a neck fracture should also be considered alongside the facial injury. It’s essential to protect the neck while managing the airway.
After initial stabilization and helping a patient with multiple injuries, it’s time to assess the facial fractures in the secondary survey phase. For Le Fort II and III fractures affecting the eye orbits, an eye specialist needs to evaluate before any surgery to ensure there’s no injury to the eyes.
A test of face movement is also important. Depending on which parts of the face are movable, we can determine the type of Le Fort fracture:
1. Le Fort I: Only the upper jawbone is movable
2. Le Fort II: Both the upper jawbone and the nose are movable together
3. Le Fort III: The upper jawbone, nose, and cheekbones are movable together
A CT scan of the facial bones is necessary to understand the extent of bone and soft tissue damage. Simple X-rays are not enough for this evaluation. It is also important to note that penetrating facial injuries might damage the brain and major blood vessels. Therefore, a CT scan of the head and a diagnostic blood vessel screening should also be considered.
Treatment Options for Le Fort Fractures
When dealing with serious cases like Le Fort fractures (breaks in the upper parts of your face), the initial check-up and stabilization should be carried out with a trauma surgeon. The actual operation should happen after the patient is stabilized and any immediate life-threatening conditions are taken care of. With Le Fort fractures, unstable areas where the fracture has occurred should be secured to stable structures.
The main goals when dealing with these fractures are to:
- Fix the damage to the face and any affected sinus cavities.
- Make sure the patient’s teeth align properly again. Good alignment is necessary for a successful repair.
- Rework and restore the structure of the nose and eye sockets.
Le Fort fractures might also come along with other injuries like dental or alveolar ridge fractures (breaks in the bone that holds your teeth or the roof of your mouth). These make the repair work more challenging and complicated. There could also be leaks of cerebrospinal fluid (the fluid that surrounds your brain and spinal cord), and severe nosebleeds.
In severe cases of Le Fort fractures (type III), there will almost certainly be visible facial swelling, changes to the shape of the face, and bruising around the eyes.
Patients with cerebrospinal fluid leaks could be given antibiotics to prevent infection, but this isn’t always done and depends on the judgement of the neurosurgeon treating them.
What else can Le Fort Fractures be?
- An immediate bruise under the skin
- Child mistreatment
- Familial aggression
- Mistreatment of seniors
- Break in the forehead bone
- Damage to the eye’s outer layer
- Jaw dislocation
- Broken jaw
- Injury to the neck
- Separation of the retina in the eye
What to expect with Le Fort Fractures
The result often depends on the nature of the injury, where the injury is, how severe it is, and whether there are other injuries present. The death rate for Le Fort fractures, which are complex facial injuries, is higher compared to simpler facial fractures.
Possible Complications When Diagnosed with Le Fort Fractures
There are some known complications associated with certain types of fractures. Specifically, with type II and type III fractures:
- Cerebrospinal fluid leak (a condition where the fluid that cushions the brain leaks out) is a common issue.
- Patients frequently experience epistaxis (nosebleeds).
