Le Fort Fracture

Over the Memorial Day weekend, I was so bored I binge watched the Rocky anthology. My favorite movie of the anthology is Rocky IV, not just because of the way he boxed, but mostly because he may have single-handedly ended the Cold War with this speech.

Who knew that many years later, we would still need a national hero like Rocky to fix the strained relations between the US and Russia.

Rocky’s mastery of diplomacy rivals (probably surpasses) that of our current leader, but it does not completely overshadow the epic battle between Rocky and the Russian, Ivan Drago.

Ivan Drago was a larger than life boxer who was pumped up with steroids to develop what seemed to be superhuman strength. During his training montage, Drago’s punch topped out at 1,860 pounds per square inch. Even Drago’s manager would brag, “Whatever he hits, he breaks.”

There’s a good chance that Rocky sustained some pretty nasty facial trauma during the fight.

I spent some time imagining how Rocky would present to the emergency department after this fight…

There’s a patient in the hallway yelling “Adrian!” repeatedly. His speech sounds somewhat slurred and undiscernible. You curiously walk over to the bedside and immediately recognize Rocky in his American flag shorts. Before you can even get giddy about seeing your lifelong hero, he starts complaining that he can’t close his mouth or speak properly.

You also notice that Rocky’s face appears flatter than usual. You recall that this is the classic “dish face deformity,” which is characteristic of a Le Fort III fracture.

What are the Le Fort fractures?

The Le Fort classification system describes common maxillary fractures resulting from blunt trauma like motor vehicle crashes, falls, sports or assault.

What are the immediate things to consider in facial trauma?

As with all trauma, ABCs are the priority. Endotracheal intubation may be difficult given the extent of injury. A tracheostomy or cricothyroidotomy should be considered due to midface instability and oropharyngeal airway obstruction that can occur with Le Fort fractures.

Additionally, Le Fort fractures occur only after high-energy injury. Therefore, it is critical to recognize concomitant injuries to the patient’s head, C-spine and orbits.

What are the signs, symptoms, and exam findings found in patients with Le Fort fractures?

Le Fort injuries often present dramatically, with significant hemorrhage, early swelling, bilateral orbital ecchymosis, diplopia, and cerebrospinal fluid leaks. The patient may sense malocclusion and will endorse localized maxillary pain.

Each pattern of Le Fort fracture results in a unique movement of the midface while gently rocking the hard palate with one hand and stabilizing the forehead with the other hand.

If mobility is detected, you can determine the level of the fractures by holding the hard palate with one hand and using your other hand to palpate the bridge of the nose, the infraorbital rims, and along the zygoma.

How is it diagnosed?

Facial CT is the test of choice to identify maxillary fractures and determine their classification.

What are the Le Fort classifications?

Le Fort I

Le Fort I fractures include the maxilla parallel to the alveolar process and hard palate extending posteriorly behind the maxillary molars and across the lateral wall of the maxillary sinus. This fracture essentially separates the maxillary teeth from the face.
Le Fort I typically presents with facial edema and mobility of the hard palate.
On exam, you will feel mobility while grasping the incisors and hard palate and gently pushing in and out.

Le Fort II

Le Fort II fractures include the fracture lines of a Le Fort I fracture but now involve the bony nasal skeleton becoming a pyramidal fracture.
This fracture is associated with marked facial edema, bilateral subconjunctival hemorrhage, and mobility of the maxilla.
The patient may have epistaxis or CSF rhinorrhea.
On exam, the nasal bridge moves along with the maxilla.

Le Fort III

Le Fort III fractures define craniofacial disjunction. The fracture extends through the frontozygomatic suture lines, across the orbit and through the base of the nose and ethmoid region. The zygoma may become completely separated in some patients.
Airway complications are common with Le Fort III. Nasotracheal intubation and NG tubes are contraindicated.
Visual acuity should be tested due to the high incidence of blindness with Le Fort III fractures.
CSF rhinorrhea and epistaxis are likely both present.
Head and C-spine imaging should be performed to look for concomitant injury.
On exam, the nose, infraorbital rims, and the zygoma move together with the maxilla.

What is the disposition?

Maxillofacial trauma surgeons should be consulted for definitive management of these fractures. Disposition of patients with these fractures often depends on the severity of concomitant injuries. These patients may need to be sent emergently to the operating room or admitted for IV antibiotics and supportive care.

Now for a classic Rocky training montage to get you pumped up for a 12-hour shift