Le Fort fracture of skull

LeFort fracture

LeFort I (red), II (blue), and III (green) fractures
Classification and external resources
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A Le Fort fracture of the skull is a classic transfacial fracture of the midface, involving the maxillary bone and surrounding structures in either a horizontal, pyramidal or transverse direction. The hallmark of Lefort fractures is traumatic pterygomaxillary separation, which signifies fractures between the pterygoid plates, horseshoe shaped bony protuberances which extend from the inferior margin of the maxilla, and the maxillary sinuses. Continuity of this structure is a keystone for stability of the midface, involvement of which impacts surgical management of trauma victims, as it requires fixation to a horizontal bar of the frontal bone. The pterygoid plates lie posterior to the upper dental row, or alveolar ridge, when viewing the face from an anterior view. The fractures are named after French surgeon René Le Fort (1869–1951), who discovered the fracture patterns by examining crush injuries in cadavers.[1]

Diagnosis

A 3-D CT reconstruction showing a LeFort type 1 fracture ( fracture line is marked by an arrow )

Diagnosis is suspected by physical exam and history, in which, classically, the hard and soft palate of the midface are mobile with respect to the remainder of facial structures. This finding can be inconsistent due to the midfacial bleeding and swelling that typically accompany such injuries, and so confirmation is usually needed by radiograph or CT.[2]

Classification

LeFort I fracture

There are three types of Le Fort fractures. As the classification increases, the anatomic level of the maxillary fracture ascends from inferior to superior with respect to the maxilla:

LeFort II fracture
LeFort III fracture

Signs and Symptoms

Lefort I - Slight swelling of the upper lip, ecchymosis is present in the buccal sulcus beneath each zygomatic arch, malocclusion, mobility of teeth. Impacted type of fractures may be almost immobile and it is only by grasping the maxillary teeth and applying a little firm pressure that a characteristic grate can be felt which is diagnostic of the fracture. Percussion of upper teeth results in cracked pot sound. Guérin's sign is present characterised by ecchymosis in the region of greater palatine vessels.

Lefort II and Lefort III (common) - Gross edema of soft tissue over the middle third of the face, bilateral circumorbital ecchymosis, bilateral subconjunctival hemorrhage, epistaxis, CSF rhinorrhoea, dish face deformity, diplopia, enophthalmos, cracked pot sound.

Lefort II - Step deformity at infraorbital margin, mobile mid face, anesthesia or paresthesia of cheek.

Lefort III - Tenderness and separation at frontozygomatic suture, lengthening of face, depression of ocular levels (enophthalmos), hooding of eyes, and tilting of occlusal plane, an imaginary curved plane between the edges of the incisors and the tips of the posterior teeth. As a result, there is gagging on the side of injury.[4]

Treatment

Treatment is surgical, and usually is able to be performed once life threatening injuries are stabilized, to allow the patient to survive the general anesthesia needed for invasive orthopedic restructuring. First a frontal bar is used, which refers to the thickened frontal bone above the frontonasal sutures and the superior orbital rim. The facial bones are suspended from the bar by open reduction and internal fixation with titanium plates and screws, and each fracture is fixed, first at its superior attachment to the bar, then at the inferior attachment to the displaced bone. For stability, the zygomaticofrontal suture is usually replaced first, and the palate and alveolar ridge are usually fixed last. Finally, after the horizontal and vertical maxillary buttresses are stabilized, the orbital fractures are fixed last.[5]

See also

References

  1. Allsop D, Kennett K (2002). "Skull and facial bone trauma". In Nahum AM, Melvin J. Accidental injury: Biomechanics and prevention. Berlin: Springer. pp. 254–258. ISBN 0-387-98820-3. Retrieved 2008-10-08.
  2. Kim, S. H.; Lee, S. H.; Cho, P. D. (2012). "Analysis of 809 facial bone fractures in a pediatric and adolescent population". Archives of Plastic Surgery 39 (6): 606–11. doi:10.5999/aps.2012.39.6.606. PMC 3518003. PMID 23233885.
  3. Winegar, B. A.; Murillo, H; Tantiwongkosi, B (2013). "Spectrum of critical imaging findings in complex facial skeletal trauma". RadioGraphics 33 (1): 3–19. doi:10.1148/rg.331125080. PMID 23322824.
  4. Lo Casto, A; Priolo, G. D.; Garufi, A; Purpura, P; Salerno, S; La Tona, G; Coppolino, F (2012). "Imaging evaluation of facial complex strut fractures". Seminars in Ultrasound, CT and MRI 33 (5): 396–409. doi:10.1053/j.sult.2012.06.003. PMID 22964406.
  5. Chung, K. J.; Kim, Y. H.; Kim, T. G.; Lee, J. H.; Lim, J. H. (2013). "Treatment of complex facial fractures: Clinical experience of different timing and order". Journal of Craniofacial Surgery 24 (1): 216–20. doi:10.1097/SCS.0b013e318267b6f7. PMID 23348288.

External links

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