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Clinical Summary

All LeFort facial fractures involve the maxilla. Clinically, the patient has facial injuries, swelling, and ecchymosis. LeFort I fractures are those involving an area under the nasal fossa. LeFort II fractures involve a pyramidal area including the maxilla, nasal bones, and medial orbits. LeFort III fractures, sometimes described as craniofacial dissociation, involve the maxilla, zygoma, nasal and ethmoid bones, and the bones of the base of the skull. LeFort IV fractures have been described as a LeFort III fracture that also involves the frontal bone. Patients may have different LeFort fractures on each side of their face. Airway compromise may be associated with LeFort II and III fractures. Physical examination is sometimes helpful in distinguishing the four. The examiner places fingers on the bridge of the nose and tries to move the central maxillary incisors with the other hand. If only the maxilla moves, a LeFort I is present; movement of the upper jaw and nose indicates a LeFort II; and movement of the entire midface and zygoma indicates a LeFort III. Because of the extent of LeFort II and III fractures, they may be associated with cribriform plate fractures and CSF rhinorrhea. The force required to sustain a LeFort II or III fracture is considerable, and associated brain or cervical spine injuries or other facial fractures are common.

Management and Disposition

Attend to the airway and life-threatening injuries first. Maxillofacial CT best identifies LeFort injuries. Management of LeFort I fractures may involve only dental splinting and oral surgery referral. Consult on all LeFort II and III fractures for admission because of the need for operative repair. Epistaxis may be difficult to control in LeFort II and III fractures, in rare cases requiring intraoperative arterial ligation.

Pearls

  1. Determine the need for immediate airway management, since the massive edema associated with LeFort II and III fractures may quickly lead to airway compromise.

  2. Avoid nasotracheal intubation because of the possibility of intracranial passage.

  3. Serious facial trauma, like head injury, is often associated with cervical spine injuries; therefore, obtain a cervical spine CT.

  4. Associated cranial injuries are common with severe facial trauma; therefore, obtain head CT.

  5. If not recognized, an occult CSF leak may result in significant morbidity. Suspected CSF leaks require neurosurgical consultation.

FIGURE 1.38

LeFort Fractures. Illustration of the fracture lines of LeFort I (alveolar), LeFort II (zygomatic maxillary complex), and LeFort III (cranial facial dysostosis) fractures.

FIGURE 1.39

LeFort Facial Fractures. Patient with blunt facial trauma. Note the ecchymosis and edema. This patient sustained a left LeFort II fracture and a right LeFort III and intracranial hemorrhages. (Photo contributor: Stephen Corbett, MD.)

FIGURE 1.40

LeFort Facial Fractures. Patient with blunt facial trauma who demonstrates the ...

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