Le Fort fracture of skull: Difference between revisions
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The '''Le Fort''' (or '''LeFort''') '''fractures''' are a pattern of midface fractures originally described by the French surgeon, [[René Le Fort]], in the early 1900s.<ref name=":0">{{Cite journal |last=Ikeda |first=Allison K. |last2=Burke |first2=Andrea B. |date=2021-11 |title=LeFort Fractures |url=https://pubmed.ncbi.nlm.nih.gov/34819806 |journal=Seminars in Plastic Surgery |volume=35 |issue=4 |pages=250–255 |doi=10.1055/s-0041-1735816 |issn=1535-2188 |pmc=8604624 |pmid=34819806 |via=}}</ref> He described three distinct fracture patterns. Although not always applicable to modern-day facial fractures, the Le Fort type fracture classification is still utilized today by medical providers to aid in describing [[facial trauma]] for communication, documentation, and [[surgical planning]].<ref name=":1">{{Cite book |title=Cummings otolaryngology: head and neck surgery ; enhanced digital version included |date=2021 |publisher=Elsevier |isbn=978-0-323-61179-4 |editor-last=Flint |editor-first=Paul W. |edition=7th edition |location=Philadelphia, Pa |chapter=Chapter 20: Maxillofactial Trauma |editor-last2=Kellman |editor-first2=Robert M.}}</ref> Several surgical techniques have been established for facial reconstruction following Le Fort fractures, including [[Maxillomandibular fixation|maxillomandibular fixation (MMF)]] and [[Internal fixation|open reduction and internal fixation (ORIF)]]. The main goal of any surgical intervention is to re-establish [[Occlusion (dentistry)|occlusion]], or the alignment of upper and lower teeth, to ensure the patient is able to eat.<ref name=":1" /> Complications following Le Fort fractures rely on the anatomical structures affected by the inciding injury. |
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| caption = Le Fort I (red), II (blue), and III (green) fractures |
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A '''Le Fort fracture of the skull''' is a classic transfacial [[bone fracture|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 processes of the sphenoid|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 (architecture)|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]].<ref name="Allsop02">{{cite book |vauthors=Allsop D, Kennett K |veditors=Nahum AM, Melvin J |chapter=Skull and facial bone trauma| title=Accidental injury: Biomechanics and prevention |publisher=Springer |location=Berlin |year=2002 |pages=254–258 |isbn=0-387-98820-3 |chapter-url=https://books.google.com/books?id=Y4l5fopEI0EC&dq=facial+trauma&pg=PA254 |accessdate=2008-10-08}}</ref> |
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== Anatomy == |
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When discussing the anatomy of the face, it is often divided into thirds. The lower third extends from the chin to approximately the level of the upper teeth. The middle third continues from the teeth to just below the brow line. Finally, the upper third stretches from the brow to the hairline.<ref name=":3">{{Cite book |title=Gray's Anatomy: the anatomical basis of clinical practice |date=2021 |publisher=Elsevier |isbn=978-0-7020-7707-4 |editor-last=Gray |editor-first=Henry |edition=42nd edition |location=Amsterdam |chapter=Chapter 36: Face and scalp |editor-last2=Standring |editor-first2=Susan |editor-last3= |editor-first3=}}</ref> |
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[[File:704_Skull-01.jpg|thumb|305x305px|The facial skeleton]] |
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The middle third of the face, or the midface, is the anatomical location in which Le Fort fractures occur. It is comprised of the [[Maxilla|maxillary bone]], [[Palatine bone|palatine bones]], [[Zygomatic bone|zygomas,]] [[Zygomatic process|zygomatic processes (of the temporal bone)]], [[ethmoid bone]], [[vomer]], [[nasal concha]], [[Nasal bone|nasal bones]], and [[Pterygoid processes of the sphenoid|pterygoid processes (of the sphenoid bone)]].<ref name=":12">{{Cite book |title=Cummings otolaryngology: head and neck surgery ; enhanced digital version included |date=2021 |publisher=Elsevier |isbn=978-0-323-61179-4 |editor-last=Flint |editor-first=Paul W. |edition=7th edition |location=Philadelphia, Pa |chapter=Chapter 20: Maxillofactial Trauma |editor-last2=Kellman |editor-first2=Robert M.}}</ref><ref name=":3" /><ref name=":10">{{Citation |last=Lenkeit |first=Christopher P. |title=Maxillary Sinus Fracture |date=2023 |url=http://www.ncbi.nlm.nih.gov/books/NBK557455/ |work=StatPearls |access-date=2023-11-20 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=32491387 |last2=Lofgren |first2=Daniel H. |last3=Shermetaro |first3=Carl}}</ref> |
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The maxillary bone contains important anatomical structures which are prone to injury during trauma. The [[Maxillary sinus|maxillary sinuses]] are housed within the maxillary bone, and traumatic injury to these sinuses may cause [[Sinusitis|sinus infections]], and changes in eye placement and movement.<ref name=":10" /> The [[infraorbital nerve]] (a terminal branch of [[CN V|CNV2]]) courses through the maxillary bone and provides sensation to the central face. Additionally, the maxillary bone contains the upper row of teeth (maxillary dentition). [[Occlusion (dentistry)|Occlusion]], or the alignment of upper and lower teeth, is vital following midface trauma to ensure a patient is able to eat and speak.<ref name=":12" /> |
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'''Le Fort 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.{{cn|date=October 2020}} |
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Facial [[biomechanics]], or the study of forces on the facial bones, plays an important role in midface reconstruction following trauma. Although the biomechanics of the face are not fully understood due to their complex nature, several vertical and horizontal buttresses, or pillars, have been established. These buttresses dissipate the powerful forces the skull endures during biting and chewing.<ref name=":12" /><ref name=":2">{{Cite journal |last=Fabrega |first=Miguel |date=2023-08 |title=Imaging of Maxillofacial Trauma |url=https://pubmed.ncbi.nlm.nih.gov/37032179 |journal=Oral and Maxillofacial Surgery Clinics of North America |volume=35 |issue=3 |pages=297–309 |doi=10.1016/j.coms.2023.02.001 |issn=1558-1365 |pmid=37032179}}</ref><ref name=":4">{{Cite journal |last=Larrabee |first=Katherine A. |last2=Kao |first2=Andrew S. |last3=Barbetta |first3=Benjamin T. |last4=Jones |first4=Lamont R. |date=2022-02 |title=Midface Including Le Fort Level Injuries |url=https://pubmed.ncbi.nlm.nih.gov/34809887 |journal=Facial Plastic Surgery Clinics of North America |volume=30 |issue=1 |pages=63–70 |doi=10.1016/j.fsc.2021.08.005 |issn=1558-1926 |pmid=34809887}}</ref> |
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'''Le Fort II''' and '''Le Fort 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.{{cn|date=October 2020}} |
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'''Le Fort II''' – Step deformity at infraorbital margin, mobile mid face, anesthesia or paresthesia of cheek. |
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'''Le Fort 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.<ref>{{cite journal|pmid=22964406|year=2012|last1=Lo Casto|first1=A|title=Imaging evaluation of facial complex strut fractures|journal=Seminars in Ultrasound, CT and MRI|volume=33|issue=5|pages=396–409|last2=Priolo|first2=G. D.|last3=Garufi|first3=A|last4=Purpura|first4=P|last5=Salerno|first5=S|last6=La Tona|first6=G|last7=Coppolino|first7=F|doi=10.1053/j.sult.2012.06.003}}</ref> |
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== Diagnosis == |
== Diagnosis == |
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Diagnosis is suspected by physical exam and history, in which, classically, the [[hard palate|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 [[edema|swelling]] that typically accompany such injuries, and so confirmation is usually needed by [[x-ray|radiograph]] or [[computed tomography|CT]].<ref>{{cite journal|pmid=23233885|pmc=3518003|year=2012|last1=Kim|first1=S. H.|title=Analysis of 809 facial bone fractures in a pediatric and adolescent population|journal=Archives of Plastic Surgery|volume=39|issue=6|pages=606–11|last2=Lee|first2=S. H.|last3=Cho|first3=P. D.|doi=10.5999/aps.2012.39.6.606}}</ref> |
Diagnosis is suspected by physical exam and history, in which, classically, the [[hard palate|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 [[edema|swelling]] that typically accompany such injuries, and so confirmation is usually needed by [[x-ray|radiograph]] or [[computed tomography|CT]].<ref>{{cite journal|pmid=23233885|pmc=3518003|year=2012|last1=Kim|first1=S. H.|title=Analysis of 809 facial bone fractures in a pediatric and adolescent population|journal=Archives of Plastic Surgery|volume=39|issue=6|pages=606–11|last2=Lee|first2=S. H.|last3=Cho|first3=P. D.|doi=10.5999/aps.2012.39.6.606}}</ref> |
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Revision as of 23:03, 20 November 2023
The Le Fort (or LeFort) fractures are a pattern of midface fractures originally described by the French surgeon, René Le Fort, in the early 1900s.[1] He described three distinct fracture patterns. Although not always applicable to modern-day facial fractures, the Le Fort type fracture classification is still utilized today by medical providers to aid in describing facial trauma for communication, documentation, and surgical planning.[2] Several surgical techniques have been established for facial reconstruction following Le Fort fractures, including maxillomandibular fixation (MMF) and open reduction and internal fixation (ORIF). The main goal of any surgical intervention is to re-establish occlusion, or the alignment of upper and lower teeth, to ensure the patient is able to eat.[2] Complications following Le Fort fractures rely on the anatomical structures affected by the inciding injury.
Anatomy
When discussing the anatomy of the face, it is often divided into thirds. The lower third extends from the chin to approximately the level of the upper teeth. The middle third continues from the teeth to just below the brow line. Finally, the upper third stretches from the brow to the hairline.[3]
The middle third of the face, or the midface, is the anatomical location in which Le Fort fractures occur. It is comprised of the maxillary bone, palatine bones, zygomas, zygomatic processes (of the temporal bone), ethmoid bone, vomer, nasal concha, nasal bones, and pterygoid processes (of the sphenoid bone).[4][3][5]
The maxillary bone contains important anatomical structures which are prone to injury during trauma. The maxillary sinuses are housed within the maxillary bone, and traumatic injury to these sinuses may cause sinus infections, and changes in eye placement and movement.[5] The infraorbital nerve (a terminal branch of CNV2) courses through the maxillary bone and provides sensation to the central face. Additionally, the maxillary bone contains the upper row of teeth (maxillary dentition). Occlusion, or the alignment of upper and lower teeth, is vital following midface trauma to ensure a patient is able to eat and speak.[4]
Facial biomechanics, or the study of forces on the facial bones, plays an important role in midface reconstruction following trauma. Although the biomechanics of the face are not fully understood due to their complex nature, several vertical and horizontal buttresses, or pillars, have been established. These buttresses dissipate the powerful forces the skull endures during biting and chewing.[4][6][7]
Diagnosis
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.[8]
Classification
Le Fort 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:
- Le Fort I fracture (horizontal), otherwise known as a floating palate, may result from a force of injury directed low on the maxillary alveolar rim, or upper dental row, in a downward direction. The essential component of these fractures, in addition to pterygoid plate involvement, is involvement of the lateral bony margin of the nasal opening. They also involve the medial and lateral buttresses, or walls, of the maxillary sinus, traveling through the face just above the alveolar ridge of the upper dental row. At the midline, the inferior nasal septum is involved. Historically, it has also been referred to as a Guérin fracture, although this name is less commonly used in practice.[citation needed]
Le Fort II fracture
- Le Fort II fracture (pyramidal) may result from a blow to the lower or mid maxillary area. In addition to pterygoid plate disruption, their distinguishing component is involvement of inferior orbital rim. When viewed from the front, the fracture is classically shaped like a pyramid. It extends from the nasal bridge at or below the nasofrontal suture through the superior medial wall of the maxilla, inferolaterally through the lacrimal bones which contain the tear ducts, and inferior orbital floor through or near the infraorbital foramen.
Le Fort III fracture
- Le Fort III fracture (transverse), otherwise known as craniofacial dissociation, may follow impact to the nasal bridge or upper maxilla. The salient feature of these fractures, beyond pterygoid plate involvement, is that they invariably involve the zygomatic arch, or cheek bone. These fractures begin at the nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of the orbit, through the nasolacrimal groove and ethmoid air cells. The sphenoid is thickened posteriorly, limiting fracture extension into the optic canal. Instead, the fracture continues along the orbital floor and infraorbital fissure, continuing through the lateral orbital wall to the zygomaticofrontal junction and zygomatic arch. Within the nose, the fracture extends through the base of the perpendicular plate of the ethmoid air cells, the vomer, which are both part of the nasal septum. As with the other fractures, it also involves the junction of the pterygoids with the maxillary sinuses. CSF rhinorrhea, or leakage of the nutrient laden fluid that bathes the brain, is more commonly seen with these injuries due to ethmoid air cell disruption, as the air cells are located immediately beneath the skull base.[9]
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 maxillofacial surgery. 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.[10]
See also
References
- ^ Ikeda, Allison K.; Burke, Andrea B. (2021-11). "LeFort Fractures". Seminars in Plastic Surgery. 35 (4): 250–255. doi:10.1055/s-0041-1735816. ISSN 1535-2188. PMC 8604624. PMID 34819806.
{{cite journal}}: Check date values in:|date=(help) - ^ a b Flint, Paul W.; Kellman, Robert M., eds. (2021). "Chapter 20: Maxillofactial Trauma". Cummings otolaryngology: head and neck surgery ; enhanced digital version included (7th edition ed.). Philadelphia, Pa: Elsevier. ISBN 978-0-323-61179-4.
{{cite book}}:|edition=has extra text (help) - ^ a b Gray, Henry; Standring, Susan, eds. (2021). "Chapter 36: Face and scalp". Gray's Anatomy: the anatomical basis of clinical practice (42nd edition ed.). Amsterdam: Elsevier. ISBN 978-0-7020-7707-4.
{{cite book}}:|edition=has extra text (help) - ^ a b c Flint, Paul W.; Kellman, Robert M., eds. (2021). "Chapter 20: Maxillofactial Trauma". Cummings otolaryngology: head and neck surgery ; enhanced digital version included (7th edition ed.). Philadelphia, Pa: Elsevier. ISBN 978-0-323-61179-4.
{{cite book}}:|edition=has extra text (help) - ^ a b Lenkeit, Christopher P.; Lofgren, Daniel H.; Shermetaro, Carl (2023), "Maxillary Sinus Fracture", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 32491387, retrieved 2023-11-20
- ^ Fabrega, Miguel (2023-08). "Imaging of Maxillofacial Trauma". Oral and Maxillofacial Surgery Clinics of North America. 35 (3): 297–309. doi:10.1016/j.coms.2023.02.001. ISSN 1558-1365. PMID 37032179.
{{cite journal}}: Check date values in:|date=(help) - ^ Larrabee, Katherine A.; Kao, Andrew S.; Barbetta, Benjamin T.; Jones, Lamont R. (2022-02). "Midface Including Le Fort Level Injuries". Facial Plastic Surgery Clinics of North America. 30 (1): 63–70. doi:10.1016/j.fsc.2021.08.005. ISSN 1558-1926. PMID 34809887.
{{cite journal}}: Check date values in:|date=(help) - ^ 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.
- ^ 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.
- ^ 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. S2CID 22579746.
External links
Wikimedia Commons has media related to Fractures of the human maxilla.