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Le Fort III Fracture (Craniofacial Disjunction)

Authors:
Mohammed Noeman at Westpfalz-Klinikum GmbH
Mohammed Noeman
Gunnar Gaffke
Gunnar Gaffke
Gunnar Gaffke
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Abstract and Figures

A 50-year-old male patient was brought by the ambulance to the emergency department after a fall on the face, which was extremely swollen with multiple bruises and haematomas raising the possibility of a midface fracture. Non-enhanced CT of the skull and paranasal sinuses (including 3D-reconstruction) was performed. The images showed a Le Fort III fracture.
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Case 10237
Le Fort III Fracture (Craniofacial Disjunction)
Mohammed Noeman , Gunnar Gaffke .
(1) (2)
Radiology Resident, Department of Diagnostic and Interventional Radiology, KMG Klinikum
(1)
Güstrow, Germany.
Chief of Department of Diagnostic and Interventional Radiology, KMG Klinikum Güstrow,
(2)
Germany.
Westpfalz Klinikum Kaiserslautern
Head & Neck Imaging Section: 2012, Aug. 10 Published:
50 year(s), malePatient:
Authors' Institution
KMG Klinikum Güstrow, Academic Teaching Hospital of the University of Rostock, Germany.
Friedrich-Trendelenburg Allee 1 18273 Güstrow, Germany;
E-mail: dr_noman99@hotmail.com
Clinical History
A 50-year-old male patient was brought by the ambulance to the emergency department after a fall
on the face, which was extremely swollen with multiple bruises and haematomas raising the
possibility of a midface fracture.
Imaging Findings
Non-enhanced CT of the skull and paranasal sinuses (including 3D-reconstruction) was performed.
Images showed a midface fracture that starts at the nasofrontal sutures then extends posteriorly
along the medial wall of the orbit through the nasolacrimal groove and ethmoid bones. The fracture
then continues along the floor of the orbit along the inferior orbital fissure and continues
superolaterally through the lateral orbital wall, through the zygomaticofrontal junction and the
zygomatic arch. Intranasally, a branch of the fracture extends through the base of the perpendicular
plate of the ethmoid, through the vomer, and through the interface of the pterygoid plates to the
base of the sphenoid (Fig. 1 - 4).
Discussion
A. Background:
*Introduction:
-Rene Le Fort (1901) was the first to document a tendency for specific fracture patterns of the
midface to occur following direct facial trauma [1].
-This classification includes Le Fort I, II, and III types of fractures [2].
*Epidemiology:
-Le Fort and maxillary fractures accounted for 25.5% of 663 facial fractures recently reported from
a level 1 trauma center [3].
-The frequency of Le Fort types is in the order of type II > type I > type III [4, 5, 6].
B. Clinical Perspective:
*Clinical presentation:
-Diagnoses are made clinically and confirmed radiologically.
-Suggestive clinical signs -in a patient with a history of blunt facial trauma- include epistaxis,
infraorbital ecchymosis or oedema, tenderness and separation at frontozygomatic suture,
lengthening of face, depression of occular levels, enophthalmos and hooding of eyes.
C. Imaging Perspective:
Best diagnostic modality of a clinically suspected midfacial injury is CT [7, 8], serving the
diagnosis and surgical planning.
*Steps of diagnosis [9]:
1. Always look at the pterygoid processes (coronal images). A fracture of the pterygoid processes
almost always indicates that there is at least one of the Le Fort fractures (Fig. 5).
2. To classify the type, look at the three bony structures that are unique to each type (Fig. 7):
-Anterolateral margin of the nasal fossa (type I),
-Inferior orbital rim (type II) (Fig. 6),
-Zygomatic arch (type III).
If one of these structures is intact, the corresponding type of Le Fort is excluded [12].
3. If one of the Le Fort fractures is suspected because of a break in its unique component, it should
be confirmed by identifying the other fractures that are expected in the plane of that type of fracture.
*Pitfalls:
1. Do not rely only on clinical history and physical examination as the characteristic findings may
not always be present [10, 11].
2. Do not terminate further search after identifying one Le Fort fracture. Fractures may occur in
more than one plane on the same side [9, 13].
3. Do not expect Le Fort fractures to be bilaterally symmetric. Fractures can occur in different
planes on each side [9, 13].
4. Le Fort fracture can occur simultaneously with other facial fractures [9].
D. Outcome:
-Surgical treatment aims at restoring the preinjury alignment by using rigid fixation.
-Satisfactory outcomes for injured patients are strongly influenced by the initial care delivered,
particularly in the ''golden hour'' following admission to hospital.
E. Take Home Message:
-Quick and accurate diagnosis of the presence and type of Le Fort fracture by evaluating the
pterygoid processes and the unique components of each type.
Final Diagnosis
Le Fort III Fracture of the Skull (Craniofacial Disjunction)
Differential Diagnosis List
Le Fort II Fracture, Le Fort I Fracture
Figures
Figure 1 3-D CT-Reconstruction image of the skull
A midface fracture starting at zygomaticofrontal suture (blue arrow), running posteriorly
through medial wall of the orbit (blue arrowheads) and passing through the nasofrontal
suture (green arrow). Also fracture of the zygomatic arch (red arrow).
© M. Noeman, Department of Diagnostic and Interventional Radiology, KMG Klinikum Güstrow, Germany.
Area of Interest: Eyes; Musculoskeletal bone; Trauma;
Imaging Technique: CT;
Procedure: Computer Applications-3D; Diagnostic procedure;
Special Focus: Trauma;
Figure 2 Axial non-enhanced CT image of the paranasal sinuses
Bilateral fracture of the lateral wall of maxillary sinus (blue arrowheads) as well as medial
wall (red arrowhead). Fracture of the nasal septum is also seen (green arrowhead). Bilateral
haematosinus (yellow asterisk).
© M. Noeman, Department of Diagnostic and Interventional Radiology, KMG Klinikum Güstrow, Germany.
Area of Interest: Ear / Nose / Throat; Musculoskeletal bone; Trauma;
Imaging Technique: CT;
Procedure: Computer Applications-3D; Diagnostic procedure;
Special Focus: Haemorrhage; Trauma;
Figure 3 Axial non-enhanced CT image of the paranasal sinuses
The red arrow shows associated nasoethmoid fracture.
© M. Noeman, KMG Klinikum Güstrow, Germany.
Area of Interest: Ear / Nose / Throat; Musculoskeletal bone; Trauma;
Imaging Technique: CT;
Procedure: Computer Applications-3D;
Special Focus: Trauma;
Figure 4 3-D CT-Reconstruction image of the skull (view from below)
Both red arrows show bilateral non-displaced fracture of the zygomatic arch which is a
characterstic feature for this type of fractures.
© M. Noeman, Department of Diagnostic and Interventional Radiology, KMG Klinikum Güstrow, Germany.
Area of Interest: Bones; Computer applications;
Imaging Technique: CT; Image manipulation / Reconstruction;
Procedure: Computer Applications-3D; Computer Applications-Detection, diagnosis;
Diagnostic procedure;
Special Focus: Trauma;
Figure 5 Coronal non-enhanced CT image of the paranasal sinuses
The blue arrows show bilateral fracture of the pterygoid processes, which is a common
association in all three types of Le Fort fractures.
© M. Noeman, KMG Klinikum Güstrow, Germany.
Area of Interest: Ear / Nose / Throat; Musculoskeletal bone; Trauma;
Imaging Technique: CT;
Procedure: Computer Applications-3D;
Special Focus: Trauma;
Figure 6 Coronal non-enhanced CT image of the paranasal sinuses
This section shows that orbital floor is bilaterally intact (red arrows) thus excluding Le Fort
II fracture.
© M. Noeman, KMG Klinikum Güstrow, Germany.
Area of Interest: Bones; Ear / Nose / Throat; Musculoskeletal bone;
Imaging Technique: CT;
Procedure: Computer Applications-3D;
Special Focus: Trauma;
Figure 7 Diagramatic illustration of the different planes of Le Fort fractures
A. Le Fort I: involves the anterolateral margin of the nasal fossa above the maxillary alveolar
process. B. Le Fort II: involves the inferior orbital rim. C. Le Fort III: involves the
zygomatic arch.
© M. Noeman, KMG Klinikum Güstrow, Germany.
Area of Interest: Ear / Nose / Throat; Musculoskeletal bone; Trauma;
Imaging Technique: CT;
Procedure: Computer Applications-3D;
Special Focus: Trauma;
MeSH
[A01.456.505]Face
The anterior portion of the head that includes the skin, muscles, and structures of the forehead, eyes,
nose, mouth, cheeks, and jaw.
[A02.835.232.781]Skull
The SKELETON of the HEAD including the FACIAL BONES and the bones enclosing the
BRAIN.
[A02.835.232.781.200]Cranial Sutures
A type of fibrous joint between bones of the head.
[A02.835.232.781.292]Ethmoid Bone
[A02.835.232.781.324]Facial Bones
The facial skeleton, consisting of bones situated between the cranial base and the mandibular
region. While some consider the facial bones to comprise the hyoid (HYOID BONE), palatine
(HARD PALATE), and zygomatic (ZYGOMA) bones, MANDIBLE, and MAXILLA, others
include also the lacrimal and nasal bones, inferior nasal concha, and vomer but exclude the hyoid
bone. (Jablonski, Dictionary of Dentistry, 1992, p113)
[A02.835.232.781.802]Sphenoid Bone
[A02.835.232.781.324.502.645]Maxilla
[C23.550.414.625]Ecchymosis
Extravasation of blood into the skin, resulting in a nonelevated, rounded or irregular, blue or
purplish patch, larger than a petechia.
[C23.550.414.712]Epistaxis
Bleeding from the nose.
[E01.370.350.350.810.800]Tomography, Spiral Computed
Computed tomography where there is continuous X-ray exposure to the patient while being
transported through a rotating fan beam. This provides improved three-dimensional contrast and
spatial resolution compared to conventional computed tomography, where data is obtained and
computed from individual sequential exposures.
References
[1] Le Fort R (1901) Etude experimental sur les fractures de la machoire superieure, Parts I, II, III
Rev Chir Paris 23:201,360,479
[2] Rhea JT, Mullins ME, Novelline RA (2002) The face. In: Rogers LF. Radiology of skeletal
trauma, 3rd ed., vol. 1 Philadelphia, PA: Churchill Livingstone 315-375
[3] Turner BG, Rhea JT, Thrall JH, Small AB, Novelline RA (2004) Trends in the use of CT and
radiography in the evaluation of facial trauma 1992-2002: implications for current costs. AJR
183:751-754
[4] McCoy FJ et al. (1962) An analysis of facial fractures and their complications Plast Reconstr
Surg 29:381
[5] Kelly DE, Harrigan WF (1975) A survey of facial fractures, Bellevue Hospital 1948-1974 J Oral
Surg 33:146
[6] Turvey TA (1977) Midface fractures: a retrospective analysis of 593 cases J Oral Surg 35:887
[7] Neuman PR, Zilkha A. (1982) Use of the CAT scan for diagnosis in the complicated facial
fracture patient Plast Reconstr Surg 70:683
[8] Robbins KT, et al. (1986) Radiographic evaluation of mid-third facial fractures J Otolaryngol
15:366
[9] James T. Rhea, Robert A. Novelline1 (2005) How to Simplify the CT Diagnosis of Le Fort
Fractures AJR 184:1700-1705
[10] Manson PN, Markowitz B, Mirvis S, Dunham M, Yaremchuk M (1990) Toward CT-based
facial fracture treatment Plast Reconstr Surg 85:202-212
[11] Romano JJ, Manson PN, Mirvis SE, Dunham M, Crawley W (1990) Le Fort fractures without
mobility Plast Reconstr Surg 85:355-362
[12] Levine RS, Grossman RI (1985) Head and facial trauma Emerg Med Clin North Am 3:447-47
[13] Richard A. Hopper, Shahram Salemy, Raymond W. Sze (2006) Diagnosis of Midface
Fractures with CT: What the Surgeon Needs to Know RadioGraphics 26:783-793
Citation
Mohammed Noeman , Gunnar Gaffke .
(1) (2)
Radiology Resident, Department of Diagnostic and Interventional Radiology, KMG Klinikum
(1)
Güstrow, Germany.
Chief of Department of Diagnostic and Interventional Radiology, KMG Klinikum Güstrow,
(2)
Germany. (2012, Aug. 10) Le Fort III Fracture (Craniofacial Disjunction) {Online}
URL: http://www.eurorad.org/case.php?id=10237
ResearchGate has not been able to resolve any citations for this publication.
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A survey of facial fractures: Bellevue Hospital, 1948-1974
Article
  • Mar 1975
  • J Oral Surg
The authors believe that each facial fracture must be evaluated on an individual basis. The method of treatment selected must be consistent with the patients' needs and his ability to undergo the procedure. There does not seem to be any set rule on the length of time intermaxillary fixation must remain in place. A good union will form in some patients in 3 wk, while in others, 10 or even 12 wk are required. Evaluation should be done on a weekly basis and fixation should be left in place as long as needed to immobilize the fractured segments. Fractures of the condylar neck should be treated by closed reduction. The authors conclude from their statistics that in most cases of zygomatic fractures, routine exploration of the orbital floor and implantation of Silastic or a similar material, or bone grafting, are not indicated. While the zygomatic fracture should be reduced as soon as possible, it is felt that the floor of the orbit should not be explored until after edema has subsided and it has been definitely determined that diplopia is present; this will eliminate a great deal of unnecessary surgery in this area.
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Toward CT-Based Facial Fracture Treatment
Article
  • Mar 1990
  • PLAST RECONSTR SURG
Facial fractures have formerly been classified solely by anatomic location. CT scans now identify the exact fracture pattern in a specific area. Fracture patterns are classified as low, middle, or high energy, defined solely by the pattern of segmentation and displacement in the CT scan. Exposure and fixation relate directly to the fracture pattern for each anatomic area of the face, including frontal bone, frontal sinus, zygoma, nose, nasoethmoidal-orbital region, midface, and mandible. Fractures with little comminution and displacement were accompanied by subtle symptoms and required simple treatment; middle-energy injuries were treated by standard surgical approaches and rigid fixation. Highly comminuted fractures were accompanied by dramatic instability and marked alterations in facial architecture; only multiple surgical approaches to fully visualize the "buttress" system provided alignment and fixation. Classification of facial fractures by (1) anatomic location and (2) pattern of comminution and displacement define refined guidelines for exposure and fixation.
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Le Fort Fractures Without Mobility
Article
  • Apr 1990
  • PLAST RECONSTR SURG
The Le Fort fracture without maxillary mobility constitutes 9 percent of maxillary fractures observed over a 3-year period. A high Le Fort (level II or III) injury exists as a one- or two-piece incomplete fracture. The degree of fracture is insufficient to permit mobility of the maxillary alveolus. Frequently, an obvious unilateral zygomatic fracture is present. Physical findings consist of bilateral eyelid ecchymosis and malocclusion. The occlusal disturbance may consist of either crossbite, open bite, maxillary rotation, or lack of proper dental intercuspation. On CT scan, fractures are best demonstrated in the posterior and medial maxillary walls at the Le Fort I level; they are most obvious unilaterally with contralateral fractures that may be subtle. Bilateral maxillary sinus fluid is consistently present on CT. Treatment usually consists of observation and traction elastics but may require mobilization of the fragments followed by open reduction and rigid fixation.
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Radiological evaluation of mid-third facial fractures
Article
  • Jan 1987
  • J Otolaryngol
Clinical assessment of patients with facial injuries can be difficult, particularly if there is extensive soft tissue swelling. The maxillofacial surgeon frequently must rely on radiographic images to confirm and delineate the presence of fractures. In particular, the mid-third of the face is a notoriously difficult area in which to delineate fracture lines in the severely injured patient. In this study, three radiographic techniques were compared for the evaluation of patients with mid-facial fractures treated in a major trauma center: plain films; panoramic zonography; and computed axial tomography. The results indicate that quality plain films are frequently difficult to obtain in the severely injured patient. In selected cases, panoramic zonography and computed axial tomography are important complementary methods for accurate assessment of mid-third facial fractures.
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Head and Facial Trauma
Article
  • Sep 1985
  • EMERG MED CLIN N AM
Computed tomography (CT) plays a vital role in the evaluation of head and facial trauma. This article describes various lesions in such patients and details their CT findings.
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Use of the CAT Scan for Diagnosis in the Complicated Facial Fracture Patient
Article
  • Jan 1983
  • PLAST RECONSTR SURG
Over the last few years, the CAT scanner has become an integral part of the physician's armamentarium for complete diagnosis and evaluation of severe facial injury. When indicated, CAP scans can clearly show both soft-tissue injury and entrapment, as well as bony fracture. Accurate surgical planning can be made with these studies in hand. Often tomograms and x-rays will clearly show the bony injury, but when muscle entrapment is considered, the CAT scan is far superior in outlining the pathology. Cost will become comparable with that of tomographic study. We find that the CAT scan can be very useful when indicated.
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Trends in the Use of CT and Radiography in the Evaluation of Facial Trauma, 1992–2002: Implications for Current Costs
Article
  • Oct 2004
CT has replaced conventional radiography of the face in many trauma centers. Concern exists that increased costs are associated with increased use of CT. Our goal was to compare the amount of CT and radiography performed for facial trauma at a level 1 trauma center in 1992 and in 2002 and to determine hospital costs for the imaging of these patients. The changes in volume and types of facial imaging examinations were determined comparing 1992 and 2002. Hospital costs of different imaging examinations were determined for 2002. Current costs of imaging facial trauma were compared with what 2002 costs would have been if the practice pattern in 1992 had continued. In 1992, 890 patients were evaluated for facial trauma. Six hundred seventy-one had only radiography, 153 only CT of the face, and 66 both CT and radiography. In 2002, 828 patients were evaluated. Five hundred eighty-four patients had only CT of the face; 228, only radiography; and 16, both CT and radiography. The number of facial imaging examinations per patient in 1992 and 2002 was 1.23 and 1.03, respectively. The 2002 hospital cost of a facial CT examination was $121 and of a facial radiography series was $154. Using CT instead of radiography for evaluating facial injury resulted in an overall cost savings of 22% per patient in 2002. The availability of CT has not resulted in increased use of facial imaging. The increased use of CT from 1992 to 2002 results in decreased current costs for the hospital.
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