These are transverse fractures of the mid-face.

Classification

1. LeFort I - separation of the hard palate from the upper maxilla due to a transverse fracture running through the maxilla and pterygoid plates at a level just above the floor of the nose
2. LeFort II - transect the nasal bones, medial-anterior orbital walls, orbital floor, inferior orbital rims and finally transversely fracture the posterior maxilla and pterygoid plates
3. LeFort III - transverse separation of the nasofrontal suture, medial orbital wall, lateral orbital wall or zygomaticofrontal suture, zygomatic arch and pterygoid plates with separation of the maxilla from the skull base

Evaluation

• Patients may present with facial bruising, nasal/oral bleeding, CSF rhinorrhea, hemotympanum, conjunctival hemorrhage, inability to smell, facial and nose disfiguration, facial emphysema, raccoon eyes, auricular hematoma, dental injuries, asymmetric pupils, exophthalmos.
• Important questions to ask the patient include: What areas hurt? What looks different when you look in the mirror? How is your vision? Any changes in your vision? Is your bite normal? Is there any tingling or numbness in your face? Have you noticed bleeding from your eyes, ears, and/or nose? Any voice changes? Any neck pain or loss of consciousness?
• Palpate face for tenderness, crepitus, and/or instability, which can detect fractures.
• Stabilize forehead the one hand, grasp teeth/hard palate with the other, and attempt to move the hard palate. If mobility is discovered, attempt to determine the level and specific areas that are mobile.
• Evaluate for C-spine injuries.

Management

• In the patient with multisystem and/or severe injuries, address your primary survey first and stabilize the patient.
• If the airway is at risk, consider awake intubation, and prepare for a difficult airway.
• Only after the primary survey and resuscitation should you perform your ocular and facial exam in the setting of suspected Le Fort Fractures.
• Control hemorrhage of the nose/oral cavity. Anterior packing may be needed. Avoid posterior packing due to risk of skull base injuries.
• Elevate head of bead to 40-60 degrees.

• Provide IV antibiotics for sinus fractures and/or suspected CSF leaks.

• If an isolated stable Le Fort I or II fracture is found, the patient may be appropriate for discharge with specialist follow up.

• Discuss patient with facial trauma team, which may include oral maxillofacial surgery or otolaryngology.
• If CSF leak is found, discuss with neurosurgery.