Le Fort III Fracture (Craniofacial Disjunction)

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.

Differential Diagnosis List

Final Diagnosis

Le Fort III Fracture of the Skull (Craniofacial Disjunction)

URL:	https://www.eurorad.org/case/10237
DOI:	10.1594/EURORAD/CASE.10237
ISSN:	1563-4086