Lefort 1 Fracture

84M with trauma, swollen upper lip, and epistaxis • Xray of the Week

Figure 1. What is the important finding on this CT scan.

Figure 2.

Left: Axial CT showing fracture of the anterior and lateral maxillary sinus walls (yellow arrows) and pterygoid plates (red arrows).

Right: 3D VR reconstruction showing bilateral Lefort 1 fractures traveling horizontally from the nasal septum to the lateral pyriform rims above the teeth (green arrows).

Figure 3. Diagram of Lefort fractures.

A. Frontal view of LeFort complex fractures 1-3.

B. Lateral view of LeFort complex fractures 1-3.

Source: University of Washington, Department of Radiology. https://rad.washington.edu/about-us/academic-sections/musculoskeletal-radiology/teaching-materials/online-musculoskeletal-radiology-book/facial-and-mandibular-fractures/

Discussion:

Lefort fractures were named for Rene Le Fort, a French army surgeon who conducted experiments on cadaver skulls by applying blunt force trauma (1,2). As a result of these experiments, he was able to identify several “lines of weakness” in the maxilla that led him to develop a system of classifying facial fractures (2). Lefort fractures refer to complex fractures from blunt facial trauma that involve separation of the midface from the skull base, and include bilateral fractures of the pterygoid plates (1). There are three types of Lefort fractures; types I, II, and III which affect the maxillary, nasal, and zygomatic bones respectively (1) (Fig.3).

This case illustrates the Lefort I fracture, which is a horizontal maxillary fracture through the lateral nasal wall and pterygoid plates (1). Lefort 1 fractures affect all three walls of the maxillary sinus and pterygoid processes due to a direct blow to the lower face in a downward direction against the upper teeth (2). Fractured bones typically include the lower nasal septum, pyriform apertures, canine fossae, zygomaticomaxillary buttresses, posterior maxillary walls, and pterygoid plates (3). Lefort I fractures present with swelling of the upper lip, nasopharyngeal bleeding, oral lacerations, and malocclusion (2,3).

According to the Iowa Head and Neck Protocols, non-contrast, fine-cut (2 mm sections) CT is recommended for Lefort fractures, with axial cuts from the skull base to the mandible (4). Coronal cuts can also be used to visualize the orbital walls (4). Bilateral fractures of the pterygoid plates on CT are key in diagnosis as they are present in all three types of Lefort fractures (3). However, Lefort 1 fractures will also show fracture of the anterolateral margin of the nasal fossa (5). If the anterolateral margin of the nasal fossa is intact, type I fracture can be excluded (5). Type I Lefort fractures are the only type of Lefort fractures to involve the lateral pyriform aperture (3). Lefort fractures are not always symmetric, and trauma can result in multiple types of Lefort fractures on the same side of the face (5). It can also occur simultaneously with non-Lefort facial fractures, so it is important to consider these possibilities. CT scan of the facial bones, head, and angiography are also important in midface trauma for possible brain injury or vascular damage (2). Treatment involves surgical restoration of midfacial height and projection by reestablishing the midfacial buttresses (3). This can be done by using gingivobuccal sulcus incision to insert 1.5 - 2.0 mm L and J plates axial to the nasomaxillary and zygomaticomaxillary buttresses (3).

References:

1. Phillips BJ, Turco LM. Le Fort Fractures: A Collective Review. Bull Emerg Trauma. 2017;5(4):221-230. doi:10.18869/acadpub.beat.5.4.499

2. Patel BC, Wright T, Waseem M. Le Fort Fractures. [Updated 2020 Sep 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526060/

3. Kim HS, Kim SE, Lee HT. Management of Le Fort I fracture. Arch Craniofac Surg. 2017;18(1):5-8. doi:10.7181/acfs.2017.18.1.5

4. Facial Fracture Management Handbook - LeFort Fractures | Iowa Head and Neck Protocols. Accessed November 15, 2020. https://medicine.uiowa.edu/iowaprotocols/facial-fracture-management-handbook-lefort-fractures

5. Rhea JT, Novelline RA. How to simplify the CT diagnosis of Le Fort fractures. AJR Am J Roentgenol. 2005 May;184(5):1700-5. doi:10.2214/ajr.184.5.01841700

Amara Ahmed is a medical student at the Florida State University College of Medicine. She serves on the executive board of the American Medical Women’s Association and Humanities and Medicine. She is also an editor of HEAL: Humanism Evolving through Arts and Literature, a creative arts journal at the medical school. Prior to attending medical school, she graduated summa cum laude from the Honors Medical Scholars program at Florida State University where she completed her undergraduate studies in exercise physiology, biology, and chemistry. In her free time, she enjoys reading, writing, and spending time with family and friends.

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Kevin M. Rice, MD is the president of Global Radiology CME

Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.

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