Le Fort Fractures

Sylvia Aparicio, IVGillian Lieberman, MD

Facial Fractures

Sylvia Aparicio Harvard Medical School Year IV

Gillian Lieberman, M.D.

September 2006


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Our Patient

• 82 year old male

• Had a mechanical fall with blunt force to face

• Taken to BIDMC by ambulance


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Facial Fractures

• Most common mechanism is auto accidents • 70 % of auto accidents produce some type of

facial injury, although most are limited to soft tissue

• The face is a target in fights or assaults

• Remainder of facial fractures produced by falls, sports, industrial accidents and gunshot wounds


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Facial Fractures

• Analysis of the fractured face requires• knowledge of normal anatomy• common fracture patterns in the face


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Anatomy-Frontal View

http://www.emedicine.com/ent/images/Large/22ent0009-01.jpg


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Anatomy-Lateral View

http://www.bartleby.com/107/


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Imaging Studies• Plain Film

• universally available• quickly obtained• economical

• CT• more accurate• 3D reconstruction very useful

• fractures involving multiple planes• fracture displacement• assessment of facial symmetry

• assess fractures, soft tissue injuries, and intracerebral hemorrhage simultaneously


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Standard Views for Plain Films

• Waters view (PA view with cephalad angulation)• Caldwell view (PA view)• lateral view• submentovertex view

• Non-traumatized patient• should be obtained with the patient erect and all

frontal projections with the central-beam PA• Patients with facial trauma

• obtained with the patient supine • cervical spine must be cleared


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Waters View PA with cephalad angulation

http://anatomy.uams.edu/anatomyhtml/xrays/xra_atlas28.html http://www.bcm.edu/oto/studs/nose.html

http://www.bcm.edu/oto/studs/waters.gif


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Caldwell View PA

Petrous pyramid

http://anatomy.uams.edu/anatomyhtml/xrays/xra_atlas27.html http://www.bcm.edu/oto/studs/nose.html


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Lateral View

http://anatomy.uams.edu/anatomyhtml/xrays/xra_atlas30.html


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Submentovertex View

• a-zygomatic arch• b-maxillary sinus• c-anterior wall,

maxillary sinus

http://www.uth.tmc.edu/radiology/test/er_primer/face/images/subment02.html

http://www.bcm.edu/oto/studs/nose.html


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Facial CT Views

http://uuhsc.utah.edu/rad/protocol/fbones.htm

Coronal View Axial View


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Key Points for Assessing Fractures

• Look at orbits carefully• Involved in 60 - 70 % of all facial fractures

• Look for most common fracture patterns • Bilateral symmetry can be very helpful.

• Normal radiopacities are usually bilateral. Abnormal ones are usually unilateral.

• Look for aberrant air


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Zygomaticomaxillary complex (tripod fracture)

http://www.rad.washington.edu/mskbook/facialfx.htmlwww.emedicine.com/ent/topic166.htm


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Orbital Floor Fractures

• "blowout" fracture• usual mechanism is a

blow to the eye• common clinical signs

• enophthalmos• diplopia

http://www.nature.com/eye/journal/v20/n1/fig_tab/6701801f2.html#figure-titlehttp://www.rad.washington.edu/mskbook/facialfx.html


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Le Fort Fractures

http://www.rad.washington.edu/mskbook/facialfx.html


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Our Patient Coronal CT

Courtesy of Dr. Handwerker-BIDMC

Bilateral Le Fort II

Fracture at naso-frontal suture

Bilateral fractures at zygomatico-maxillary sutures


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Our Patient Axial CT, Bone Window


Fracture at naso-frontal suture

Axial view through orbits


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Fracture of anterior maxillary walls

Fracture of posterior maxillary walls

Aberrant air in subcutaneoustissues

Axial view through maxillary sinuses

Our Patient Axial CT, Bone Window


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Our Patient Axial Views Through Nasal Bones


Comminuted nasal bone fractures


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Our Patient 3D Reconstruction



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3D Reconstruction

• CT 3D reconstruction can often be used to plan surgical management

• Can also be used to evaluate facial skeleton post-surgically


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Second Patient

• Post-fixation CT with 3D Reconstruction slides of another patient with a bilateral Le Fort Type II fracture


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Second Patient

Courtesy of Dr. Guo - BWH


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Second Patient



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Second Patient



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Second Patient



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Second Patient



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Second Patient



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Second Patient



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Second Patient



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Second Patient



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Second Patient



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Second Patient



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Second Patient



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Second Patient



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Summary

• Knowing normal anatomy and common fractures is important

• CT-most common modality used

• Consider mechanism

• Look for asymmetry• Look for cortex

interruption


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Resources• Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery. Nose and Paranasal Sinuses 21

May 2006. 12 Sept. 2006 <http://www.bcm.edu/oto/studs/nose.html>.• Department of Neurobiology and Developmental Sciences, University of Arkansas for Medical Sciences.

Gross Anatomy 2005. 12 Sept. 2006 <http://anatomy.uams.edu/anatomyhtml/gross.html>.• Gray H. Anatomy of the Human Boday. Gray’s Anatomy. 12 Sept. 2006 <http://www.bartleby.com/107/>.• Harris J and Troetscher T. Emergency Radiology Primer 2000. 12 Sept.2006

<www.uth.tmc.edu/radiology/test/er_primer/face/images/subment02.html>.• Jahan-Parwar B. Facial Bone Anatomy. eMedicine 17 Oct. 2005. 12 Sept. 2006

<http://www.emedicine.com/ent/topic9.htm>.• Mauriello Jr JA, Lee HJ, Nguyen L. CT of Soft Tissue Injury and Orbital Fractures. Radiologic Clinics of

North America 1999; 37: 241-252.• Mullins RJ. The Influence of Imaging on the Trauma Surgeon’s Initial Evaluation of Seriously Injured

Patients. Seminars in Roentgenology 2006; 41: 159-167.• Rhea JT, Rao PM, Novelline RA. Helical CT and Three-Dimensional CT of Facial and Orbital Injury.

Radiologic Clinics of North America 1999; 37: 489-513. • Richardson M. Facial and Mandibular Fractures 24 Jan. 2001. 12 Sept. 2006

<http://www.rad.washington.edu/mskbook/facialfx.html>.• Vose M, Maloof A, and Leatherbarrow B. Orbital floor fracture: an unusual late complication. Eye (2006) 20,

120–122. • Wiggins R. Facial Bones CT Protocol 2002. 12 Sept. 2006 <http://uuhsc.utah.edu/rad/protocol/fbones.htm>.


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Acknowledgements

• Atif Zaheer, MD• Jason Handwerker, MD• Andrew Hines-Peralta, MD• Gillian Lieberman, MD• Pamela Lepkowski• Larry Barbaras• Lifei Guo, MD

Le Fort Fractures

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