Fractures of the maxilla are high-energy injuries. An impact 100 times the force of gravity is required to break the midface. Accordingly, these patients often have significant multisystem trauma. Many require resuscitation and admission.
If the patient is conscious, inquire about malocclusion and visual symptoms. On physical examination, a patient may have an open bite, facial lengthening, CSF rhinorrhea, or periorbital ecchymosis. LeFort fractures are best diagnosed by grasping and rocking the hard palate. In most cases, parts of the midface will shift with this maneuver, but greenstick and impacted fractures may be immobile. Although the classic fracture patterns are diagrammed in this text ( Fig...249-5) they are more likely to be seen in print than in the ED. In clinical practice, fracture patterns are often mixed, with a low-grade LeFort on one side and a higher grade on the other.
In LeFort I, a transverse fracture separates the body of the maxilla from the lower portion of the pterygoid plate and nasal septum. With stress of the maxilla, only the hard palate and upper teeth move. A pyramidal fracture of the central maxilla and the palate defines a LeFort II injury. Facial tugging moves the nose but not the eyes. LeFort III, also called cranial-facial disjunction, occurs when the complete facial skeleton separates from the skull. The fracture extends through the frontozygomatic suture lines, across the orbit and through the base of the nose and ethmoid region. The entire face, including most of both orbits, shifts with mobilization. The LeFort IV fracture (not initially described by LeFort) involves the frontal bone as well as the midface.
These catastrophic injuries often require aggressive airway control and frequently intubation. Look for associated injuries, especially intracranial spinal thoracic, and abdominal. A test of visual acuity, if at all possible, is especially important for patients with LeFort III fractures, where the incidence of blindness is high. Plain films are unnecessary, and CT scans of the face may be ordered in conjunction with brain CT in clinically stable patients. Patients with complex maxillary fractures require admission for open reduction and internal fixation. Even if surgery is delayed, admission is prudent to monitor these often multiply injured victims.
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