A 51 year-old man is brought into the resus bay as a blunt head altered trauma. He was found down by paramedics in a park with a 40oz next to him, and witnesses state he was assaulted by someone wielding a baseball bat.
On primary survey he has blood in the oropharynx but he’s protecting his airway, and on your secondary survey you note extensive facial and periorbital swelling, blood in the nares and oropharynx, a lip laceration, and a mobile palate.
These are images from his CT scan:
What are the significant midface fractures that you should worry about in this patient?
Zygomaticomaxillary Complex Fractures (ZMC or Tripod Fractures)
Usually result from a direct blow to the cheekbone and involve the zygomatic arch, the inferior orbital rim and maxillary sinus, and the lateral orbital rim. Depending on displacement, often need operative repair or else your patient will end up with a sunken cheekbone and facial asymmetry. Significant displacement can also result in trismus due to interference with the mandibular condyle.
LeFort Fractures I, II, and III
Involve bilateral dissociation of various parts of the face from the skull base (if unilateral are called “hemi-LeFort”) and are classified based on the plane of injury. Very often seen in combination with other facial fractures.
LeFort I a.k.a. floating palate
Horizontal fracture line through alveolar ridge/maxilla and inferior wall of maxillary sinus (the transmaxillary plane). As the name “floating palate” suggests, grasping your patient’s teeth and rocking will result in movement of the palate.
LeFort II a.k.a. pyramidal fracture or floating maxilla/nose
The fracture line involves the nasal bridge, maxillary sinus, and orbital floor and rim (pyramidal or subzygomatic plane). The nose and maxilla will move when grasping your patient’s teeth.
LeFort III a.k.a. craniofacial dissociation/dysjunction or floating face
Fracture through the zygomatic arch, lateral orbital wall, orbital floor, medial orbital wall, across the nasal bones and then out through the same structures on the other side (craniofacial plane). Your patient’s entire face is basically no longer connected to the skull.
Why do we care?
Well, as ED physicians we’ve got two major emergent concerns when patients present with significant facial trauma such as LeFort fractures – airway and associated injuries. Patients are at high risk for airway compromise (and difficult intubation) for a number of reasons – associated intracranial injury leading to depressed mental status, bleeding and swelling in the oropharynx, avulsed teeth acting as foreign bodies, and decreased mouth opening and direct airway obstruction due to downward/posterior displacement of maxillary fracture fragment, to name a few. A full discussion of this type of difficult airway management is well beyond the scope of this blog post, but a few things to keep in mind – it may be impossible to get a good seal with BVM because of those mobile fracture fragments, and nasotracheal intubation is contraindicated.
A double set-up when you prepare to intubate is a good idea (i.e. be ready to crich), and consider awake intubation due to the likelihood of difficulty with BVM (although obviously not appropriate in all cases).
As for associated injuries – it takes a lot of force to cause a LeFort II or III, and you have to worry about concomitant intracranial and skull injuries in a patient with one of these fractures. In addition, both the EAST and Denver guidelines for screening for blunt cerebrovascular injury (BCVI) recognize displaced midface or LeFort II and III fractures as high risk features for BCVI (essentially “soft signs”), meaning a CT angio is probably in your patient’s future.
So, what happened to our patient?
Turns out he had LeFort I, II, AND III fractures! His CT head was negative for any acute intracranial pathology. He hovered around a GCS 13-14 in the ED and maintained his airway, so was not intubated. Trauma and ENT were consulted. His CT angio of the neck was negative and he was admitted to the SICU for airway monitoring. He signed out AMA a day later.
Cornelius CP et al. Midface. AO Foundation. Accessed online November 10, 2015. (Awesome diagrams/images!)
Mayersak RJ. Facial Trauma in Adults. UpToDate. Nov 4, 2014. Accessed online November 10, 2015.
Thompson JN, Gibson B, Kohut RI. Airway obstruction in LeFort fractures. Laryngoscope. 1987;97:275-9. PMID: 3821346.