In a patient with suspected Le Fort fracture, which CT imaging study is indicated for each fracture type and should it be performed with or without intravenous contrast?

CT Imaging for Suspected Le Fort Fractures

For all Le Fort fracture types (I, II, and III), obtain CT maxillofacial WITHOUT intravenous contrast as the primary imaging study. 1

Primary Imaging Recommendation

CT maxillofacial without IV contrast is the single imaging study indicated for evaluating all Le Fort fracture types. The fracture classification itself does not change the imaging protocol—all suspected Le Fort fractures require the same initial study 1.

Why No Contrast?

• Contrast does not aid in detecting bony facial injuries 1
• CT without contrast provides excellent delineation of osseous structures and fracture lines
• Multiplanar and 3D reconstructions from non-contrast CT are sufficient for surgical planning 1, 2

Additional Imaging Based on Fracture Type

Le Fort II and III Fractures: Add CTA Head and Neck

For Le Fort II and III fractures specifically, you must add CTA head and neck WITH contrast to screen for blunt cerebrovascular injury (BCVI). 1

• Le Fort II and III are established risk factors for BCVI
• The Eastern Association for the Surgery of Trauma recommends screening ALL patients with Le Fort II or III fractures for BCVI 1
• Le Fort III involves complete craniofacial separation with potential orbital apex and carotid canal involvement 1
• BCVI carries significant morbidity and mortality if missed—irreversible neurologic damage or death can occur 1

Le Fort I Fractures: Consider CTA

For Le Fort I fractures, CTA screening for BCVI is controversial but increasingly recommended. 1

• One large study of 4,398 patients recommended BCVI screening even for Le Fort I fractures 1
• Use clinical judgment based on mechanism and associated injuries

Complementary Head CT

Add CT head without contrast when there is concern for intracranial injury. 1

Key Clinical Indicators:

• 68% of facial fracture patients have associated head injury 1
• Le Fort II and III fractures involve high-energy mechanisms with frequent brain injury
• Posterior table frontal sinus involvement (common in Le Fort II/III) suggests dural disruption

Important caveat: Head CT alone detects 95% of facial fractures but often only partially images midface fractures—it cannot replace dedicated maxillofacial CT 1

Practical Algorithm

1. All suspected Le Fort fractures: CT maxillofacial without contrast
2. If Le Fort II or III identified: Add CTA head and neck with contrast
3. If high-energy mechanism or neurologic signs: Add CT head without contrast
4. Never use MRI acutely—it is time-consuming and not useful for initial evaluation 1

Common Pitfalls to Avoid

• Don't order head CT alone for suspected midface injury—it will miss fracture details needed for surgical planning 1
• Don't forget BCVI screening in Le Fort II/III—this is a potentially fatal missed diagnosis 1
• Don't add IV contrast to the maxillofacial CT—it provides no additional information for bone evaluation 1
• Don't rely on plain radiographs—they are inferior to CT for complex midface fractures 1