Emergency Management of LeFort Fractures
The primary focus in emergency management of LeFort fractures must be securing the airway, as these fractures can cause life-threatening airway obstruction requiring immediate intervention. 1, 2
Initial Assessment and Stabilization
Airway Management
- Immediate Priority: Assess for airway compromise from hemorrhage, soft-tissue edema, or loss of facial architecture 3
- High Risk Patients: LeFort III fractures have the highest risk (83.9%) of requiring emergent airway control 1
- Intervention Options:
- Endotracheal intubation (may be difficult due to midface instability)
- Emergency surgical airway (tracheostomy) if intubation fails
- Consider awake fiberoptic intubation with surgeon standby for difficult cases 2
Hemodynamic Stabilization
- Maintain systolic blood pressure >110 mmHg 4
- Rapid correction of hypotension using:
- Fluid resuscitation
- Vasopressors (phenylephrine, norepinephrine) if needed 4
- Control active bleeding with direct pressure
Diagnostic Imaging
- CT maxillofacial scan is the first-line diagnostic modality (superior to plain radiographs) 3, 4
- CT head should be performed concurrently as 68% of facial fracture patients have associated head injuries 3, 4
- CT angiography of supra-aortic and intracranial vessels if risk factors present:
- LeFort II or III fractures
- Cervical spine fracture
- Basal skull fractures
- Focal neurological deficit
- Claude Bernard-Horner syndrome
- Soft tissue lesions at the neck 4
Specific Management for LeFort Fractures
Temporary Stabilization
- Manual reduction of grossly displaced fragments to improve airway patency
- Intermaxillary fixation (if patient is conscious and not at risk of vomiting)
- External fixation may be considered for temporary stabilization 4
Management of Associated Injuries
- CSF Leak: Monitor for clear rhinorrhea suggesting dural tear 3
- Orbital Assessment: Check for enophthalmos, diplopia, and infraorbital nerve paresthesia 4
- Occlusion Evaluation: Document malocclusion for later surgical correction 3
- Intracranial Pressure Monitoring: Consider in patients with associated severe TBI 4
Pain Management
- Begin with non-opioid analgesics
- Escalate to opioids only when necessary for severe pain 3
Definitive Management Planning
Timing of Surgical Intervention
- Early definitive repair (within 24 hours) if patient is hemodynamically stable with no severe associated injuries 4
- Delayed definitive repair in presence of:
- Severe visceral injuries (brain, thorax, abdomen)
- Circulatory shock
- Respiratory failure 4
Surgical Approach
- Damage Control Approach: Temporary stabilization followed by delayed definitive repair for unstable patients 4, 5
- Sequencing: Restore facial width first, then projection, then length 6
Common Pitfalls to Avoid
- Overlooking airway compromise: LeFort III fractures have highest risk of requiring emergent airway intervention 1
- Missing associated injuries: Always evaluate for intracranial, cervical spine, and vascular injuries 5, 4
- Inadequate imaging: Relying on plain radiographs instead of CT scans 3, 4
- Delaying treatment: Increases risk of complications including malunion and functional deficits 3
- Underestimating severity: LeFort III fractures have significantly higher ISS scores and mortality rates compared to LeFort I 7
By following this systematic approach to emergency management of LeFort fractures, clinicians can reduce morbidity and mortality while optimizing functional and aesthetic outcomes.