Management of LeFort III Fractures
LeFort III fractures require immediate multidisciplinary management focusing on airway protection, vascular screening, and surgical stabilization to reduce mortality and improve outcomes.
Initial Assessment and Stabilization
Airway Management
- Immediate airway assessment is critical as LeFort III fractures involve complete craniofacial separation with high risk of airway compromise 1
- Secure airway through early intubation or tracheostomy when indicated (22.4% of LeFort III patients require tracheostomy) 2
- Control ventilation with tracheal intubation and end-tidal CO2 monitoring to prevent secondary brain injury 3
Hemodynamic Stabilization
- Maintain systolic blood pressure >110 mmHg to prevent worsened neurological outcomes 3
- Use vasopressors (phenylephrine, norepinephrine) for rapid correction of hypotension 3
- Avoid hypotensive sedative agents; prefer continuous sedation over bolus administration 3
Diagnostic Imaging
Primary Imaging
- Maxillofacial CT is the gold standard for diagnosis and surgical planning 1, 3
- CT provides high-resolution images allowing detection of subtle fractures and assessment of comminution 3
- 3D reconstructions are critical for preoperative planning 3
Vascular Assessment
- Perform CT-angiography for all LeFort III fractures due to high risk of blunt cerebrovascular injury (BCVI) 1, 3
- LeFort III is a significant risk factor for traumatic vascular dissection 3
- Consider MRI if cranial nerve deficits are not fully explained by CT findings 3
Associated Injury Screening
- Screen for cervical spine injuries (high association with maxillofacial trauma) 3
- Perform brain CT to evaluate for traumatic brain injury (TBI) which commonly accompanies LeFort III fractures 3, 2
- Evaluate for CSF leaks and skull base fractures 3
Surgical Management
Timing of Surgery
- Initial focus on life-threatening injuries and stabilization
- Definitive surgical repair typically within 7-14 days when swelling subsides
- Earlier intervention may be needed for:
- Airway compromise
- Severe bleeding
- Open fractures with contamination
- Vision-threatening injuries
Surgical Approach
- Direct realignment and stabilization of zygomaticomaxillary buttresses 4
- Rigid fragment-to-fragment fixation for precise reconstruction of vertical dimension 4
- May require craniofacial suspension in severe cases
Complications Management
- Monitor for intracranial hypertension; consider external ventricular drainage if needed 3
- Address ocular injuries promptly (common in LeFort III) 2
- Manage CSF leaks when present
- Monitor for and treat vascular injuries identified on angiography
Prognostic Considerations
- LeFort III fractures have higher Injury Severity Scores compared to LeFort I/II 2
- Higher probability of ICU admission and immediate operative intervention 2
- Higher mortality rate (8.7% in LeFort III vs 0% in LeFort I) 2
- Increased need for neurosurgical intervention and management of vision-threatening trauma 2
Pitfalls to Avoid
- Never underestimate airway risk - even stable-appearing patients can deteriorate rapidly
- Don't delay vascular imaging - BCVI can lead to stroke if untreated
- Avoid focusing solely on facial injuries - associated TBI and cervical spine injuries are common and potentially fatal
- Don't overlook ocular injuries - vision-threatening trauma requires urgent ophthalmologic consultation