What is the appropriate management for a patient with a Lefort II fracture?

Management of Le Fort II Fractures

Patients with Le Fort II fractures require immediate CT maxillofacial imaging without contrast, CT angiography to screen for blunt cerebrovascular injury (BCVI), airway assessment with consideration for intubation, and open reduction with internal fixation (ORIF) as definitive treatment. 1, 2

Initial Assessment and Resuscitation

Airway Management

• Airway control is the absolute priority in Le Fort II fractures, as these injuries can compromise the airway through hemorrhage, edema, or anatomical disruption 1
• Pre-hospital tracheal intubation decreases mortality in trauma patients with severe facial fractures 1
• Maintain end-tidal CO2 monitoring throughout to prevent hypocapnia-induced cerebral vasoconstriction 1

Hemodynamic Stabilization

• Maintain systolic blood pressure >110 mmHg to prevent secondary brain injury, as mortality increases markedly when SBP drops below this threshold 1
• Use vasopressors (phenylephrine or norepinephrine) for rapid correction of hypotension rather than waiting for fluid resuscitation or sedation adjustment 1
• Avoid hypotensive agents for sedation induction 1

Diagnostic Imaging Protocol

Primary Imaging

• MDCT maxillofacial with thin-section acquisitions is the first-line imaging modality, providing superior osseous and soft-tissue delineation 1, 2
• CT should be performed without delay and visualized with double fenestration (CNS and bone windows) 1
• CT contrast is NOT useful for detecting facial injury 2
• 3-D reconstructions are critical for preoperative surgical planning 2

Mandatory Vascular Screening

• All patients with Le Fort II fractures must undergo CT angiography of the head and neck to screen for BCVI, as recommended by the Eastern Association for the Surgery of Trauma 1
• Le Fort II fractures are an established risk factor for traumatic dissection of supra-aortic and intracranial arteries 1
• CTA has high sensitivity and excellent negative predictive value for BCVI, with short acquisition time and low complication rate 1
• If CTA is normal but clinical suspicion remains high, complete with MR-angiography or digital subtraction angiography 1

Associated Injury Screening

• 68% of facial fracture patients have associated head injury 2
• 7% have concomitant cervical spine injury 2
• Screen for infraorbital nerve injury causing anesthesia of upper teeth, gingiva, upper lip, and lateral nose 2
• MRI is only indicated for cranial nerve deficits not explained by CT or suspected CSF leak 2

Definitive Surgical Management

Timing and Approach

• Open reduction and internal fixation (ORIF) is the standard definitive treatment for Le Fort II fractures 3
• The goal is reduction, reposition, fixation of fractures, and restoration of occlusion 3
• Patients with Le Fort II injuries have significantly higher probability of ICU admission or immediate operative intervention compared to Le Fort I 4

Surgical Technique Considerations

• Stable fixation in the vertical dimension is essential to prevent caudal and dorsal displacement of the maxilla 5
• Frontal or zygomatic-bone wire suspension alone is often insufficient for Le Fort II fractures 5
• Intermaxillary immobilization in good occlusion is necessary to avoid maxillary displacement 5
• Consider simultaneous rhinoplasty using diced cartilage fascia graft during ORIF to prevent post-operative aesthetic complaints and eliminate need for secondary rhinoplasty 3

Critical Pitfalls to Avoid

• Do not delay CT angiography - BCVI screening is mandatory, not optional, for Le Fort II fractures 1
• Do not allow hypotension - even a single episode of SBP <110 mmHg worsens neurological outcome and increases mortality 1
• Do not rely on wire suspension alone - inadequate vertical stabilization leads to maxillary displacement 5
• Do not overlook cervical spine injury - 7% incidence requires systematic screening 2
• Do not perform MRI as initial imaging - it is time-consuming and inferior to CT for acute facial trauma 1, 2