Monday, February 05, 2024

EMS Trauma Emergencies - Le Fort Fractures

EMS Providers should be familiar with Le Fort fractures as they are severe injuries to the facial bones that require immediate attention.

There are three main types of Le Fort fractures, each affecting different parts of the face. Here's what EMS providers should know about them:

Le Fort I Fracture (Horizontal Maxillary Fracture):

This fracture involves a horizontal separation of the maxilla (upper jaw) from the rest of the face.

Mechanism of injury often involves a blow to the front of the face, such as a dashboard impact in a motor vehicle accident.

Signs and symptoms may include:

- Pain and tenderness in the upper jaw region.

- Mobility or instability of the teeth.

- Numbness or tingling in the upper lip or gums.

Complications can include airway compromise due to displacement of the maxilla.

Le Fort II Fracture (Pyramidal Fracture):

This fracture involves separation of the central portion of the face from the skull, including the nasal bones, ethmoid bone, and maxilla.

Mechanism of injury often involves a high-energy impact to the middle third of the face, such as a direct blow to the nose or cheekbones.

Signs and symptoms may include:

- Swelling and deformity of the mid-face.

- Crepitus (grinding sensation) upon palpation.

- Periorbital ecchymosis (bruising around the eyes).

- CSF (cerebrospinal fluid) rhinorrhea or otorrhea, if there is associated skull base fracture.

Complications can include orbital and ocular injuries, as well as CSF leakage which may lead to increased risk of meningitis.

Le Fort III Fracture (Transverse Fracture):

This fracture involves separation of the entire facial skeleton from the skull, including the zygomatic arches, orbits, and nasal bones.

Mechanism of injury often involves a severe, high-velocity impact to the face, such as a fall from height or a significant blunt force trauma.

Signs and symptoms may include:

- Gross facial deformity with flattening of the mid-face.

- Bilateral periorbital ecchymosis (raccoon eyes).

- Subconjunctival hemorrhage.

- Epistaxis (nosebleed).

Complications can include severe facial disfigurement, orbital compartment syndrome, and optic nerve injuries leading to visual impairment or blindness.

The concept of Le Fort fractures was developed by a French surgeon named RenĂ© Le Fort. RenĂ© Le Fort conducted extensive anatomical studies on the human skull in the early 20th century. 

In 1901, he published his findings on patterns of fractures involving the mid-face region, which came to be known as Le Fort fractures. His work laid the foundation for understanding and classifying these severe injuries to the facial bones.

For EMS providers, prompt recognition and stabilization of patients with Le Fort fractures are crucial. Management typically involves securing the airway, controlling bleeding, and providing pain management while transporting the patient to an appropriate medical facility for further evaluation and treatment by a maxillofacial surgeon or a trauma specialist. 

Additionally, EMS providers should be vigilant for associated injuries, particularly to the cervical spine and head, given the mechanism of injury typically associated with these fractures.

Further Reading:

Alexander, M. & Belle, R (2012) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). New Jersey: Pearson. 

Bledsoe, B. E., Cherry, R. A. & Porter, R. S. (2023) Paramedic Care: Principles and Practice Volume 1 (6th Ed). New Jersey: Pearson. 

Brown, C. A., III., & Walls, R. M. (2023) The Walls Manual of Emergency Airway Management (6th Ed). Pennsylvania: Lippincott Williams & Wilkins. 

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). New Jersey. Pearson Education. 

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