Le Fort Fractures: Types I, II, III, and IV
Le Fort Fractures: Learn the different types of Le Fort fractures (I, II, III, and IV) using this memory trick mnemonic! Review of Le Fort fracture classification and treatment included.
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What is a Le Fort Fracture?
Definition:
A Le Fort fracture is a type of facial fracture involving the midface
Le Fort Fractures - Quick Notes:
Le Fort fractures are fractures of the midface
The midface is the center third of the face, between the orbital cavities (eyes) and oral cavity (mouth)
The midface includes the maxilla (upper jawbone), nasal bones (nose), zygomatic bones (cheekbones), lacrimal bones and parts of the orbital walls (eye sockets), etc.
Le Fort fractures are typically caused by blunt trauma
They involve partial or full separation of the midface from the skull
There are 3 main types of Le Fort fractures, and a possible 4th, classified as:
Le Fort I
Le Fort II
Le Fort III
Le Fort IV (debated - see below)
Le Fort Fracture Types
Midface fractures can be differentiated using the Le Fort classification system.
The different types of Le Fort fractures are determined by their anatomical location and which facial bones are involved (see below).
Le Fort I fractures primarily involve the maxilla.
Le Fort II fractures primarily involve the maxilla, nasal bridge, lacrimal bones, orbital floors, and orbital rims.
Le Fort III fractures involve the nasal bridge, medial orbital walls, lateral orbital walls, maxilla, and zygomatic arch.
Le Fort IV fractures are a Le Fort III plus involvement of the frontal bone.
The central incisors can be pulled anteriorly (if appropriate) to assess which parts of the face are mobile.
This can help determine the type of Le Fort fracture present, along with imaging (CT face).
Memory Trick
The saying “see no evil, hear no evil, speak no evil” can be used as a memory trick to remember the different types of Le Fort fractures (see below).
Le Fort I = Speak No Evil (maxilla/mouth)
Le Fort II = See No Evil (orbits/eyes)
Le Fort III = Hear No Evil (zygoma/ears)
Disclaimer: This memory trick is commonly used in numerous medical resources and literature. The publisher neither claims credit nor is there one specific resource to credit.
Le Fort I = Speak No Evil
A Le Fort I fracture can be remembered using the saying “speak no evil”.
Speaking involves the mouth, which will help you remember the maxilla.
A Le Fort I fracture involves a unilateral or bilateral fracture through the inferior maxilla, just above the roots of the teeth.
Pulling on the central incisors can lead to a “floating palate” due to mobility of the dental arch.
Le Fort II = See No Evil
A Le Fort II fracture can be remembered using the saying “see no evil”.
Seeing involves the eyes, which will help you remember the orbits.
A Le Fort II fracture extends superiorly from the maxilla, through the orbital floor and rim, and medially through the lacrimal bones and nasal bridge.
Le Fort II fractures are pyramidal in shape.
The entire nasal complex is mobile when the central incisors are pulled.
Le Fort III = Hear No Evil
A Le Fort III fracture can be remembered using the saying “hear no evil”.
Hearing involves the ears, which will help you remember the zygomatic bone (zygoma).
A Le Fort III fracture extends laterally from the nasal bridge, through the medial and lateral orbits, to the zygoma.
This results in complete or near complete craniofacial dislocation.
Pulling on the central incisors will result in entire anterior displacement of the face.
A cerebrospinal fluid (CSF) leak may be present, as the intranasal portion of the fracture may extend posteriorly through the sphenoid.
Le Fort Fracture Mnemonic
In summary, the different types of Le Fort fractures can be remembered using the saying “speak no evil, see no evil, and hear no evil”.
Speak No Evil = Le Fort I = Maxilla (speak)
See No Evil = Le Fort II = Orbits (see)
Hear No Evil = Le Fort III = Zygoma (hear)
How do you remember the order of “speak, see, and hear”?
Simply list them in reverse alphabetical order: speak (I) - see (II) - hear (III)
Le Fort IV Fracture
A Le Fort IV fracture is a Le Fort III fracture plus involvement of the frontal bone.
Memory Trick: “Four” and “Frontal” both start with the letter “F” to help you remember Le Fort IV fractures involve the frontal bone.
The presentation and management of Le Fort IV fractures are similar to a Le Fort III fracture.
Note: Not all resources recognize Le Fort IV fractures as a separate classification, and the Le Fort types are instead limited to I, II, and III. Please use your institutional classification system.
Le Fort Fracture Treatment
Midface (Le Fort) fractures can potentially compromise the patient’s airway due to deformities and/or significant bleeding.
It is important to protect the patient’s airway and intubate the patient if necessary.
In addition to optimizing the patient’s airway and breathing, it is important to manage the patient’s circulation as Le Fort fractures can cause bleeding.
Facial trauma can cause arterial damage and hemorrhage, and it may be necessary to pack the nasopharynx/oropharynx as a result.
Arterial embolization may also be required for a more definitive treatment option.
Prophylactic IV antibiotics and analgesics (monitor blood pressure) should be considered.
Oral maxillofacial surgery (or the team responsible for facial trauma in your facility) should also be involved, as surgical intervention is typically required.
Surgery may involve restoring facial structure and function.
If a CSF leak is present, then the neurosurgery team may also be involved.
Summary
Hopefully this gave you a simple way to remember the different types of Le Fort fractures, as they are commonly tested on medical exams.
Remember speak no evil (Le Fort I), see no evil (Le Fort II), and hear no evil (Le Fort III).
Le Fort IV is simply a Le Fort III plus frontal bone involvement (Frontal and Four start with “F”)
Treatment involves optimizing the patient’s airway, controlling hemorrhaging if present, and typically surgical intervention.
The patient should also receive prophylactic antibiotics.
Oral maxillofacial surgery (or the appropriate service at the facility) +/- neurosurgery should be involved as well.
Resources
First Aid for the Emergency Medicine Boards; 2016; Blok, Cheung, Plats-Mills; Page 769-770
https://radiopaedia.org/articles/le-fort-fracture-classification
https://www.yalemedicine.org/clinical-keywords/le-fort-fracture
https://epomedicine.com/medical-students/lefort-fractures-mnemonics/