01Approach to the Critical Patient/attcp45

Airway priorities

›Immediate airway threat recognition

›Posterior maxillary displacement causing oropharyngeal obstruction

›Tongue falls back with mobile maxilla

›Manual disimpaction: grasp alveolus and pull anteriorly

›Oronasal hemorrhage compromising airway

›Active bleeding obscuring oropharynx

›Blood pooling at posterior pharynx

›26.5% of Le Fort fracture patients present with airway obstruction requiring emergent airway management

›13.6% ultimately require tracheostomy

›LOC present in 83.9% of those requiring emergent airway

›Airway management pathway

›Orotracheal intubation preferred route

›RSI with in-line C-spine stabilization

›Video laryngoscopy preferred given facial trauma and hemorrhage

›Nasotracheal intubation contraindicated if skull base fracture suspected

›Avoid any nasal instrumentation if CSF rhinorrhea present

›Surgical airway standby for failed intubation

›Cricothyrotomy kit at bedside

›ENT or trauma surgery immediate availability

Hemorrhage control

›Oronasal hemorrhage management

›Anterior nasal packing with Merocel or ribbon gauze

›Bilateral packing may be needed

›Posterior nasal packing or Foley balloon tamponade for posterior epistaxis

›Foley 14Fr inflated with 10-15 mL saline and retracted to choanae

›Direct intraoral pressure for buccal sulcus lacerations

›If hemorrhage uncontrolled, angioembolization of internal maxillary artery

02History/hx45

Mechanism and presentation

›Mechanism of injury

›Motor vehicle collision — most common etiology at 78%

›High-energy impact to lower midface

›Unrestrained occupant higher risk

›Assault/interpersonal violence

›Fall from height, especially intoxicated or elderly

›Contact sport injury

›Core symptoms

›Facial pain, especially midface and upper teeth

›Malocclusion: sensation teeth "do not fit together"

›Open bite, crossbite, premature posterior contact

›Epistaxis, often bilateral

›Facial swelling and ecchymosis of upper lip

›Difficulty chewing and opening mouth

›Neurological symptoms

›Upper lip and lateral nose numbness (infraorbital nerve V2 distribution)

›Lower eyelid numbness (V2)

›Loss of consciousness — present in 83.9% requiring emergent airway

›Headache suggesting associated intracranial injury

Associated features and red flags

›Alarm symptoms indicating higher-level injury

›Raccoon eyes (periorbital ecchymosis) — suggest Le Fort II or III

›CSF rhinorrhea — clear watery nasal discharge

›Halo sign on filter paper or beta-2 transferrin testing

›Diplopia or visual change — orbital floor involvement

›Telecanthus — increased intercanthal distance >35 mm

›History details critical for surgical planning

03Physical Exam/exam53

Vitals and airway assessment

›Hemodynamic stability screen

›Heart rate and blood pressure for hemorrhagic shock

›SBP <90 mmHg triggers hemorrhage protocol

›Respiratory rate and oxygen saturation

›Stridor or stertor indicates airway compromise

›GCS compared to baseline

›Impaired consciousness worsens airway risk

›Airway patency

›Oropharyngeal blood pooling

›Posterior displacement of midface causing obstruction

›Snoring or gurgling respirations

Midface examination

›Inspection

›Midface edema and ecchymosis of buccal sulcus and upper lip

›Facial elongation or "dish face" deformity from posterior displacement

›Epistaxis, bilateral nasal bleeding

›Intraoral ecchymosis in buccal sulcus

›High specificity for midface fracture

›Palatal ecchymosis or laceration

›Palpation

›Step-off at piriform rim and zygomaticomaxillary buttress

›Tenderness along lateral maxillary wall

›Crepitus over maxillary sinus

›Guerin's sign (pathognomonic test)

›Grasp anterior maxillary alveolus bimanually

›One hand on alveolus, other stabilizing nasal bridge and glabella

›Movement of entire maxillary dental arch while nose and upper face remain stable = Le Fort I

04Differential Diagnosis/ddx36

Midface fracture patterns

›Le Fort II fracture (pyramidal)

›ICD-10: S02.401A

›Fracture line extends through inferior orbital rims

›Periorbital ecchymosis, infraorbital hypoesthesia

›Nose and maxilla move together; nasal bridge is mobile

›Le Fort III fracture (craniofacial disjunction)

›ICD-10: S02.411A

›Entire face mobile relative to cranium

›Bilateral raccoon eyes, telecanthus, CSF leak common

›Highest risk of intracranial and vascular injury

›Le Fort I fracture (target diagnosis)

›ICD-10: S02.42XA

›Maxillary dental arch mobile; nose and upper face stable

›Horizontal fracture through pterygoid plates at base

Focal maxillary and adjacent fractures

›Zygomaticomaxillary complex (ZMC) fracture

›Malar flattening and trismus

›Infraorbital nerve paresthesia

›No maxillary mobility (maxilla not floating)

›Isolated maxillary sinus fracture

›No mobility, no malocclusion

›Hemosinus on CT without Le Fort fracture lines

›Dentoalveolar fracture

›Localized mobile segment of teeth and alveolar bone

›Entire maxilla not mobile

›Palatal fracture

›Sagittal split of palate

05Laboratory Tests/lt24

Trauma and pre-operative labs

›Type and screen or crossmatch

›Indicated for significant hemorrhage or operative planning

›Crossmatch 2 units pRBC if ongoing hemorrhage

›Complete blood count

›Baseline hemoglobin for hemorrhage trending

›Leukocytosis suggests concurrent infection or stress response

›Basic metabolic panel

›Pre-operative renal and electrolyte baseline

›Glucose: hyperglycemia predicts worse surgical outcomes

›Coagulation panel

›PT/INR and PTT: mandatory if on anticoagulants or significant bleeding

›Reversal agents needed pre-operatively if INR >1.5

Toxicology and point-of-care

›Blood alcohol level

›Detected in approximately 28% of Le Fort fracture patients

›Affects mental status interpretation and GCS validity

›Urine drug screen

›Standard trauma panel

›Affects pain management and anaesthetic planning

›Arterial or venous blood gas

›Indicated if airway compromise, respiratory distress, or shock

›Lactate for hemorrhagic shock assessment

›Lactate >2 mmol/l suggests inadequate perfusion

›Pregnancy test

›Female patients of childbearing age prior to CT and operative intervention

06Diagnostic Tests/dt60

Scoring Systems

›Le Fort fracture classification system

›Le Fort I: horizontal fracture through maxilla at level of nasal fossa floor

›Lowest severity of the three patterns

›Floating maxillary dental arch

›Le Fort II: pyramidal fracture through inferior orbital rims and nasal bones

›Le Fort III: craniofacial disjunction through zygomatic arches and orbits

›Classic isolated Le Fort patterns seen in only ~9% of cases

›Most present as incomplete, unilateral, or combination patterns

›Severity stratification for Le Fort I

›Mild: non-displaced or minimally displaced, stable occlusion

›Candidates for conservative management

›Moderate: displaced with malocclusion, stable airway

›ORIF within 5-7 days

›Severe: significant displacement, airway compromise, or polytrauma

›Emergent stabilization, operative within 24-48 hours

MRI

›MRI role in Le Fort fractures

›Not first-line for acute fracture diagnosis

›CT is gold standard for osseous detail

›Indications for MRI after stabilization

›Suspected intracranial soft tissue injury not seen on CT

›Optic nerve injury or vision loss

›Vascular injury assessment in combination with MR angiography

›MRI of orbit and optic nerve

›Traumatic optic neuropathy evaluation

›Retrobulbar hematoma

›MRI brain

07Disposition/dispo33

Admission criteria

›Admission indications

›Virtually all Le Fort I fractures warrant hospital admission

›52% require ICU level care

›27% managed on trauma ward

›21% go directly to operating room

›Airway compromise or risk of deterioration

›Significant oronasal hemorrhage requiring monitoring or packing

›Associated injuries requiring inpatient management

›TBI, intracranial hemorrhage

›Cervical spine injury

›Polytrauma

›Anticipated operative intervention within 5-7 days

›ICU criteria

›Airway managed with intubation or surgical airway

›Hemodynamic instability or significant hemorrhage

›Concomitant TBI with GCS <13

›Polytrauma with multiple organ involvement

›Need for continuous monitoring post-angioembolization

Transfer criteria

›Transfer to Level I trauma center

›No oral and maxillofacial surgery or craniofacial surgery capability on site

›Associated neurosurgical emergency requiring specialized care

›Pediatric Le Fort in facility without pediatric surgical coverage

›Transfer with secured airway if any airway compromise

›Pre-transfer requirements

›Airway secured before transport if instability present

›Hemorrhage controlled with nasal packing

08Treatment/t77

Immediate ED interventions

›Airway management

›Manual disimpaction of posteriorly displaced maxilla

›Rowe disimpaction forceps or bimanual technique

›Pulls maxilla anteriorly to relieve oropharyngeal obstruction

›Orotracheal intubation with RSI

›Ketamine 1.5-2 mg/kg IV + succinylcholine 1.5 mg/kg IV

›Rocuronium 1.2 mg/kg IV if succinylcholine contraindicated

›Cricothyrotomy for cannot-intubate cannot-oxygenate scenario

›Hemorrhage control

›Anterior nasal packing

›Merocel sponge moistened with saline or oxymetazoline

›Bilateral packing for bilateral epistaxis

›Posterior packing or balloon tamponade

›14Fr Foley catheter, inflate 10-15 mL, traction to choanae

›Commercial posterior balloon (e.g., Rapid Rhino) as alternative

›Oxymetazoline 0.05% nasal spray for vasoconstriction

›Interventional radiology angioembolization for refractory hemorrhage

›Target: internal maxillary artery and branches

Analgesics and supportive medications

›Pain management

›Morphine 0.05-0.1 mg/kg IV q4h PRN for acute severe pain

›Titrate to pain control; monitor for respiratory depression

›Fentanyl 1-1.5 mcg/kg IV for rapid onset acute pain

›Preferred if hemodynamic instability present

›Ketorolac 15-30 mg IV for moderate pain once hemorrhage controlled

›Avoid if active hemorrhage or surgical intervention within 24 hours

›Acetaminophen 1000 mg IV or PO q6h as adjunct

›Antiemetics

›Ondansetron 4-8 mg IV q6h PRN

›Critical in patients with MMF: vomiting is life-threatening with wired jaw

›Administer prophylactically post-operatively

›Metoclopramide 10 mg IV as alternative

›Antibiotics for open fractures

›Ampicillin-sulbactam 3 g IV q6h (piperacillin-tazobactam if high-risk flora)

›Covers oral flora: streptococci, anaerobes

›Clindamycin 600 mg IV q8h for penicillin allergy

›Duration: perioperative only; not prolonged course for uncomplicated fracture

›Tetanus prophylaxis

›Tetanus-diphtheria toxoid if last booster >5 years

›TIG (250 units IM) if immunization history unknown or incomplete

Surgical treatment

›Open reduction and internal fixation (ORIF)

›83% of Le Fort fractures undergo ORIF with maxillomandibular fixation

›Timing: typically 5-7 days to allow edema to subside

›100% of fractures in one series repaired within 1 week

›Surgical approach: intraoral upper buccal sulcus incision

›Access to zygomaticomaxillary and nasomaxillary buttresses

›Titanium miniplate fixation at piriform rim and zygomaticomaxillary buttress

›Restores vertical buttress height and dental occlusion

›Maxillomandibular fixation (MMF)

›Arch bars, Ivy loops, or MMF screws for temporary occlusal fixation

›Held 4-6 weeks for bony union

›Overall postoperative complication rate: 2.49%

›Wound dehiscence, transfusion requirement, reoperation

›Conservative management (selected cases)

›Non-displaced fractures with stable occlusion

›Observation and elastic traction alone

›Close OMFS outpatient follow-up required

›Nasogastric tube considerations

›Use orogastric route if skull base fracture suspected

›Avoid nasal instrumentation with CSF rhinorrhea

›Post-operative NGT for nutrition if prolonged MMF

Post-operative care

›MMF safety protocol

›Wire cutters at bedside at all times

›Patient and family instructed to cut wires if vomiting or airway distress

›Prophylactic antiemetics essential

›Suction at bedside during hospital stay

›Oral hygiene

›Chlorhexidine 0.12% oral rinse twice daily

›Warm saline rinses after meals

›Nutrition

›Strict liquid diet during MMF phase (4-6 weeks)

›High-protein liquid nutritional supplements

›IV hydration if oral intake inadequate

›Edema management

›Head of bed elevation 30-45 degrees

›Ice packs to midface first 48 hours

›Short course dexamethasone 4-8 mg IV q6-8h x 24-48h

›Reduces perioperative edema; not standard for all patients

09Special Populations/sp67

Pregnancy

›Imaging considerations in pregnancy

›CT face, head, and C-spine: obtain if clinically indicated

›Fetal abdominal radiation dose from head CT negligible

›Maternal benefit outweighs fetal risk in high-energy trauma

›Shield abdomen where feasible without compromising image quality

›MRI without gadolinium as adjunct for soft tissue assessment

›Gadolinium crosses placenta; avoid in first trimester

›Medication considerations in pregnancy

›Opioids (morphine, fentanyl): acceptable short term for acute pain

›Neonatal opioid withdrawal risk with prolonged use near term

›Ondansetron: category B; preferred antiemetic

›NSAIDs (ketorolac): avoid after 30 weeks (premature ductus closure)

›Ampicillin-sulbactam: safe in pregnancy (category B)

›Clindamycin: safe in pregnancy

›Tetanus immunization: safe in all trimesters

›Operative and anesthetic considerations

›Obstetrics consultation for all pregnant trauma patients

›Fetal monitoring perioperatively after 24 weeks gestation

›Left lateral tilt to avoid aortocaval compression in supine position

›General anesthesia for ORIF: rapid sequence induction due to aspiration risk

Geriatric

›Fracture risk and mechanism in elderly

›Lower-energy mechanism sufficient due to osteoporosis and bone loss

›Falls predominate over MVCs compared to younger population

›Anticoagulant use increases hemorrhagic risk

›Warfarin, DOAC, antiplatelet agents

›Physiologic considerations

›Reduced physiologic reserve limits hemorrhage tolerance

›Airway anatomy changes: poor dentition, reduced neck mobility

›Baseline cognitive impairment confounds GCS interpretation

›Cardiac comorbidities: ECG and cardiac monitoring pre-operatively

›Medication adjustments in elderly

›Opioid dosing: reduce by 25-50% and titrate cautiously

›Increased sensitivity; higher delirium and respiratory depression risk

›Ketorolac: use cautiously; renal insufficiency common in elderly

›Limit to 15 mg dose, shorter duration (3-5 days maximum)

›Benzodiazepines: avoid for pain control (delirium risk)

›Anticoagulant reversal if INR elevated pre-operatively

›Vitamin K 5-10 mg IV plus 4-factor PCC for urgent reversal

›Idarucizumab 5 g IV for dabigatran; andexanet alfa for factor Xa inhibitors

›Surgical risk and rehabilitation

›Higher postoperative complication risk (NSQIP data)

›Nutritional supplementation especially important during MMF phase

›Speech and swallowing therapy post-operatively

Pediatrics

›Epidemiology in pediatric patients

›Le Fort fractures uncommon in children due to prominent frontal bone, unerupted dentition providing cushioning, and smaller facial skeleton

›Peak pediatric facial fracture risk: adolescence, as facial skeleton approaches adult proportions

›Motor vehicle collision and fall from height predominate in children

›Anatomic considerations

›Mixed dentition affects MMF application

›Arch bars on primary teeth unreliable

›Circum-mandibular wires or piriform aperture wires may be needed

›Growing facial skeleton: minimize rigid internal fixation to avoid growth restriction

›Resorbable plates preferred in young children

›Unerupted permanent teeth at risk during surgical approach; preoperative panorex or dental CT

›Radiation and imaging

›CT face indicated for suspected Le Fort; fetal concern not applicable

›Limit cumulative CT exposure; consider low-dose protocol

›Pediatric dosing and preparation for CT (sedation if needed)

›Medication dosing in pediatrics

›Morphine: 0.05-0.1 mg/kg IV q4h PRN (max single dose 4 mg in young children)

›Fentanyl: 1-2 mcg/kg IV for procedural pain

›Ondansetron: 0.1 mg/kg IV (max 4 mg under 6 years; max 8 mg in older child)

›Ampicillin-sulbactam: 100-200 mg/kg/day ampicillin component divided q6h (max adult dose)

›Child protection

›Non-accidental trauma (NAT) must be considered in young children

›Pattern of injury inconsistent with stated mechanism warrants child protection consultation

›Skeletal survey and ophthalmology consult if NAT suspected

10Background/b64

Epidemiology

›Incidence and demographics

›Male sex predominates: 75% of maxillary fracture patients

›Peak incidence age 21-30 years

›Le Fort fractures represent a subset of all midfacial fractures

›True Le Fort classification applies to high-energy mechanisms

›Motor vehicle collision: 78% of Le Fort fractures

›Assaults and falls comprise remaining etiology

›Associated injury burden

›Skull fractures in 28% of Le Fort fracture patients

›Intracranial hemorrhage in 13%

›Cervical spine injury in 9.8%

›Tracheostomy required in 13.6%

›Postoperative complication rate 2.49% (wound dehiscence, transfusion, reoperation)

›Healthcare utilization

›52% of Le Fort patients require ICU admission

›83% undergo ORIF; 100% of those repaired within 1 week in published series

›Seatbelt laws associated with decreased Le Fort fracture frequency

›Original description

›René Le Fort, 1901: cadaveric experiments with blunt trauma to facial skeleton

›Classic isolated Le Fort patterns seen in only ~9% of modern trauma cases

›Most present as incomplete, unilateral, or combination patterns

Pathophysiology

›Fracture mechanism

›High-energy direct blow to lower midface or upper lip region

›Force transmitted through maxilla along lines of relative weakness

›Le Fort I fracture line traverses:

›Anterolateral margins of the nasal fossa

›Lateral walls of the maxillary sinuses

›Pterygoid plates posteriorly (hallmark of all Le Fort patterns)

›Pterygoid plate fracture present in all Le Fort patterns

›37% of pterygoid plate fractures are non-Le Fort in origin

›Resulting instability

›"Floating palate": maxillary dental arch detaches from midface skeleton

›Posterior displacement causes oropharyngeal obstruction

›Mechanism of airway compromise in Le Fort I

›Disruption of maxillary sinus walls causes hemosinus

›Bilateral sinus opacification consistently present on CT

›Infraorbital nerve V2 at risk as it exits infraorbital foramen

›Hypoesthesia in 10-16% of patients

›Associated vascular injury

›Internal maxillary artery and terminal branches at risk

›Posterior epistaxis source in significant hemorrhage

›Rare carotid-cavernous fistula with high-energy panfacial trauma

Therapeutic Considerations

›Timing of surgical repair

›Conventional teaching: repair within 5-7 days to allow edema to subside

›Delay >14 days associated with increased risk of malunion and malocclusion

›Early repair (within 24-48h) in selected cases: massive displacement, airway instability

›100% of patients in one large series were repaired within 1 week

›Buttress reconstruction principle

›Vertical facial buttresses: nasomaxillary, zygomaticomaxillary

›ORIF targets piriform rim and zygomaticomaxillary buttress

›Restores vertical height and projects occlusal plane correctly

›Horizontal buttresses contribute to facial width and projection

›Titanium miniplates provide rigid fixation for buttress reconstruction

›Antibiotic evidence

›Open fractures communicating with oral cavity or sinuses benefit from perioperative antibiotics

›No high-quality RCT data for prolonged antibiotic courses

›Perioperative coverage for oral flora sufficient for uncomplicated repair

›Complications and long-term outcomes

›Malocclusion: most common late complication if repair delayed or suboptimal

›Infraorbital hypoesthesia: 10-16%, may take months to resolve

›Oroantral fistula: communication between oral cavity and maxillary sinus

›Hardware infection: rare; titanium plates have low infection rate

›Devitalized teeth: especially with alveolar involvement

›Nonunion/malunion: risk increases with delayed repair

11Patient Discharge Instructions/pdi40

copy discharge instructions

›Discharge instructions for Le Fort I Fracture

›You have been diagnosed with a Le Fort I fracture: a break in the upper jaw (maxilla) caused by significant facial trauma

›Your fracture was/will be treated with surgery to realign the bones and restore your bite

›Jaw wiring and diet

›Your jaw may be wired or banded shut with arch bars or MMF screws

›Carry wire cutters with you at all times if jaw is wired

›Cut wires immediately if you vomit or cannot breathe, then call 911

›Strict liquid diet for 4-6 weeks: soups, protein shakes, smoothies, juices

›No solid food until cleared by your surgeon

›No straws if told to avoid suction

›Drink plenty of fluids to avoid dehydration

›Wound and oral hygiene

›Rinse mouth gently with chlorhexidine 0.12% rinse twice daily

›Warm salt water rinses after every meal (1/2 tsp salt in 240 mL warm water)

›No vigorous rinsing or spitting for 48 hours after surgery

›Keep incision sites clean and dry as directed

›Activity restrictions

›No contact sports or strenuous activity for 6-8 weeks

›No blowing nose forcefully (risk of air entering sinus)

›Sleep with head elevated on 2-3 pillows to reduce swelling

›No driving while taking opioid pain medications

›Medications

›Take prescribed pain medications as directed

›Complete any prescribed antibiotic course

›Antiemetic medication prescribed: take if nauseated

›Do not take aspirin or ibuprofen unless specifically approved by your surgeon

›Return to Emergency Department immediately for

12References/r26

Guidelines and key sources

›ACR Appropriateness Criteria for facial trauma imaging

›Expert Panel on Neurological Imaging, Parsons MS et al. ACR Appropriateness Criteria Imaging of Facial Trauma Following Primary Survey. J Am Coll Radiol. 2022

›CT face rated "usually appropriate" for suspected midface fracture

›Available at: https://doi.org/10.1016/j.jacr.2022.02.013

›CT diagnosis of Le Fort fractures

›Hopper RA, Salemy S, Sze RW. Diagnosis of Midface Fractures With CT: What the Surgeon Needs to Know. Radiographics. 2006. PMID: 16702454

›Rhea JT, Novelline RA. How to Simplify the CT Diagnosis of Le Fort Fractures. AJR. 2005. PMID: 15855142

›Epidemiology and outcomes

›Lee KC, Chuang SK, Eisig SB. The Characteristics and Cost of Le Fort Fractures: A Review of 519 Cases. J Oral Maxillofac Surg. 2019. PMID: 30853420

›Bagheri SC et al. Comparison of Severity of Bilateral Le Fort Injuries in Isolated Midface Trauma. J Oral Maxillofac Surg. 2005. PMID: 16094579

›Airway management in Le Fort fractures

›Thompson JN, Gibson B, Kohut RI. Airway Obstruction in LeFort Fractures. Laryngoscope. 1987. PMID: 3821346

›Khandelwal G et al. Are Le Fort Fracture Lines Relevant in Modern Trauma? Eur J Trauma Emerg Surg. 2026. PMID: 41697362

›Surgical management and outcomes

›Manson PN et al. Midface Fractures: Advantages of Immediate Extended Open Reduction and Bone Grafting. Plast Reconstr Surg. 1985. PMID: 3892561

›Gruss JS, Mackinnon SE. Complex Maxillary Fractures: Role of Buttress Reconstruction. Plast Reconstr Surg. 1986. PMID: 3523557

›Wood Matabele KL et al. Risk Factors for Acute Postoperative Complications Following Operative Management of Le Fort Fractures: a NSQIP Study. J Craniofac Surg. 2023. PMID: 36991535

›Pediatric maxillary fractures

›Moffitt JK et al. The Epidemiology and Management of Pediatric Maxillary Fractures. J Craniofac Surg. 2021. PMID: 32941219

›Physical examination accuracy

›Rozema R et al. Diagnostic Accuracy of Physical Examination Findings for Midfacial and Mandibular Fractures. Injury. 2021. PMID: 34103150

›Complications of midfacial fractures

›Kloss FR et al. Complications Related to Midfacial Fractures: Operative Versus Non-Surgical Treatment. Int J Oral Maxillofac Surg. 2011. PMID: 20870393

›Cohn JE et al. An Update on Maxillary Fractures: A Heterogenous Group. J Craniofac Surg. 2020. PMID: 32890151

›Pterygoid plate fractures

›Garg RK et al. Pterygoid Plate Fractures: Not Limited to Le Fort Fractures. J Craniofac Surg. 2015. PMID: 26147022

Evidence & Review

Evidence & Review