01Approach to the Critical Patient/attcp46

Airway management

›Airway priority

›26.5% of Le Fort fracture patients require emergent intubation or tracheostomy

›Orotracheal intubation is preferred first-line

›Avoid blind nasotracheal intubation if skull base fracture suspected

›Nasotracheal intubation under direct visualization has equivalent complication rates to tracheostomy

›Surgical airway indications

›Failed orotracheal intubation

›Inability to visualize cords due to hemorrhage or distortion

›Cricothyrotomy or tracheostomy as bailout

›Manual reduction of displaced maxilla

›Pull midface anteriorly if posterior displacement causes airway obstruction

›Temporary measure until definitive airway secured

Hemorrhage control

›Hemorrhage management

›Anterior nasal packing for epistaxis control

›Apply with nasal tampon or ribbon gauze

›Bilateral packing if posterior bleeding

›Posterior nasal packing for posterior epistaxis

›Foley catheter balloon tamponade

›Inflated to 10–15 mL in nasopharynx

›Direct pressure for external facial lacerations

›Hemostasis before imaging where feasible

›Vascular surgical consult if major vessel injury

Trauma resuscitation

›Polytrauma priorities

›ATLS primary survey completion before facial focus

›C-spine immobilization until cleared

02History/hx68

Mechanism and injury context

›High-energy blunt trauma mechanism

›Motor vehicle collisions most common (78% of midface fractures)

›Speed and direction of impact

›Airbag deployment, seatbelt use

›Assault, falls, work-related injuries

›Weapon type, height of fall

›Witnesses to mechanism

›Blood alcohol level elevated in approximately 28% of Le Fort patients

›Substance use at time of injury

›Altered reliability of history

Symptom complex

›Cardinal presenting symptoms

›Facial pain and swelling

›Onset and progression since injury

›Sensation of face "moving" or instability

›Visual complaints

›Diplopia (binocular versus monocular)

›Decreased visual acuity

›Periorbital swelling limiting eye opening

›Nasal symptoms

›Epistaxis

›Clear nasal drainage suggesting CSF leak

›Nasal obstruction

›Occlusal complaints

›Inability to bite down properly

›Crossbite or open bite sensation

›Trismus (limited mouth opening)

03Physical Exam/exam70

Vital signs and general assessment

›Stability markers

›Heart rate

›Tachycardia suggesting hemorrhagic shock

›Rate > 120 as hemorrhage alarm

›Blood pressure

›SBP < 90 mmHg requiring emergent resuscitation

›Hypotension with facial fractures suggests additional injuries

›GCS

›GCS <= 8 mandates ICU-level care

›GCS deterioration triggers neurosurgical consultation

›Respiratory rate and oxygen saturation

›Tachypnea from airway obstruction or pain

›Desaturation requiring immediate airway intervention

Facial inspection

›External facial findings

›Bilateral periorbital ecchymosis (raccoon eyes)

›High specificity for midface and skull base fractures

›May be delayed up to 24 hours post-injury

›Facial elongation or dish-face deformity

›Characteristic of midface downward and posterior displacement

›Asymmetry suggesting unilateral component

›Midface edema and ecchymosis

›Swelling peaks at 48–72 hours post-injury

›May obscure underlying step-offs early

›Clear rhinorrhea

›Halo sign on gauze (CSF migrates beyond blood stain)

›Beta-2 transferrin confirmatory test

Palpation

›Structural palpation findings

›Infraorbital rim step-off

›High positive predictive value for Le Fort II

›Bilateral involvement typical of true Le Fort II

›Midface mobility

›Grasp maxilla between thumb and index finger and apply anteroposterior force

›Nose and maxilla move as a unit while zygomas remain stable — pathognomonic for Le Fort II

›Approximately 9% of Le Fort fractures present without maxillary mobility

›Infraorbital nerve hypoesthesia

›V2 distribution: cheek, upper lip, lateral nose

›Indicate infraorbital canal involvement

›Crepitus over the midface

›Subcutaneous emphysema from sinus communication

›Avoid nose blowing if suspected

Intraoral and dental examination

›Intraoral findings

›Malocclusion

›Open bite, crossbite, or loss of dental intercuspation

›Pre-injury occlusion history essential for comparison

›Maxillary buccal sulcus ecchymosis

›Bruising along upper vestibule

›Indicates maxillary buttress disruption

›Alveolar or palatal fractures

›Palatal split may accompany sagittal fracture component

›Assess for loose or avulsed teeth

Ophthalmologic examination

›Eye findings

›Visual acuity

›Decreased acuity with afferent pupillary defect suggests orbital apex syndrome

›Lateral canthotomy indicated for retrobulbar hemorrhage with vision loss

›Extraocular movements

›Diplopia on upgaze or lateral gaze

›Entrapment pattern requiring urgent ophthalmology

›Pupillary reflexes

›Relative afferent pupillary defect (RAPD) testing

›Blown pupil suggesting herniation or direct nerve injury

›Globe position and subconjunctival hemorrhage

›Enophthalmos or exophthalmos indicating orbital volume change

›Subconjunctival hemorrhage without posterior limit suggests skull base fracture

Nasal examination

›Nasal findings

›Septal hematoma

›Boggy bluish swelling of nasal septum

›Requires urgent incision and drainage to prevent avascular necrosis

›External nasal deformity

›Assess after acute edema subsides for definitive assessment

›Nasal dorsum deviation or saddling

04Differential Diagnosis/ddx42

Midface fracture spectrum

›Le Fort fracture classification differentials

›Le Fort I fracture (ICD-10 S02.400)

›Horizontal fracture through maxilla below nasal aperture

›No orbital rim involvement

›Maxilla and hard palate move independently from the rest of midface

›Le Fort III fracture (ICD-10 S02.410)

›Craniofacial disjunction

›Involves zygomatic arch and lateral orbital wall

›Differentiated from Le Fort II by zygomatic arch fracture

›Panfacial fracture

›Combination of upper, mid, and lower face fractures

›Le Fort components coexisting with mandible fractures

Associated midface fractures

›Concomitant fracture patterns

›Zygomaticomaxillary complex (ZMC) fracture (ICD-10 S02.40)

›Often unilateral, involves zygomatic body and arch

›32% of Le Fort II ORIFs have concomitant malar fractures

›Naso-orbito-ethmoid (NOE) fracture (ICD-10 S02.2)

›Involves medial canthal tendon and ethmoid sinuses

›May coexist with Le Fort II (nasofrontal component)

›Isolated orbital blowout fracture (ICD-10 S02.3)

›Orbital floor or medial wall without the pyramidal Le Fort II pattern

›Inferior rectus entrapment possible

Isolated facial injuries to distinguish

›Non-Le Fort diagnoses

›Nasal bone fracture (ICD-10 S02.2XXA)

›Isolated nasal fracture without infraorbital rim or pterygoid involvement

05Laboratory Tests/lt31

Hemorrhage and coagulation

›Hematologic assessment

›Complete blood count

›Baseline hemoglobin for hemorrhage quantification

›Thrombocytopenia affecting surgical planning

›Type and screen or crossmatch

›Significant hemorrhage possible from midface vascularity

›Crossmatch if active bleeding or surgical candidate

›Coagulation studies (PT/INR, aPTT)

›Anticoagulant use requiring reversal

›Baseline before surgical intervention

Metabolic and safety labs

›Metabolic panel

›Basic metabolic panel

›Renal function for antibiotic dosing adjustment

›Electrolytes for perioperative management

›Glucose

›Hyperglycemia in stress response

›Diabetic patients at higher surgical complication risk

›Liver function tests

›Drug metabolism baseline

›Alcohol-related hepatic impairment

Toxicology and special tests

›Toxicologic and CSF assessment

›Blood alcohol level and urine drug screen

›Intoxication detected in approximately 28% of Le Fort patients

›Affects reliability of neurologic examination

›Beta-2 transferrin for CSF confirmation

06Diagnostic Tests/dt50

Scoring Systems

›Injury Severity Score (ISS) context

›Le Fort II/III patients have significantly higher ISS than Le Fort I (p < 0.0001)

›Higher ISS correlates with ICU admission rates

›ISS > 15 indicates major trauma

›Mortality risk stratification

›Le Fort II independently confers 94% increased risk of death (RR 1.94) versus simple midface fractures

›Cumulative mortality 11.6% for complex midface fractures versus 5.1% for simple

MRI

›MRI role in Le Fort II fracture

›Indications

›Orbital apex syndrome with vision loss (MRI brain and orbits with fat suppression)

›Neurologic deficits not explained by CT findings

›Soft tissue injury assessment when CT equivocal

›Limitations in acute trauma

›Not first-line in acute polytrauma (time and monitoring constraints)

›CT remains gold standard for bony fracture diagnosis

›MRI orbital protocol

›T2 fat-saturated sequences for orbital hemorrhage

›Diffusion-weighted imaging for optic nerve injury

›Coronal reconstructions for extraocular muscle assessment

CT

›CT maxillofacial imaging

›First-line imaging modality

›CT maxillofacial without IV contrast is gold standard per ACR Appropriateness Criteria

›Thin-cut axial images (1 mm or less) with coronal and sagittal reformats

›Often reconstructed from head and C-spine CT source data obtained in primary trauma survey

›Key Le Fort II CT findings

07Disposition/dispo40

Admission criteria

›Inpatient admission indications

›All Le Fort II fractures require inpatient admission

›High complication burden precludes outpatient management

›Over 52% of Le Fort patients admitted to ICU

›ICU admission criteria

›GCS <= 8

›Intracranial hemorrhage

›Hemodynamic instability

›Active CSF leak

›Airway compromise or post-intubation management

›Trauma ward criteria

›Stable patients with isolated Le Fort II without intracranial injury

›Airway intact and hemorrhage controlled

Surgical planning and timing

›Operative disposition

›Immediate OR indications

›Uncontrolled hemorrhage

›Orbital compartment syndrome with vision loss

›Airway not securable by other means (tracheostomy)

›Delayed operative planning (within 7–14 days)

›Once perioperative edema subsides

›ORIF performed in approximately 73% of Le Fort fracture patients

›Allows time for preoperative dental and surgical planning

Transfer criteria

›Transfer indications

›Facilities without oral/maxillofacial or plastic surgery coverage

›All Le Fort II fractures require specialist surgical availability

08Treatment/t65

Airway and emergent interventions

›Definitive airway

›Orotracheal rapid sequence intubation

›Ketamine 1.5–2 mg/kg IV for induction (preferred in hemorrhagic shock)

›Succinylcholine 1.5 mg/kg IV or rocuronium 1.2 mg/kg IV for paralysis

›Direct laryngoscopy or video laryngoscopy as first attempt

›Surgical airway backup

›Cricothyrotomy (needle or surgical) if cannot intubate/oxygenate

›Tracheostomy preferred for definitive airway in complex panfacial trauma

Hemorrhage management

›Epistaxis control

›Anterior nasal packing

›Nasal tampon (Merocel) inserted along floor of nasal cavity

›Bilateral if bleeding crosses septum

›Posterior epistaxis

›Foley catheter balloon inflated 10–15 mL in nasopharynx

›Anterior pack placed after posterior balloon secured

›Hemostatic adjuncts

›Tranexamic acid 1 g IV over 10 minutes (within 3 hours of injury)

›Repeat dose 1 g IV over 8 hours

Analgesia and antiemetics

›Pain management

›Multimodal analgesic approach

›Acetaminophen 1 g IV or PO every 6 hours (scheduled)

›Ketorolac 15–30 mg IV every 6 hours (avoid if active hemorrhage or planned surgery)

›Opioids (morphine 0.05–0.1 mg/kg IV) for breakthrough severe pain

›Antiemetics

›Ondansetron 4–8 mg IV every 8 hours

›Rationale: vomiting increases intracranial pressure if CSF leak present

›Metoclopramide 10 mg IV as alternative

Antibiotic prophylaxis

›Evidence-based antibiotic use

›Non-operative closed fractures

›Prophylactic antibiotics not recommended per AAST consensus

›No benefit demonstrated in closed non-operative cases

›Operative fractures undergoing ORIF

›Perioperative antibiotic prophylaxis indicated

›Single preoperative dose sufficient (no benefit beyond 24 hours postoperatively)

›Cefazolin 2 g IV (3 g if weight > 120 kg) within 60 minutes of incision

›CSF leak with basilar skull fracture

›Prophylactic antibiotics not recommended per IDSA guidelines

›Pneumococcal vaccination recommended instead

Tetanus prophylaxis

›Wound prophylaxis

›Tetanus toxoid if open wound and last vaccination > 5 years ago

›Td 0.5 mL IM if immunization history current

›TIG 250 units IM plus Td if immunization history unknown or incomplete

Definitive surgical management

›Open reduction and internal fixation (ORIF)

›Surgical approach

›Intraoral vestibular incision for maxillary buttress access

›Subciliary or transconjunctival incision for orbital rim access

›Extended transcaruncular approach for nasofrontal buttress

›Fixation targets

›Nasofrontal buttress fixation

›Infraorbital rim fixation

›Zygomaticomaxillary buttress fixation

›Intermaxillary fixation (IMF)

›Used intraoperatively to establish dental occlusion

›Restoration of occlusion is the primary surgical goal

›May be used alone for minimally displaced non-operative fractures

›Wire cutters at bedside if IMF placed postoperatively

CSF leak management

›CSF rhinorrhea treatment

›Conservative management (first-line)

›Bed rest with head of bed elevated 30–45 degrees

›Avoidance of straining, nose blowing, Valsalva maneuvers

›Most traumatic CSF leaks resolve within 7–10 days

›Surgical repair

›Indicated if CSF leak persists beyond 7 days

›Endoscopic endonasal approach preferred for anterior skull base

›Neurosurgical and otolaryngology co-management

09Special Populations/sp56

Pregnancy

›Pregnancy-specific considerations

›Maternal resuscitation priority

›Left lateral tilt at 15–20 degrees if > 20 weeks gestation

›Adequate maternal oxygenation (SpO2 > 95%) for fetal wellbeing

›Fetal heart rate monitoring after stabilization

›Imaging considerations

›CT maxillofacial and head indicated when maternal indication exists

›Lead shielding of uterus where feasible but not to delay diagnosis

›Fetal radiation dose from facial CT is negligible (well below 50 mGy threshold)

›Medication safety

›Acetaminophen safe for analgesia in all trimesters

›NSAIDs avoided in third trimester (premature ductal closure)

›Succinylcholine and rocuronium considered safe for RSI

›Cefazolin safe for perioperative prophylaxis

›Surgical timing

›Delay elective ORIF to second trimester when possible

›Emergent indications (hemorrhage, airway) take priority regardless of gestational age

Geriatric

›Geriatric-specific considerations

›Fall mechanism dominates in elderly (versus MVC in younger patients)

›Lower energy mechanism can cause equivalent fracture severity due to osteoporosis

›Higher associated mortality in elderly patients

›Age-related outcomes

›Increased ICU admission rates

›Prolonged recovery due to comorbidities

›Higher risk of postoperative complications

›Anticoagulation management

10Background/b55

Epidemiology

›Incidence and population data

›Le Fort II fractures occur predominantly in young adult males

›Male-to-female ratio approximately 5:1

›Peak incidence age 18–30 years

›Mechanism distribution

›Motor vehicle collisions account for 78% of midface fractures

›Assault, falls, sports, and occupational injuries account for remainder

›Mortality and severity data

›Le Fort II independently confers 94% increased risk of death versus simple midface fractures (RR 1.94)

›Cumulative mortality 11.6% for complex midface fractures versus 5.1% for simple

›Over 52% of Le Fort patients require ICU admission

›Associated injuries prevalence

›Skull fractures in 28% of Le Fort patients

›Intracranial hemorrhage in 13%

›Cervical spine injury in 9.8%

›Concussion in 9.1%

›ICD-10 coding

›S02.400A — fracture of Le Fort I type

›S02.401A — Le Fort II fracture (pyramidal fracture of midface)

Pathophysiology

›Fracture mechanism and anatomy

›Le Fort II pyramidal fracture pattern

›High-energy frontal impact to the midface causes the pyramidal fracture

›Fracture extends from pterygoid plates superiorly through inferior orbital rim to nasofrontal junction

›The central midface separates from the cranial base as a pyramid

›Anatomic lines of the Le Fort II fracture

›Inferior: through the pterygoid plates (shared with all Le Fort types)

11Patient Discharge Instructions/pdi29

copy discharge instructions

›Discharge instructions for Le Fort II Fracture

›Activity restrictions

›No contact sports or strenuous activity for 3 months

›No blowing your nose for 6 weeks after surgery

›Sneeze with your mouth open to avoid pressure on healing bones

›No use of drinking straws for 6 weeks

›Diet instructions

›Soft mechanical diet for 6–8 weeks (yogurt, mashed foods, soft fish)

›If jaw wires are in place, wire cutters must be at your bedside

›If you vomit and your jaw is wired, cut the wires and call emergency services immediately

›Adequate protein and calcium intake supports bone healing

›Wound and sinus care

›Keep incisions clean and dry as instructed

›Salt water rinses after meals if intraoral incisions present

›Avoid sinus-related pressure (no scuba diving, no swimming)

›Follow-up schedule

›Oral/maxillofacial surgery or plastic surgery in 1–2 weeks

›Return visits at 4, 6, and 12 weeks for bone healing and hardware assessment

›Ophthalmology follow-up if any eye symptoms at discharge

›Seatbelt and protective equipment reminder

›Wear your seatbelt on every trip

›Helmet use for cycling and motorcycling

›Return to emergency department immediately for

›New or worsening clear nasal drainage (possible CSF leak)

›Fever above 38.3 degrees Celsius or increasing redness/swelling of face

›Any decrease in vision, double vision, or new eye pain

›Difficulty breathing or swallowing

12References/r31

Guidelines and key sources

›ACR Appropriateness Criteria

›Expert Panel on Neurological Imaging, Parsons MS et al. ACR Appropriateness Criteria Imaging of Facial Trauma Following Primary Survey. Journal of the American College of Radiology. 2022

›CT maxillofacial without IV contrast as gold standard

›CT head routinely indicated with Le Fort II pattern

›Expert Panel on Polytrauma Imaging, Lee JT et al. ACR Appropriateness Criteria Major Blunt Trauma: Update 2025. Journal of the American College of Radiology. 2026

›Trauma and surgical society guidelines

›Appelbaum RD et al. Antibiotic Prophylaxis in Injury: AAST Critical Care Committee Clinical Consensus Document. Trauma Surgery and Acute Care Open. 2023

›No prophylaxis for non-operative closed fractures

›Single perioperative dose for ORIF cases

›Coccolini F et al. Antibiotic Prophylaxis in Trauma: GAIS, WISE, WSES, AAST, and WSES Guidelines. Journal of Trauma and Acute Care Surgery. 2024

›Tunkel AR et al. 2017 IDSA Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clinical Infectious Diseases. 2017

›No prophylactic antibiotics for traumatic CSF leak

›Pneumococcal vaccination recommended

›Key studies

›Bellamy JL, Mundinger GS, Reddy SK et al. Le Fort II Fractures Are Associated With Death: A Comparison of Simple and Complex Midface Fractures. Journal of Oral and Maxillofacial Surgery. 2013

›Le Fort II independently associated with RR 1.94 for death

›2.88-fold increased intracranial injury risk

›Limanto CA, Galvez Cabezas K, Saadat GH et al. Age-Related Outcomes in Le Fort Fractures. The American Surgeon. 2023

›Associated injury rates (skull fractures 28%, ICH 13%, C-spine 9.8%)

›ORIF performed in 73% of cases

›Kuhrau C, Easton J, Woodyard De Brito K et al. Safety of Intubation Methods in Patients With LeFort Pattern Facial Trauma. Journal of Craniofacial Surgery. 2025

›Nasotracheal intubation equivalent to tracheostomy when performed under direct visualization

›Soong PL, Schaller B, Zix J et al. Role of Postoperative Prophylactic Antibiotics in Treatment of Facial Fractures. British Journal of Oral and Maxillofacial Surgery. 2014

›No benefit of extending prophylaxis beyond single perioperative dose

›Girotto JA, MacKenzie E, Fowler C et al. Long-Term Physical Impairment and Functional Outcomes After Complex Facial Fractures. Plastic and Reconstructive Surgery. 2001

›Long-term complications correlate with fracture complexity

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

Evidence & Review

Evidence & Review