Signs and symptoms common to Le Fort II and III fractures

At first sight patients with either of these varieties of fracture are seen to have gross oedema of the soft tissues overlying the mid-facial skeleton, giving rise to the characteristic «moon-face» appearance. This ballooning of the features is not seen in isolated Le Fort I fractures, and occurs within a very short time of injury although it is rarely maximal until the next day.

Bilateral circumorbital ecchymosis is invariably a feature of both fractures and this also develops quite rapidly after injury. The associated rapid swelling of the eyelid makes examination of the eyes difficult but it is absolutely essential to do this at an early stage to exclude damage to the globe of the eye. Steady but gentle pressure upon the swollen eyelids, sustained for 1 or 2 minutes, will diminish the oedema sufficiently to allow them to be parted. This manoeuvre also allows the orbital rim to be palpated with accuracy.

Subconjunctival ecchymosis usually develops rapidly, but it sometimes requires several hours to become fully established. Subconjunctival haemorrhage tends to occuradjacent to those parts of the orbit where fracture has occurred, but the pattern is so variable that it is of little diagnostic value.

Oedema of the conjunctiva or chemosis is frequently seen in association with a periorbital haematoma. This causes the swollen conjunctiva to bulge out from between the eyelids, a feature which becomes more obvious as the eyelid swelling subsides.

Both Le Fort II and III fractures involve the orbit and if they coexist, the orbit itself is usually extensively damaged It is essential that the eyes are examined at an early stage by an ophthalmologist. Fortunately, it is extremely rare for the fracturing force to damage the optic nerve, as the nerve is protected by a strong ring of compact bone which forms the optic foramen, and the fracture line goes around the foramen rather than through it. Nevertheless vision can be impaired as a result of the injury, and it is therefore imperative to test it as soon as possible. Careful note should be made of any variation in the size of the pupils, which may be the result of peripheral damage to the oculomotor nerve in the superior orbital fissure, or more seriously be an early sign of intra-cranial haemorrhage.

In the early stage of the injury it is often difficult to test ocular movements or test for diplopia, but diplopia is usually present and ocular movements may be limited.

Both fractures pass through the nasal complex of bones at their base, and may extendbackwards to involve the cribriform plate area. The nasal complex itself exhibits varying degrees of comminution, but in general when a Le Fort III fracture is present, the damage in this region tends to be more extensive than in the Le Fort II fracture alone. Usually the pattern of nasal fracture is characteristic of an anterior rather than a lateral blow, when associated with Le Fort II and III fractures. It is accordingly usually flattened over the bridge and there may be spreading of the intercanthal distance. There may sometimes be lengthening of the nose where the mid-face fracture is very loose, and where it has dropped, as a whole, away from the skull base.

The nares tend to be filled with clotted blood and there may be a steady trickle of straw-coloured fluid from the nose, suggesting a cerebrospinal fluid leak mixed with serum.

In both types of fracture, the bones of the mid-face have been separated from the inclined plane of the base of the skull and forced downwards and backwards to a variable degree. A very large impacting force tends to cause comminution of the bones in the anterior parts of the face, rather than an increase in the posterior displacement, a fact demonstrated quite clearly by Le Fort in his original experiments. Hence, the backward and downward displacement of the tuberosity area of the maxilla and palate is rarely, if ever, sufficient to obstruct the nasopharynx as classically described. This fact can be readily appreciated by passing a finger around the posterior edge of the soft palate in an anaesthetized patient prior to reduction of the fracture of the mid-face. The posterior nares are in almost every case clearly defined even when the impact has caused considerable concavity of the anterior part of the face. However, even slight downward displacement of the maxillary molar teeth is sufficient to cause gagging of the occlusion, and there will usually be some retroposition of the maxilla as a whole.

Occasionally there is wide separation of the mid-face from the skull base. Clinicians frequently refer to a «floating» maxilla in such cases. When this occurs, there is usually an additional fracture at the Le Fort I level, although the maxillae may be very loose in some pure Le Fort II and III fractures. In such cases there will be extreme lengthening of the face. It should be appreciated that extreme mobility of Le Fort II and III fractures is the exception rather than the rule. A lesser degree of mobility of the mid-face is readily detected by grasping the maxillary alveolus and gently moving it forwards and backwards. Tapping of the upper teeth will give a characteristic 'cracked-pot' sound.

In both Le Fort II and III fractures there may be extensive bruising of the soft palate, particularly when the maxillae have separated in the midline. Blood clot frequently accumulates around the teeth and particularly in the vault of the palate, where it causes the patient considerable discomfort.