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Case 5 - Bilateral Le Fort 1 & 2 Fractures

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We're going to return to this case and evaluate it from

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the standpoint of the René Le Fort fractures.

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So on the axial scans,

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we can see that there are bilateral fractures involving

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the orbital rims as well as the orbital floors.

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And we also see on the axial scans that there is

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discontinuity and displacement inward

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of the medial orbital walls bilaterally.

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So with those findings,

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we are concerned about the possibility of a fracture

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whose planes are going through the maxilla,

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the orbital floor and bilateral medial orbital wall.

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So we might say, oh, well, maybe this could be a Le Fort fracture.

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What should we do? Well,

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first thing we should do in evaluating the patient is

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to see whether the pterygoid plates are fractured,

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because the sine qua non of Le Fort fractures

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is involvement of the pterygoid plates.

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So the pterygoid plates are these structures down here,

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and we can see that the left pterygoid plate is comminuted

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and dislocated from the back of the maxilla.

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You see the back of the maxilla has a fracture, as well.

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Here on the right side,

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we see that the lateral pterygoid plates has been

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displaced lateral to the main pterygoid process.

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And there also is some comminution.

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And we also see that the medial pterygoid plate

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here is also looking a little bit irregular.

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So we have the combination of findings of a Le Forte fracture.

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Frankly,

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the Le Forte fractures are best evaluated in the coronal plane.

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So let's shift to this coronal image that was done at the same

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time. What we see is a fracture which goes across the maxilla.

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Here you can see a little bit of the

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comminuted fracture of the maxilla.

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And this represents the Le Forte I fracture in which there's a

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fragment that is involving the maxilla and potentially causing

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malocclusion. In this case, when we look at the teeth,

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there is a little bit of offset here and here.

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So there could be an element of malocclusion.

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Here you can see it looks a little bit better

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further posteriorly. However,

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we also see the orbital floor fractures which are seen here.

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This is orbital rim and anterior orbital floor.

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Here we have the orbital rim and anterior orbital floor

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with the depression of the portion of the orbital floor.

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And here we can see the previously described

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fractures going across the medial orbital wall.

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Here's the defect in the lamina papyracea on the right side.

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And a little bit further anteriorly,

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we saw the fracture involving the medial orbital

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wall a little bit more inferiorly located.

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So we have a fracture going from maxilla to orbital floor

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across the medial orbital wall,

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through the contralateral orbital floor,

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and then across the maxilla.

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This is representation of a Le Fort II fracture.

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Finally, we want to look at the lateral orbital walls.

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And we've seen before this normal suture here,

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and that looks fine. It's not diastatic.

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And we don't see any involvement of the lateral orbital wall.

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You can see here orbital roof fracture

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and comminuted fracture.

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This is the patient who had the Naso-orbito-ethmoidal fracture.

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So, just to be sure, we go back to the pterygoid plates.

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And here you can see the gross fracture and displacement

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of the pterygoid plates in this individual.

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So, in summary, bilateral Le Forte I,

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bilateral Le Forte II fractures, no Le Forte III fracture.

Report

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Neuroradiology

Head and Neck

Emergency

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