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.
David M Yousem, MD, MBA
Professor of Radiology, Vice Chairman and Associate Dean
Johns Hopkins University
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