Le Fort Fractures: See No Evil, Hear No Evil, Speak No Evil
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Example Case
A male patient presents with facial trauma. The patient was on his motorcycle when another vehicle abruptly changed lanes in front of him. The back of the other vehicle side-swiped the motorcycle causing the patient to lose control.
The patient was not wearing a helmet and was thrown off the bike face first. He suffers from obvious facial trauma and is having difficulty speaking. The patient was unable to be intubated prior to arrival.
Le Fort Fractures
Facial trauma can become life-threatening, especially if there is risk of airway compromise.
It is important to rapidly assess the patient’s airway, breathing, and circulation, and take action as deemed necessary.
Once the primary survey is complete, secondary survey can help evaluate the extent of the injury.
Midface fractures are typically due to blunt trauma and are differentiated using the Le Fort classification system.
During secondary survey, the central incisors can be pulled anteriorly to assess which parts of the face are mobile.
This can help determine which type of Le Fort fracture is present.
As always on EZmed, you will be provided a simple memory trick to learn and remember the material.
Today’s simple trick will use the “see no evil, hear no evil, speak no evil” saying to understand the different types of Le Fort fractures.
Facial Bone Anatomy
Let’s first begin with a refresher on craniofacial anatomy.
As mentioned above, facial fractures can be differentiated using the Le Fort classification system.
Each of the Le Fort types will be discussed below, but they are determined by anatomical location and which facial bones are involved.
Le Fort I fractures primarily involve the maxilla.
Le Fort II fractures primarily involve the maxilla, nasal bridge, lacrimal bones, orbital floors, and orbital rims.
Le Fort III fractures involve the nasal bridge, medial orbital walls, lateral orbital walls, maxilla, and zygomatic arch.
Le Fort IV - which is not in the video above - as it is simply a Le Fort III fracture plus involvement of the frontal bone.
Below illustrates the anatomy of the major craniofacial bones as a refresher.
Le Fort Type I = Speak No Evil
The first type of midface fracture is “speak no evil”.
This represents a Le Fort I fracture.
There is a unilateral or bilateral fracture through the inferior maxilla just above the roots of the teeth.
Pulling on the central incisors can lead to a “floating palate” due to mobility of the dental arch.
Le Fort I = Speak No Evil: Fracture through maxilla leading to mobile palate.
Le Fort Type II = See No Evil
The second type of midface fracture is “see no evil”.
This represents a Le Fort II fracture.
The fracture extends superiorly from the maxilla, through the orbital floor and rim, and then medially through the lacrimal bones and nasal bridge.
The shape of this fracture has a pyramidal appearance.
The entire nasal complex is mobile when the central incisors are pulled.
Le Fort II = See No Evil: Fracture extending superiorly from maxilla through orbital floor and rim, then across nasal bridge.
Le Fort Type III = Hear No Evil
The third type of midface fracture is “hear no evil”.
This represents a Le Fort III fracture.
The fracture spreads laterally from the nasal bridge through the medial and lateral orbits, and then involves the zygoma.
This results in complete or near complete craniofacial dislocation.
A cerebrospinal fluid (CSF) leak may be present as the intranasal portion of the fracture extends posteriorly through the sphenoid.
Pulling on the central incisors will result in entire anterior displacement of face.
Le Fort III = Hear No Evil: Fracture extending laterally from nasal bridge through medial and lateral orbits, and then involves the zygoma.
Speak No Evil, See No Evil, Hear No Evil
Speak No Evil = Le Fort I = Maxilla
See No Evil = Le Fort II = Orbits
Hear No Evil = Le Fort III = Zygoma
How do you remember the order of “speak, see, and hear”?
You simply go in reverse alphabetical order: speak - see - hear.
Le Fort Type IV
There is a Le Fort IV classification as well.
This simply is a Le Fort III fracture plus involvement of the frontal bone.
You can remember this because Four and Frontal both start with the letter “F”.
Presentation and management are going to be similar to a Le Fort III fracture.
Treatment
As eluded to above, the airway can potentially be compromised in the presence of a midface fracture due to deformity and/or significant bleeding.
It is important to protect the patient’s airway and intubate if deemed necessary.
Once the airway and breathing are optimized, then it is important to address circulation as bleeding can accompany these injuries (may be required to manage circulation concurrently with airway/breathing).
Arterial damage can result in fairly significant hemorrhaging, and packing the nasopharynx and/or oropharynx may be necessary.
Definitive management with arterial embolization may also be required.
Administration of prophylactic IV antibiotics should be considered.
Oral maxillofacial surgery should also be involved (or the team that is responsible in your facility as each is different).
If a CSF leak is present then neurosurgery may need to be involved as well.
Summary
Hopefully this gave you a simple way to remember the different types of Le Fort fractures as they are commonly tested on medical exams.
Remember speak no evil (Le Fort I), see no evil (Le Fort II), and hear no evil (Le Fort III).
Le Fort IV is simply a Le Fort III plus frontal bone involvement (Frontal and Four start with “F”)
Treatment involves optimizing the airway and controlling hemorrhaging if present.
The patient should also receive prophylactic antibiotics.
Oral maxillofacial surgery (or whoever is the correct service at the facility) +/- neurosurgery should be involved as well.
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First Aid for the Emergency Medicine Boards; 2016; Blok, Cheung, Plats-Mills; Page 769-770