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Surgery > General Surgery > Trauma

Question 1

A 32-year-old man is brought to the emergency department following a high-speed motorcycle collision. He is alert and oriented (GCS 15) but reports severe facial pain and an inability to close his teeth together properly. Vital signs are HR 110 beats/min, BP 130/85 mmHg, and RR 20/min. Physical examination reveals diffuse facial edema, bilateral periorbital ecchymosis ('raccoon eyes'), and a flattened, concave facial profile ('dish-face' deformity). Palpation demonstrates mobility of the entire midfacial skeleton, including the nose, maxilla, and zygomatic arches, independent of the cranium. CT imaging reveals fracture lines extending through the nasofrontal suture, orbital floors, and frontozygomatic sutures. Which of the following is the most likely diagnosis?

Possible answer options:

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Surgery > General Surgery > Trauma

Question 1

A 32-year-old man is brought to the emergency department following a high-speed motorcycle collision. He is alert and oriented (GCS 15) but reports severe facial pain and an inability to close his teeth together properly. Vital signs are HR 110 beats/min, BP 130/85 mmHg, and RR 20/min. Physical examination reveals diffuse facial edema, bilateral periorbital ecchymosis ('raccoon eyes'), and a flattened, concave facial profile ('dish-face' deformity). Palpation demonstrates mobility of the entire midfacial skeleton, including the nose, maxilla, and zygomatic arches, independent of the cranium. CT imaging reveals fracture lines extending through the nasofrontal suture, orbital floors, and frontozygomatic sutures. Which of the following is the most likely diagnosis?

Possible answer options:

  • Naso-orbital-ethmoid (NOE) fracture
  • Le Fort type I fracture
  • Le Fort type II fracture
  • ✓Le Fort type III fracture
  • Zygomaticomaxillary complex fracture

Answer Key:

The correct answer is Le Fort type III fracture.

This patient presents with the classic signs of craniofacial disjunction, where the entire facial skeleton is separated from the cranial base. The key differentiating features in this scenario are:

  1. Mobility of the zygomatic arches: Le Fort III is the only Le Fort fracture that involves the zygomatic arches, separating them from the frontal bone.
  2. 'Dish-face' deformity: A concave facial profile resulting from the posterior and inferior displacement of the entire midface.
  3. Fracture pattern: Involvement of the frontozygomatic sutures and nasofrontal suture confirms the high transverse level of the injury.

Le Fort Classification Overview:

TypeNameFracture PathKey Clinical Finding
Le Fort IFloating PalateTransverse above teethMobile palate/alveolus only
Le Fort IIPyramidalNasal bones, orbital floor, infraorbital rimMobile maxilla/nose; zygomas stable
Le Fort IIICraniofacial DisjunctionNasofrontal, orbital walls, zygomatic archesMobile face (including zygomas)

Key Points:

Le Fort fractures are classified by the level of midface separation from the skull; all three types involve fracture of the pterygoid plates.

Le Fort I (Horizontal): Separates the palate from the maxilla. Look for a mobile palate.

Le Fort II (Pyramidal): Separates the central maxilla and nose from the rest of the face. Involves the infraorbital rim but spares the zygomatic arches.

Le Fort III (Transverse): Complete craniofacial disjunction. Involves the frontozygomatic sutures and zygomatic arches. Presents with a 'dish-face' deformity and mobility of the entire face.

Management: Priority is airway protection (high risk of compromise due to edema/displacement), followed by hemodynamic stabilization and eventual Open Reduction and Internal Fixation (ORIF).

Imaging: CT face (with 3D reconstruction) is the gold standard for diagnosis.

Explanation:

This is the correct answer. A Le Fort type III fracture represents complete craniofacial disjunction. The fracture line runs transversely through the nasofrontal suture, along the medial and lateral orbital walls, and through the zygomatic arches (frontozygomatic sutures). This pattern detaches the entire facial skeleton from the skull base, resulting in mobility of the nose, maxilla, and zygomas as a single unit ('floating face'). The 'dish-face' deformity is caused by the posterior recession of the facial bones.

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SurgeryPlastic SurgeryFacial Injuries

Facial Injuries

Master MCCQE1 Facial Injuries: Essential plastic surgery, ATLS, and airway management for Canadian licensing exams.

Le Fort Fractures (Midface)

Le Fort fractures involve the separation of all or a portion of the midface from the skull base.

Le Fort I

Horizontal Fracture (Floating Palate) — Separates the teeth/palate from the maxilla.

Le Fort II

Pyramidal Fracture (Floating Maxilla) — Involves the nasal bridge, maxilla, and orbital rim.

Le Fort III

Craniofacial Dysjunction (Floating Face) — The entire face separates from the cranium.

Initial Assessment

The primary concern in any facial trauma is the Airway. Facial injuries can lead to rapid airway obstruction.

1Airway and C-Spine Control
2Breathing and Ventilation
3Circulation (Hemorrhage Control)

High-Yield MCCQE1 Points

  • All Le Fort fractures involve the pterygoid plates
  • Never insert NG tube with suspected cribriform plate fracture
  • CT face with 3D reconstruction is gold standard
  • Priority: Airway protection, then hemodynamic stabilization
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