Fractures of the midface account for up to 20% of facial fractures presenting to the emergency department. When fractures of the midface occur, significant functional problems and aesthetic deformities can result. Much of the understanding of midface trauma is attributed to Rene Le Fort’s work published in 1901. Le Fort studied the impact of low-velocity blunt force to cadaver facial skeletons and noted three distinct fracture patterns based upon inherent lines of weakness (Fig. 51.1). The original descriptions were represented as symmetric and occurring in isolation. In today’s society, Le Fort fractures are rarely seen in their pure form and can present as a unilateral fractures, combined fracture patterns, or comminuted fractures. Timely diagnosis and treatment of these injuries is important in order to optimize patient outcomes and minimize long-term sequela. The goals of management are directed toward the reestablishment of preinjury structure and function. Advances in implant technology have allowed the reconstructive surgeon the ability to perform a single-stage repair with rigid internal fixation. This provides the patient more rapid bone healing, improved cosmesis, enhanced nutrition, and earlier return of preinjury function.

In the United States, Le Fort fractures typically are sustained as a result of motor vehicle accidents, physical assault, and occupation-related, sport-related, or gunshot injuries. The majority of these injuries occur in males during their 3rd and 4th decade of life. However, the elderly remain an at-risk group due to a higher incidence of falls in this population. Rarely do children sustain these injuries due to their developing craniofacial anatomy.

The mechanism of injury, including the velocity, direction, and location of the force, can help the physician anticipate the fracture pattern. Le Fort I fractures typically occur following blunt force directed in an anterior to posterior direction to the midface. Le Fort II injuries can result either from a horizontal force directed across the midface or from a transmitted force from the mandible following forces directed to the chin. Due to the amount of force needed to fracture the midface, it is not uncommon for patients to present with coexistent complex fractures to the surrounding facial skeleton, cervical spine, central nervous system, and/or orbit.

The treating physician must have a high index of suspicion for associated injuries. Critical components of the history should focus on the status of the dentition, cranial nerve defects, vision changes, and rhinorrhea. Malocclusion is common following fractures of the craniofacial skeleton and, in some instances, may be the only clue in a patient without obvious signs of injury. Cranial nerve defects may accompany these fractures, particularly the second branch of the trigeminal nerve (V2). Any change in vision reported by the patient raises the possibility of an orbital fracture or orbital trauma. Finally, anosmia, rhinorrhea, or otorrhea may be indicative of a skull base injury with potential cerebrospinal fluid (CSF) leak.

High-resolution computer tomography (CT) of the facial skeleton with axial and coronal thin cut (1.5-mm) imaging has become the standard imaging modality in the evaluation of a patient with facial trauma. CT provides superior characterization of the facial fracture segments and overlying soft tissue compared to traditional plain film radiography. It also allows the reconstructive surgeon the opportunity to evaluate the degree of injury and the potentially involved adjacent structures such as the optic canal, skull base, carotid canal, and integrity of the globe.