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An unusual Le Fort II fracture
An unusual Le Fort II fracture A. M. Monaghan Department
of Oral Surgery,
RAF
Hospital,
Wegherg,
-.
BFPO
40, Germany .-
SUMMARY. A case of a Le Fort II fracture pattern which occurred in a military setting is presented in which the displacement of the fragment differed from that normally seen in civilian injuries. .--. -..
viously. IIe had been standing in a fox-hole (a one-man trench) when a tank moved towards him; as the tank moved nearer he attempted to duck down but caught his
INTRODUCTION
The most frequent causes of fractures of the facial skeleton are road traffic accidents and interpersonal violence, with injuries arising from contact sports or industrial accidents being far less common (Kahnberg 8r Gothberg, 1987). A case of Le Fort I1 fracture of the midface due to indirect trauma in a military situation- is reported. The direction, slow delivery and magnitude of the force produced a fracture with some unusual features.
chin on the concrete surround, the tank wheel runner engaged the top of his helmet and continued to move forwards crushing his face. Fortunately the angled front
edge of the tank track, and the slippage of his helmet, forced him backwards into the trench before further injury could occur. First aid measures were implemented on site and he was evacuated to hospital by helicopter. His appearance on arrival at hospital is shown in Figure 1. His general condition was stable. He had full recollection of the accident and general examination excluded injuries other than those to the face. Examination of the maxillofacial region revealed abrasions and small lacerations to the skin in the submental region, spreading of the nose with steady epistaxis and palpable, bilateral, superior step deformities of approximately 1 cm on the medial orbital
Case report A 21-year-old soldier was admitted injuries
sustained
to hospital with facial while on a military exercise 7 h pre-
Fig. 1 -The patient’s appearance on admission illustrating the superiorly displaced bony fragment.
Fig. 2 - A lateral view of the maxilla. The orbital portion of the fragment can bc seen displaced superiorly.
256
Unusual
Ix
Fort
II
fracture
2.57
Fig. 3- An occipito-mental
radiograph illustrating the Lc Fort II fracture pattern and the buckling of the nasal septum.
Fig. 5 -The
patient’s facial appearance
3 months postoperatively.
DISCUSSION
Fig. 4-A
radiograph showing the satisfactory position of the bony fragment following reduction of the fracture.
margins. The midface was solidly impacted. The intercanthal distance was within normal limits and there were no abnormal ophthalmological findings. Radiographs confirmed the clinical impression of a Le Fort II fracture pattern; the fragment having been displaced superiorly, en bloc (Fig. 2). The nasal bones were splayed and the septum buckled to the right due to the reduced vertical height (Fig. 3). The mandible was intact. A computerised tomographic (CT) scan excluded a fracture of the skull base. The patient was taken to theatre 4 days after the injury and the fragment was disimpacted, reduced and immobilised using craniomaxillary fixation. The nasal bones and septum were reduced. His postoperative progress was uneventful and radiographs (Fig. 4) showed a satisfactory position of the facial bones. The clinical appearance at 3 months is shown in Figure 5.
The traditional Le Fort II fracture occurs when an impact force, often of high velocity, strikes the anterior or lateral aspect of the midface (Haskell, 1985). The fragment produced tends to be displaced down and backwards along the skull base producing lengthening (London et al., 1985) or, in cases in which the fragments are cornminuted, dishing of the face (Banks, 1987a). Moreover, displacement of the fragment in an upward direction is unusual because the bony walls of the antral and nasal cavities, together with the vomer and facial cortical plates, are functionally arranged to resist the forces of mastication, which are directed vertically (Kempf, 1988). In the case reported, the slow delivery of considerable force in a vertical direction, through the occluded dentition and against the cranium, was sufficient to overcome these anatomical constraints and resulted in the fragment being displaced superiorly, en bloc. A description of this clinical picture does not appear to have previously been reported. The relative fragility of the maxilla when compared to the mandible and calvarium has been suggested as a possible means of protecting the cranial contents from injury (Banks, 1987b). In the case described, the cranium or any p?rt of the facial skeleton may have fractured but it was the midface which was disrupted, dissipating much of the force and preventing fracture of the mandible and, more importantly, the calvarium. This gives support to the proposed protective adaptation. Also, there is little.doubt that
25X
British
Journal
of Oral
and Maxillofacial
Surgerv
the steel helmet played a major part in preventing more serious injury. Acknowledgements The author is grateful to Air Commodore Dental
Services.
RAF,
for his permission
J. Mackcy, Director of to publish the article
and to Group Captain R. G. Shcphcrd, Consultant for his help and advice during the preparation.
Oral Surgeon,
References Killey’s Frucmres of rhe Middle Third of the Facial Skeleton, 5th Ed., p. 6. Bristol: John Wright. Banks, P. (1987b). Killeys Fractures of the Middle Third of fhe FaciulSkele/on, 5th Ed., p. 5. Bristol: John Wright. Haskell, R. (1985). Applied surgical anatomy. In: Muxilfofuciul Injuries, N. L. Rowe & J. LI. Williams (Eds.), pp. 24. Edinburgh and London: Churchill Livingstone. Kahnberg. K.-E. & Gothbcrg, K. A. T. (1987). Le Fort fractures.
Banks, P. (1987a).
A study of frequency, etiology and treatment. Internarionul Journal of Oral & Muxillofucial Surgery, 16,154. Kempf, K. K. (1988). Maxillary fractures. In: Muxillofacial Traumu, C. C. Ailing III, C. C. & D. B. Osbon (Eds.), pp. 287-332. Philadelphia: Lea and Febiger. London, P. S., Rowe, N. i. & Williams, J. LI. (1985). Definitive clinical examination. In: Maxillofaciul Injuries, N. L. Rowe, J. LI. Williams (Eds.), p. 104. Edinburgh and London: Churchill Livingstonc.
The Author A. M. Monaghan BDS, FDSRCS Senior Specialist in Oral and Maxillofacial
Department of Oral Surgery RAF Hospital Wegberg BFPO 40 Paper rcccivcd Accepted
17 September 14 February 1991
1990
Surgery
of Oral Surgery,
RAF
Hospital,
Wegherg,
-.
BFPO
40, Germany .-
SUMMARY. A case of a Le Fort II fracture pattern which occurred in a military setting is presented in which the displacement of the fragment differed from that normally seen in civilian injuries. .--. -..
viously. IIe had been standing in a fox-hole (a one-man trench) when a tank moved towards him; as the tank moved nearer he attempted to duck down but caught his
INTRODUCTION
The most frequent causes of fractures of the facial skeleton are road traffic accidents and interpersonal violence, with injuries arising from contact sports or industrial accidents being far less common (Kahnberg 8r Gothberg, 1987). A case of Le Fort I1 fracture of the midface due to indirect trauma in a military situation- is reported. The direction, slow delivery and magnitude of the force produced a fracture with some unusual features.
chin on the concrete surround, the tank wheel runner engaged the top of his helmet and continued to move forwards crushing his face. Fortunately the angled front
edge of the tank track, and the slippage of his helmet, forced him backwards into the trench before further injury could occur. First aid measures were implemented on site and he was evacuated to hospital by helicopter. His appearance on arrival at hospital is shown in Figure 1. His general condition was stable. He had full recollection of the accident and general examination excluded injuries other than those to the face. Examination of the maxillofacial region revealed abrasions and small lacerations to the skin in the submental region, spreading of the nose with steady epistaxis and palpable, bilateral, superior step deformities of approximately 1 cm on the medial orbital
Case report A 21-year-old soldier was admitted injuries
sustained
to hospital with facial while on a military exercise 7 h pre-
Fig. 1 -The patient’s appearance on admission illustrating the superiorly displaced bony fragment.
Fig. 2 - A lateral view of the maxilla. The orbital portion of the fragment can bc seen displaced superiorly.
256
Unusual
Ix
Fort
II
fracture
2.57
Fig. 3- An occipito-mental
radiograph illustrating the Lc Fort II fracture pattern and the buckling of the nasal septum.
Fig. 5 -The
patient’s facial appearance
3 months postoperatively.
DISCUSSION
Fig. 4-A
radiograph showing the satisfactory position of the bony fragment following reduction of the fracture.
margins. The midface was solidly impacted. The intercanthal distance was within normal limits and there were no abnormal ophthalmological findings. Radiographs confirmed the clinical impression of a Le Fort II fracture pattern; the fragment having been displaced superiorly, en bloc (Fig. 2). The nasal bones were splayed and the septum buckled to the right due to the reduced vertical height (Fig. 3). The mandible was intact. A computerised tomographic (CT) scan excluded a fracture of the skull base. The patient was taken to theatre 4 days after the injury and the fragment was disimpacted, reduced and immobilised using craniomaxillary fixation. The nasal bones and septum were reduced. His postoperative progress was uneventful and radiographs (Fig. 4) showed a satisfactory position of the facial bones. The clinical appearance at 3 months is shown in Figure 5.
The traditional Le Fort II fracture occurs when an impact force, often of high velocity, strikes the anterior or lateral aspect of the midface (Haskell, 1985). The fragment produced tends to be displaced down and backwards along the skull base producing lengthening (London et al., 1985) or, in cases in which the fragments are cornminuted, dishing of the face (Banks, 1987a). Moreover, displacement of the fragment in an upward direction is unusual because the bony walls of the antral and nasal cavities, together with the vomer and facial cortical plates, are functionally arranged to resist the forces of mastication, which are directed vertically (Kempf, 1988). In the case reported, the slow delivery of considerable force in a vertical direction, through the occluded dentition and against the cranium, was sufficient to overcome these anatomical constraints and resulted in the fragment being displaced superiorly, en bloc. A description of this clinical picture does not appear to have previously been reported. The relative fragility of the maxilla when compared to the mandible and calvarium has been suggested as a possible means of protecting the cranial contents from injury (Banks, 1987b). In the case described, the cranium or any p?rt of the facial skeleton may have fractured but it was the midface which was disrupted, dissipating much of the force and preventing fracture of the mandible and, more importantly, the calvarium. This gives support to the proposed protective adaptation. Also, there is little.doubt that
25X
British
Journal
of Oral
and Maxillofacial
Surgerv
the steel helmet played a major part in preventing more serious injury. Acknowledgements The author is grateful to Air Commodore Dental
Services.
RAF,
for his permission
J. Mackcy, Director of to publish the article
and to Group Captain R. G. Shcphcrd, Consultant for his help and advice during the preparation.
Oral Surgeon,
References Killey’s Frucmres of rhe Middle Third of the Facial Skeleton, 5th Ed., p. 6. Bristol: John Wright. Banks, P. (1987b). Killeys Fractures of the Middle Third of fhe FaciulSkele/on, 5th Ed., p. 5. Bristol: John Wright. Haskell, R. (1985). Applied surgical anatomy. In: Muxilfofuciul Injuries, N. L. Rowe & J. LI. Williams (Eds.), pp. 24. Edinburgh and London: Churchill Livingstone. Kahnberg. K.-E. & Gothbcrg, K. A. T. (1987). Le Fort fractures.
Banks, P. (1987a).
A study of frequency, etiology and treatment. Internarionul Journal of Oral & Muxillofucial Surgery, 16,154. Kempf, K. K. (1988). Maxillary fractures. In: Muxillofacial Traumu, C. C. Ailing III, C. C. & D. B. Osbon (Eds.), pp. 287-332. Philadelphia: Lea and Febiger. London, P. S., Rowe, N. i. & Williams, J. LI. (1985). Definitive clinical examination. In: Maxillofaciul Injuries, N. L. Rowe, J. LI. Williams (Eds.), p. 104. Edinburgh and London: Churchill Livingstonc.
The Author A. M. Monaghan BDS, FDSRCS Senior Specialist in Oral and Maxillofacial
Department of Oral Surgery RAF Hospital Wegberg BFPO 40 Paper rcccivcd Accepted
17 September 14 February 1991
1990
Surgery