CC
A 41-year-old male is transported to the emergency department (ED) by emergency medical services (EMS) personnel status after a motor vehicle accident (the most common etiology of Le Fort II and III injuries). You are called to the trauma bay to evaluate his facial injuries.
HPI
The patient was an unrestrained driver (higher risk for more severe facial injuries) involved in a high-speed, head-on collision with another vehicle. There was no rollover or ejection (lower risk of cervical, thoracic, and lumbar spine injury), but significant damage was done to the front side of the car, with 6-inch intrusion and a steering wheel deformity (evidence of significant energy transfer to the head and neck). Upon arrival of EMS personnel, the patient was hunched over the steering wheel; he had a Glasgow Coma Scale (GCS) score of 13.
Fifteen minutes later, at the ED (rapid transport time has reduced prehospital morbidity), the repeat GCS score was 11 (moderate head injury), vital signs were consistent with mild volume loss (tachycardia and hypotension), and there was active bleeding from both nares. The patient could not recall events surrounding the accident and admitted to loss of consciousness for an unknown period after striking the steering wheel with his face (indicative of intracranial injury, which can occur with up to 50% of midfacial fractures). Deteriorating mental status and uncontrolled nasopharyngeal hemorrhage necessitated a definitive airway, so the patient was orally intubated in the ED. (Approximately 40% of patients with Le Fort III injuries require advanced airway interventions.) A cervical collar was placed for in-line cervical spine stabilization. (The reported incidence of cervical spine fracture in patients with maxillofacial injuries is ∼2%.)
PMHX/PDHX/medications/allergies/SH/FH
The patient’s histories are unknown. (When possible, information may be obtained from family members.)
Examination
Advanced trauma life support primary survey
Airway and cervical spine control. The patient is orally intubated with a transport cervical collar in place. (Intubation is difficult with unstable midfacial fractures because of altered anatomy, soft tissue edema, expanding hematoma, and hemorrhage from the nasopharynx. An emergency surgical airway, including cricothyroidotomy, may be necessary if intubation fails.)
Breathing and oxygenation. An oral endotracheal tube is in place, with mechanical ventilation on Fi o 2 of 100%. The patient has bilateral chest rise, clear breath sounds bilaterally, and an oxygen saturation of 99%. Respirations are spontaneous and regular at 12 breaths per minute.
Circulation and hemorrhage control. Blood pressure is 107/90 mm Hg, and heart rate is 115 bpm. Peripheral pulses are regular and thready. Extremities are pale and mildly diaphoretic, with delayed capillary refill. (Class II hypovolemic shock occurs with 15%–30% blood volume loss and is characterized by normal mean arterial blood pressure, increased diastolic blood pressure, decreased pulse pressure, tachycardia, decreased urine output [20–30 mL/hr], peripheral vasoconstriction, and anxiety.) Slow, active hemorrhage is observed in the nasopharynx with blood pooling in the oral cavity. (Uncontrolled nasal bleeding can be a source of significant blood loss and commonly arises from Woodruff’s plexus posteriorly or Kiesselbach’s plexus anteriorly.) For posterior nasal packing, a Foley catheter (a nasal balloon catheter or cuffed endotracheal tube may also be used) is inserted into the nares and passed beyond the nasopharynx; the balloons are inflated, and the catheter or tube is advanced until the balloons occlude the posterior nasal aperture. Anteriorly, Merocel packing (Medtronic) is coated with bacitracin, inserted along the floor of the nasal cavity, and expanded with a saline solution. (Many other forms of nasal packing are available, including ribbon gauze, sponges [Rhino Rocket, Shippert Medical Technologies Corp.], biodegradable foam [NasoPore, Polyganics], and balloon catheters [Rapid Rhino, ArthroCare]). The anteroposterior nasal packs effectively control the acute hemorrhage. The patient responds well to a 2-L bolus of lactated Ringer’s solution. The control of hemorrhage and adequacy of fluid resuscitation are frequently reassessed.
Disability and dysfunction. On the AVPU (A, awake; V, responds to voice; P, responds to pain; U, unresponsive) scale, the patient is responsive to pain. His GCS score is E2 + M5 + V1T = 8T. The right pupil is 4 mm and reactive, and the left pupil is 8 mm and nonreactive. (A fixed, dilated pupil may be a sign of increased intracranial pressure [ICP] or globe injury.) There are no lateralizing signs.
Exposure and environmental control. The patient’s clothing is removed, and a warm blanket or other warming devices are used to prevent hypothermia.
Advanced trauma life support secondary survey
History. The AMPLE history (allergy, medications, past medical history, last meal, events leading to presentation) is taken from available sources.
General. The patient is a well-developed and well-nourished male who is intubated and sedated. He has a GCS score of 8T. A transport cervical collar is in place.
Neurologic. Sequential neurologic examination is more challenging in an intubated patient than in a conscious patient. Sedation should be discontinued for an accurate assessment of mental status. The use of propofol as the sedative drug allows for rapid emergence and facilitates hourly neurologic evaluations. AVPU and GCS scores, pupil size and responsiveness, and motor strength and responsiveness are assessed. (Weakness, hyporeflexia or hyperreflexia, and posturing can be indicative of intracranial or spinal derangement.)
In an intubated patient, a high index of suspicion for intracranial hemorrhage and edema should be maintained. Any acute deterioration in neurologic status warrants a STAT head computed tomography (CT) scan. An ICP monitoring device is indicated in cases involving an initial low-yield neurologic examination (unconscious and unresponsive), deep sedation, paralysis, or severe head injury with evidence of elevated ICP.
Eyes. There is significant bilateral periorbital ecchymosis (raccoon eyes are indicative of anterior basilar skull fracture) and periorbital edema, with OS (left) greater than OD (right). There is chemosis (conjunctival edema) and subconjunctival hemorrhage bilaterally. The OD pupil is round, reactive, and sluggish (4 to 2 mm). The OS pupil is large, irregular (the apex of a tear-shaped pupil points toward the site of rupture), and nonreactive. The globe is flaccid (indicating possible ruptured globe) with a grade II hyphema (blood in the anterior chamber of the eye). No orbital pressure measurements are obtained. Visual acuity cannot be assessed.
Maxillofacial. Examination shows significant facial edema and ecchymosis. Step deformities are palpated at the right lateral orbital rim, the left infraorbital rim, and at the nasofrontal junction. The intercanthal distance is 32 mm, with a negative bowstring test. (A normal intercanthal distance is 30–34 mm and varies by race and gender [increased for those of African and Asian descent and for males].) There is no vertical or horizontal dystopia (disturbance in globe position). There is mild left enophthalmos (loss of anteroposterior projection of the globe; however, enophthalmos and dystopia are difficult to assess in the presence of significant edema). Bimanual palpation yields gross mobility of the maxilla with associated mobility and crepitus at the nasofrontal junction, left lateral orbital rim, and right infraorbital rim (indicative of maxillary or midfacial disjunction at the Le Fort II and III levels).
On otoscopic examination, tympanic membranes are clear and intact, and there is no evidence of cerebrospinal fluid (CSF) otorrhea. There is no Battle’s sign (ecchymosis in the mastoid region, indicative of posterior basilar skull fracture). An 8-cm laceration of the lower face involving the full thickness of the lip and multiple other abrasions are present. Hypoesthesia along the infraorbital nerve distribution is present bilaterally (commonly seen after fractures of the anterior maxillary wall, inferior orbital rim, and orbital floor).
Intranasal. There is bright red blood in the bilateral nasal cavities. The nasal septum is deviated to the right, with no evidence of a septal hematoma. There is no evidence of CSF rhinorrhea.
Intraoral. Occlusion is difficult to assess secondary to orotracheal intubation. Ecchymosis is present along the posterior soft palate bilaterally (Guerin’s sign, indicative of pterygoid plate disjunction or fracture). The mandible is stable, without any signs of fracture (e.g., ecchymosis, step deformity, bony crepitus, mobility, or deviation). The dentition is in good repair.
Imaging
For trauma patients, the protocol for plain film radiographs includes cervical spine, anteroposterior chest, and anteroposterior pelvis radiographs. Other studies are completed if indicated, including a cervical spine series (suspected cervical spine injury), thoracic and lumbar spine series (motor vehicle accident with ejection or rollover or in symptomatic patients), and extremity radiographs (suspected fracture or dislocation).
To evaluate midfacial fractures, noncontrast, axial cut CT with cuts of 1 mm or less is the gold standard imaging modality. Direct coronal CT should be avoided in patients with suspected cervical spine injury because it requires hyperextended head positioning.
In the current patient, a maxillofacial CT scan reveals fracture lines extending from the nasofrontal suture through the medial wall of the orbit. On the right side, the fracture extends through the superior orbital fissure, lateral orbital wall along the zygomaticofrontal (ZF) suture, and along the zygomaticosphenoid suture. There is a fracture of the right zygomatic arch near the zygomaticotemporal (ZT) suture. On the left side, a pyramidal fracture extends from the nasofrontal suture along the orbital floor, inferior orbital rim, and anterior and lateral maxillary walls. Sagittal and coronal views demonstrate a minimally displaced, left orbital floor defect. There is separation of the pterygomaxillary junction bilaterally (pterygoid plates). (This is a classic description of a pure right Le Fort III and a pure left Le Fort II fracture pattern.)
The anterior maxilla is grossly comminuted bilaterally. (Le Fort fractures most commonly present in combination with other facial fractures.) There are air-fluid levels in the bilateral maxillary sinuses (consistent with blood in the sinuses). A moderate amount of soft tissue edema and emphysema are also noted. A three-dimensional reconstruction provides the most graphic representation of the fractures, degree of displacement, and orientation of fragments.
Because of the patient’s decrease in mental status (risk of intracranial injury), an initial head CT scan was obtained. It demonstrated bilateral frontal lobe contusions, with no evidence of skull fracture, epidural or subdural hematoma, or increased ICP. A repeat head CT scan after 24 hours showed no evolution of the intracranial injury. (An initially negative head CT scan may also require a repeat scan at 12–24 hours because closed head injuries may produce CT findings only after 24 hours.)
Labs
Standard laboratory tests for the evaluation of multisystem trauma patients included a complete blood count, complete metabolic panel, arterial blood gas, urinalysis, and coagulation studies (prothrombin time, partial thromboplastin time, and international normalized ratio). A urine drug screen and blood alcohol level are indicated in patients with decreased mental status.
The current patient demonstrates decreased hemoglobin (11.2 g/dL) and hematocrit (32.6%) (true and relative anemia secondary to hypovolemia and hemodilution from fluid resuscitation). Arterial blood gas analysis shows a mild base deficit of −3.5. (Base deficit is a reliable indicator of adequacy of resuscitation and mortality in trauma patients and is a better marker of blood loss than are the hemoglobin and hematocrit.) There is also a mild elevation in blood urea nitrogen (BUN) and creatinine (Cr), with a BUN:Cr ratio of 15 (prerenal azotemia secondary to hypovolemia) and a positive blood alcohol level (common in trauma patients). The remainder of the patient’s laboratory values are within normal limits.
Assessment
Comminuted midfacial fractures consistent with a right Le Fort III and left Le Fort II pattern, with a concomitant left orbital floor fracture and displaced nasal septal fracture, complicated by significant nasopharyngeal hemorrhage, bilateral frontal lobe contusions, ruptured left globe, and laceration of the lower face and lip. Facial Injury Severity Scale score is 6.
Treatment
A variety of treatment modalities have been advocated for the treatment of Le Fort II and III fractures. Techniques are generally categorized as open or closed reduction or a combination of the two. Commonly, Le Fort fractures are sustained at more than one level, and all combinations of Le Fort I, II, and III fractures are possible. Moreover, Le Fort fractures are usually comminuted and occur in conjunction with other facial fractures, including naso-orbito-ethmoid, orbital floor or rim, and zygomaticomaxillary (ZM) complex fractures. As such, these fractures should be considered by their individual components when developing a treatment plan. Medical comorbidities, associated systemic trauma, airway status, hemorrhage, and available resources further dictate the course of treatment in each case.
Intraoperative and perioperative airway management should allow for safe anesthetic administration, optimal surgical care, and decreased morbidity. Nasoendotracheal intubation facilitates intraoperative maxillomandibular fixation (MMF) and is considered if extubation is expected on completion of the procedure. Care must be taken in placing nasoendotracheal tubes in patients with midfacial fractures that may have basilar skull components because there have been isolated reports of intracranial placement of the endotracheal tube. However, there is insufficient evidence to exclude this technique in the hands of skilled personnel. Nasotracheal intubation may interfere with nasal septal correction.
Oral intubation is considered if the endotracheal tube may pass through an edentulous space, to allow for MMF, or for submental intubation, in which the endotracheal tube is passed through the anterior floor of the mouth and through a submental transcutaneous incision. Early tracheostomy is considered for severe midfacial fractures in which intubation is difficult and if prolonged postoperative intubation is expected ( Fig. 57.1 ).
