• Term applied to transverse fractures of the midface. The fractures involve three bones of the midface
    • Maxilla
    • Orbital rims
    • Zygoma
  • All involve the pterygoid processes of the sphenoid bones, which make up intrinsic support of the midface
    • Results in discontinuity of the midfaceHartstein 2012

Fun fact: These fractures were named by Rene Le Fort, a French surgeon in 1901 who took intact cadavers and caused forceful blunt trauma to the skulls.


  • Low-velocity mechanism (fall from standing, blunt trauma) resulted in the majority of Le Fort I fractures (56%)
  • High-velocity mechanism (fall >1 story, high-speed MVC) were associated with higher grade Le Fort fractures (e.g. II, III) (Phillips 2017)
  • Associated head and neck injuries with higher grade Le Fort fractures: (ibid.)
    • Skull fracture (40.7%)
    • Closed head injury (5.4%)
    • Cervical spine injury (5.4%)


Three types, dependent on the plane of injury

  • Le Fort Type I: “Floating palate”
    • Involves a transverse fracture through the maxilla. Occurs above the roots of the teeth and may result in mobility of the maxilla and hard palate from the midface
    • Can be associated with malocclusion and dental fractures

  • Le Fort Type II: “Floating maxilla”
    • This fracture involves extension of the fracture superiorally. Includes fractures of the nasal bridge, maxilla, lacrimal bones, and orbital floors and rims
    • Typically bilateral and triangular in shape

  • Le Fort Type III: “Floating face”
    • Rare but are considered “craniofacial dysjunction”
    • They involve the bridge of the nose, the medial walls of the orbit (ethmoids), the lateral orbital walls, the maxilla and the zygomatic arch
    • The entire face can shift

Phillips 2017


Findings on presentation

  • Severe facial ecchymosis (balloon face)
  • Severe nasal or oral hemorrhaging
  • Conjunctival hemorrhage.
  • CSF Rhinorrhea
  • Hemotympanum
  • Anosmia
  • Paresthesias of the face
  • Elongation of the face
  • Nasal disfiguration
  • Emphysema of the face
  • Exophthalmos
  • Racoon eyes
  • Auricular hematoma
  • Pupil asymmetry
  • Dental injuries
  • Sinking over the anterior face (dish face)

Knoop, Atlast of Emergency Medicine, 3rd Ed.


  • Primary survey (ABCs) and then secondary survey (where your facial and ocular exam occur)

Physical exam

  • Palpation of the entire face will detect most fractures
  • Mobility in the hard palate (intraoral palpation) or maxilla when teeth are grasped and evaluated while stabilizing the forehead with the other hand
  • Pertinent questions to ask if the patient is awake and alert:
    • How is your vision? (document visual acuity)
    • Does your bite feel normal?
    • Does anything feel numb?


  • Dedicated facial CT
    • Allows for imaging of orbits and fine fracture lines as well
  • Consider CT C-spine given high incidence of concomitant cervical spine injury
    • 1.4% of patients with concomitant c-spine fracture / dislocation (Hasler 2012)
  • No role in plain films due to the complexity of the facial bones


  • Airway should always be managed first, protection from bleeding or mechanical disruption is key
    • Severe bleeding may occur from the nose or oropharynx and these can be managed with anterior packing
    • Posterior packing should be avoided if possible unless the skull base is known to be intact.
    • In one series, 43.5% of patients with Le Fort III required tracheostomy (Bagheri 2005)
  • After the primary stabilization is achieved, other management can occur
    • Elevate the head of the bed to 40-60 degrees for anyone with a possible CSF leak (if not in spinal precautions)
    • Administering IV antibiotics, especially if CSF leak known orsuspected (though this is not well supported by literature) (Soong 2014)
      • First generation cephalosporins or Augmentin when sinus fractures are involved
    • Perform secondary exam
  • Disposition
    • There is an association between Injury Severity Score (ISS) and grade of Le Fort fracture (Bagheri 2005)
    • Majority of patient require admission; in one series:
      • 52.2% placed in ICU
      • 20.9% taken directly to OR (ibid.)
        • Goal is to restore the facial skeleton and proper masticatory function
    • Consult oral maxillofacial surgery (or whoever may be on call for facial trauma at your institution)
    • Consider neurosurgery consult if CSF leak noted
      • These patients commonly do not need intervention though
    • Consider ophthalmology consult within 24 hours depending on any ocular damage or involvement


  • Usually due to high velocity accidents, with an association b/w ISS and Le Fort grade
  • These injuries tend to have low mortality, but the associated injuries with it usually do
  • CT is the most specific and sensitive test for Le Fort fracture diagnosis
  • Protect the airway and control any hemorrhage
    • It is important to stabilize any serious injuries to airway, spine, chest, abdomen and skull prior to definitive treatment of facial bones
  • Admit, consult for operative repair, +/- antibiotics for definitive management

Read More

Facial Fracture Management Handbook: Iowa Head and Neck Protocols 

Radiopaedia: LeFort Fracture Classification

AO Surgery Reference (great for clinical exam pearls): Midface Exam


Bagheri SC, Holmgren E, Kademani D, Hommer L, Bell RB, Potter BE, et al. Comparison of the severity of bilateral Le Fort injuries in isolated midface trauma. J Oral Maxillofac Surg. 2005;63(8):1123-9. PMID: 16094579

Hasler RM, Exadaktylos AK, Bouamra O, Benneker LM, Clancy M, Sieber R, et al. Epidemiology and predictors of cervical spine injury in adult major trauma patients: a multicenter cohort study. J Trauma Acute Care Surg. 2012;72(4):975-81. PMID: 22491614

Hartstein ME, Wulc AE, Holck DEE. Midfacial rejuvenation. New York: Springer; 2012. xvi, 252 p.

Kaul RP, Sagar S, Singhal M, Kumar A, Jaipuria J, Misra M. Burden of maxillofacial trauma at level 1 trauma center. Craniomaxillofac Trauma Reconstr. 2014;7(2):126-30. PMID:25071877

Marx JA, Rosen P. Rosen’s emergency medicine : concepts and clinical practice. 8th ed. Philadelphia, PA: Elsevier/Saunders; 2014.

Phillips BJ, Turco LM. Le Fort Fractures: A Collective Review. Bull Emerg Trauma. 2017;5(4):221-30. PMID: 29177168

Salonen EM, Koivikko MP, Koskinen SK. Multidetector computed tomography imaging of facial trauma in accidental falls from heights. Acta Radiol. 2007;48(4):449-55. PMID: 17453528

Soong PL, Schaller B, Zix J, Iizuka T, Mottini M, Lieger O. The role of postoperative prophylactic antibiotics in the treatment of facial fractures: a randomised, double-blind, placebo-controlled pilot clinical study. Part 3: Le Fort and zygomatic fractures in 94 patients. Br J Oral Maxillofac Surg. 2014;52(4):329-33. PMID: 24602602

Tintinalli JE, Stapczynski JS, Ma OJ, Cline D, Meckler GD, Yealy DM. Tintinalli’s emergency medicine : a comprehensive study guide. Eight edition. ed. New York: McGraw-Hill Education; 2016. xliii, 2128 pages p.