Mid face can be drawn forward upon pulling incisors, especially in Le fort I and II. Signs include tenderness along fracture lines, with or without hematoma. The usual symptoms are pain in affected area with malocclusion. Such injury is best recognized with 3D (3 dimensional) CT scan coronal view of face, as in our case. Inferior orbital rim injury is characteristic of Le fort II fracture. All Le fort injuries are associated with pterygoid process fracture. In this type, the fracture line runs posteriorly and laterally from the bridge of nose towards zygomatic arch passing through medial and lateral orbital walls on both sides, usually associated with cerebrospinal fluid leak (Figure 4A, B-III). Le fort III fracture is rare and is basically a separation of skull and facial bones. In Le fort II the fracture line is pyramid shaped running down from bridge of the nose, bilaterally across lachrymal bones, orbital rims and floors reaching up to maxillae (Figure 4A, B-II). Also involves pterygoid process of sphenoid bone (Figure 4A, B-I). In Le fort I, fracture line runs horizontally (transverse) across maxillae (tranmaxillary plant) above the upper dentine line. Axial loading of the head is very unusual and never reported to cause this type of injury, as in this case. The common causes of Le fort fracture include motor vehical collisions and fall,. A reasonable amount of force is required to produce such fracture. About 15% of facial fractures fall into the category of Le fort fractures. He observed that all mid facial fractures are horizontal, pyramidal or transverse and labeled them as Le fort I (horizontal), Le fort II (pyramidal) and Le fort III (transverse) (Figure 4A). He experimented by applying blunt force of varying magnitude at different angles on cadaver heads and discovered predictable nature of mid facial fractures. Surgeon Rene Le fort, in 1901, introduced mid facial fractures classification after studying cadaver facial crush injuries. For cerebral contusions, neurosurgical team treated patient conservatively and patient was discharged after one week of uneventful recovery. Patient was referred to maxillo-facial team who conducted surgical fixation of Le fort II facial fractures. CT face showed fracture of pterygoid plates, anterior and postero-lateral maxillary sinuses with orbital floors fracture bilaterally, making this case as the first report of Le fort II fracture from Bahrain (Figures 2 and 3). CT head showed bilateral frontal bone fracture with multiple bilateral hemorrhagic contusions, more on the left side (Figure 1). CT head, face and cervical spine were done. His full blood count, coagulation and electrolytes were normal. Lacerations were sutured according to standard protocols. Patient was treated immediately with analgesia, intravenous fluids, antibiotics and tetanus toxoid. Cervical spine was non-tender with rest of the secondary survey being insignificant. Mandible and ear examination was fine bilaterally. Jaw occlusion was abnormal for the patient with slight mobility felt upon anterior drawing of incisors. There was tenderness in frontal and maxillary sinus areas bilaterally along with orbital margins tenderness. Eye movements were fine bilaterally with normal vision. Facial examination showed a laceration of about three centimeters (cm’s) over his nasal bridge and about four cm’s laceration over his upper left lip extending over face. In secondary survey head shows hematoma of about five cm’s in mid frontal area. On examination, primary survey was intact with patent airway, normal bilateral air entry, blood pressure of 120/75 mmHg and heart rate of 86/minute. He lost consciousness for a few seconds and was brought to ED within one hour of his injury. A case of a 55-year-old male is presented here, who presented in Emergency Department of a tertiary care hospital with complaints of nausea, vomiting and headache after being hit accidentally by a hammer on his head while working at a construction site.
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