Monday, August 15, 2005

Willie Mae is a 74 year-old woman who fell at home. As she stated, "I just tripped over my feet." When evaluating patients with falls, you have to be as concerned with the reason for the fall as you are with the results of the fall, perhaps more so.

Willie Mae had good vital signs and was alert. Her family members indicated that her mental status was as sharp as ever.

However, Willie Mae had lost her battle with her sidewalk. On inspection, she had a superficial 5 cm laceration on the right cheek, following the zygoma. She had crusted blood in her nares and the beginning of a pair of impressive shiners. The bridge of her nose was flattened and wide. She had normal occlusion.

She complained of pain in the left shoulder and was unable to lift that arm.

However, CT of her facial bones was markedly abnormal. Her maxillary sinuses were full of blood, as were her ethmoids. She had fractures through both alveolar ridges and through the pterygoid plates. She had almost powdered her nasal bone.

Willie Mae had a LeFort II fracture:

LeFort complexes. These are complex bilateral fractures associated with a large unstable fragment ("floating face") and invariably involve the pterygoid plates. Legend has it that LeFort dropped skulls off of a French tavern roof and analyzed the resulting fracture patterns. This certainly sounds like the kind of study that we would all like to do, even without NIH funding. In reality, LeFort studied fracture patterns produced in cadavers. He found three main planes of "weakness" in the face, which correspond to where fractures often occur: the transmaxillary plane, the subzygomatic or pyramidal plane (this is really two planes with an apex up at the bridge of the nose), and a craniofacial plane.

The LeFort I, or transmaxillary fracture runs between the maxillary floor and the orbital floor. It may involve the medial and lateral walls of the maxillary sinuses and invariably involves the pterygoid processes of the sphenoid. Clinically, the floating fragment will be the lower maxilla with the maxillary teeth.

The LeFort II occurs along yet another weak zone in the face, and is sometimes called a pyramidal fracture because of its shape. A common mechanism is a downward blow to the nasal area.

The most severe of the classic LeFort fracture complexes is the LeFort III. I suppose that this is pretty obvious, given a three-part grading system. In this case, the large unstable (floating) fragment is virtually the entire face! Thus, this fracture is also referred to as craniofacial disassociation. This is a very severe injury, and is often associated with significant injury to many of the soft tissue structures along the fracture lines. Generally, considerable force is necessary to produce this injury, and it is uncommon as an isolated injury. It may also occur in association with severe skull and brain injuries.

With the exception of the LeFort I injury, "pure" LeFort injuries are not commonly seen. More commonly seen are variants of the LeFort classification. One of the most common of these is the LeFort II - tripod fracture complex. This complex is usually due to the large forces encountered in a motor vehicle accident. LeFort was probably unable to apply this much force to the cadaver faces in his study, and it is therefore not too mysterious why he didn't describe these more complex injuries. When describing these injuries, one should probably give a separate diagnosis to each half of the face. Even more complex patterns may be encountered, such as a mixed LeFort II/LeFort III complex or a LeFort III/LeFort II/tripod complex.
From Facial and Mandibular Fractures

She also had a proximal humerus fracture:


Gravity was her enemy.