Le Fort 2 fracture
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Bilateral orbital floor fractures, more prominent on the left. The left orbital floor fracture is associated with partial herniation of orbital floor contents through the bony defect, as well as a 3 mm step in the left inferior orbital rim. Loculated gas demonstrated within both orbits, as well as bilateral periorbital subcutaneous emphysema, worse on the right.
Comminuted, minimally displaced fracture of the right zygomatic arch. Comminuted, depressed fractures of anterior, medial and lateral walls of both maxillary sinuses. Comminuted nasal bone fractures, with nasal septal deviation to the right. Minimally displaced fracture of the right lateral pterygoid plate. Fluid levels within the left frontal, left sphenoid, most ethmoid air cells and within both maxillary sinuses.
No mandibular fracture. No base of skull fracture identified. Minimal frontal bone pneumatization, with no frontal bone fracture seen. Edentulous patient.
Complex bilateral orbital and facial fractures, and given the fractured right lateral pterygoid plate the right sided facial fractures can be classified as Le Fort 2.