Monday, December 16, 2013
The violence that is football does not exempt any player on the field. The crushing block on Cincinnati Bengal punter, Kevin Huber, is a reminder that even helmets and pads may not adequately protect the body. Mr. Huber ay on the field for more than a few minutes before walking off the field with blood soaked gauze in his mouth. The initial injury report was of a broken jaw and only later was it found that he also broke a vertebra in his neck. There are lessons to be learned from his injuries. The first is that mandible fractures (a broken jaw) tend to happen in pairs and the second is that a broken neck does not equal a spinal cord injury.
The mandible is a semicircular bone that attaches to the temporal bone of the skull. When hit, the bone tends to break (fracture and crack mean the same thing) at the site of the blow, but another fracture often occurs on the opposite side. It is the same physics principle that makes it tough to break a pretzel in only one place. Understanding the way force is transmitted helps diagnosing where other injuries might exist. Mandible fractures often occur in the weakest and thinnest part of the bone, where the teeth are located and the subcondylar area, just beneath where the mandible attaches to the skull.
The diagnosis is often made clinically. Aside from pain, all broken bones hurt, the patient may complain that their bite is off, their teeth don’t fit right or that they cannot fully open their mouth. Often, the fracture causes the gum or the lining of the mouth to tear and bleeding may occur.
The treatment of a mandible fracture depends where the bone is broken and whether the teeth alignment is affected. Oral surgeons are the doctors who deal with repairing the bone and aligning the teeth. Plain x-rays including a panorex (think a panorama pic of the jaw) and CT may be done to visualize any or all breaks. Restorative dentistry may be needed if teeth are lost are broken, but the goal is to end up with a jaw that works, teeth that chew and a nice cosmetic result.
The second lesson that comes from being hit in the jaw is that other structures in the head and neck can be affected. In boxing, the goal is to knock out the opponent, effectively causing a concussion. For that reason, a concussion should be suspected with any blow to the face. Similarly, the head swivels on the neck and if there is enough force to fracture the mandible, there may be enough force to fracture a vertebra or bone in the neck. Once again broken bones hurt and relatively quickly, the muscles that help support the neck go into spasm. For that reason, it is important to consider a neck fracture with any head injury. The spinal cord may not be damaged initially, but if the neck injury is not stable, there is potential that the spinal cord can be put at risk.
Some neck (cervical spine) injuries are stable and need no more than a stiff collar to provide support and pain control, but most often, a neurosurgeon is involved in reviewing the situation, either directly, or by reviewing x-rays and CT scans. Not too long ago, Jermichael Finley of the Green Bay Packers lay on the field with a spinal cord contusion. The cervical spine was not fractured but the cord was injured, the reverse situation for Mr. Huber. It is a reminder that the diagnosis of a patient requires both high touch and high tech. Radiology needs history and physical exam to accurately assess a patient.
While Mr. Huber has been placed on injury reserve ending his season, the good news is that the prognosis is positive for him to play again next season. The bad news is that Christmas dinner may be a little difficult to chew.
Image attribution: rad.washington.edu
This entry was tagged broken jaw, concussion, Kevin Huber, mandible fracture, neck fracture, vertebra
Dr. Wedro weighs in
“The difference between doctors who look after mere mortals and those who look after elite athletes may have to do with how many tests they can order, regardless of the cost.”