broken jaws always come in pairs

Monday, August 17, 2015

That Geno Smith, Jets quarterback, broke his mandible in two places, is not a testament to the severity of the blow that struck him, but instead, a result of the physics and anatomy and design. There are many circles found throughout the human body and whether it is the mandible (jaw bone), the tibia and fibula (shin bone), the radius and ulna (forearm) or pelvis, it is tough to break a circle in just one spot. Just imagine breaking a pretzel.

Mr. Smith was in a locker room altercation when he was punched in the face and sustained a fractured mandible (jaw). Just to be clear with word, fractured and broken mean the same thing. The jaw is a common facial bone to break, second only to broken noses and the most common causes are motor vehicle crashes and altercations. Most people know that something is wrong almost immediately. Aside from the pain, there is a sense that the teeth don’t quite fit properly. The muscles that attach to the mandible, and allow us to open and close our mouths, shift the bone fragments and the lower teeth that are attached don’t quite align with the upper teeth in the maxilla. And as with any injury, swelling and spasm occurs gradually making it difficult to open the mouth. This is called trismus.

LatMandible Mandible-front-with-orientation-01

For the doctor, though, the important thing to remember is anatomy and physiology and how the body absorbs force. If there is one fracture found in the jaw, the search must happen for the second break. Most often, a fracture of the body of the jaw is associated with a fracture of the condyle on the opposite side. The condyle is the thin bone that connects the jaw to the skull.

Even before worrying about the broken bone, other issues need to be thought of. If there is enough bleeding and swelling, breathing can become an issue. Associated broken teeth or dentures can fall into the back of the throat, trachea or lung, obstructing the airway, so making certain breathing happens is always job one.

In boxing, the one goal of the sport is to inflict a concussion and knock out the opponent. If there is enough force to break the jaw, there is also enough potential force to cause a head injury or break a neck. With most trauma resuscitation, the obvious injuries are appreciated but take second stage to the injuries that are lethal or permanently disabling. Even if takes just a minute or two to consider what badness might occur, that time is invaluable in caring for the patient.

The diagnosis of a broken jaw is often made clinically by appreciating the swelling, pain and disfigurement that is associated with the broken jaw. X-ray and CT scan then confirm the location of the break. Sometimes special dental x-rays are required to assess damage to individual teeth and their roots, especially if the fracture line goes into the tooth socket and that might affect treatment options.

Treatment is almost always surgery to align the bone fragments, especially those that are teeth bearing. Some children or elderly patients without teeth may be spared the scalpel. The teeth must be aligned as perfectly as possible so that bite is maintained. Fractures that heal with poor alignment can cause wear and tear on the temporomandibular joint (TM joint). This is the joint where the mandible attaches to the temporal bone of the skull. Like any joint that is placed under stress; it can develop arthritis, inflammation and pain. There are many surgical options but often titanium plates are screwed in place across the fracture site to hold it in place. Not only does the fracture needs to be plated, but in some cases, the jaw needs to be wired shut s the bone heals.

The use of wiring depends upon the clinical situation, the stability of the fracture and the discretion of the surgeon. There are different wiring techniques but, in general, wires are tightened from the upper teeth to the low teeth preventing the jaw from moving and opening. Just like any other bone, a mandible fracture needs about 6-8 weeks to start to heal and that means the jaw will be wired shut for that long as well. There are exceptions, especially with condyle fractures, where the wires are kept in place for only a couple of weeks.

If the mandible fracture is an isolated injury, then there is little reason to limit activity. Geno Smith was seen playing catch shortly after surgery and for a football player that seems like a pretty reasonable thing to do… as long as he avoids helmets, pads and the risk of getting hit in the jaw again.

It goes without saying that when it comes to trauma, prevention is always the best treatment. From seatbelts to bicycle helmets, it’s what is done before the accident that can help minimize damage. Unfortunately, in Mr. Smith’s case, turning the other cheek didn’t quite work out.



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it’s just a sprain…not

Monday, August 12, 2013

It’s a common scenario in football. A player lay injured on the field while trainers run to his side, assess the injury and either allow the victim to hop up and hobble from the field, or wait for the stretcher to carry him away. The initial evaluation tends to be very conservative since nobody wants to complicate a potentially bad injury. It looked like Kansas City Chief running back, Jamaal Charles, might have had a significant foot injury when he was taken away, but x-rays were negative. This allowed his coach, Andy Reid, to proclaim that it was “just” a foot sprain. And New York Jets rookie quarterback, Geno Smith, was advised to deal with the pain of his ankle sprain, as his coach, Marty Mornhinweg told him: “don’t limp.”

While professional athletes are paid to abuse their bodies and to play through pain, in the real world, a normal x-ray does not equal the absence of injury. Cartilage lines joints, ligaments stabilize them, muscles and tendons attach into bone, arteries and nerves run nearby and all are targets for potential injury. One or all can be damaged even with normal x-rays. Pictures are just one way of assessing the potential for injury. History and physical exam are the keystones of diagnosis and the initial evaluation by the trainer on the field starts the process and perhaps is most important.

On the field, the player can usually describe the mechanism of injury, how his body was hit or twisted, and provide clues as to what injuries might lurk. The ability to examine the player immediately can find potential disasters, like dislocated joints or displaced fractures (remember that fracture, broken or cracked all mean the same thing) where arteries can be stretched and pulses lost. Examining a joint early, before the swelling sets in, may help decide whether a ligament is completely torn or just stretched. Sometimes a dislocated shoulder can be reduced or put back into place on the field before the surrounding muscles spasm.

When it comes to the neurologic system, the initial on field assessment is crucial. Head, neck and back injuries are not taken lightly. Any potential for neck or back fracture will lead to the player being immobilized on a stretcher with their neck in a collar. Power tools are helpful to remove face masks and specific techniques are used to remove the helmet without levering and moving the neck. The fear always exists that the player may have a neck fracture with a normal spinal cord, but manipulating the helmet and shoulder pads would cause the cord to kink, leading to a spinal cord injury.

Physical examination is an art form that is often all that is needed to make a diagnosis, however, the pro athlete is a special breed, who is often is excessively x-rayed, CT scanned and MRI’d to confirm the diagnosis. Identifying the extent of injury can help plan the length of rehabilitation and perhaps helps the general manager and coach more than the player. A player who cannot perform in the short term needs to be replaced for the team to succeed and the CT or MRI can help decide how long that short term might be.

A player will recover as his body allows. No matter how much physical therapy and rehabilitation, body parts need time to regenerate and heal. Muscle, tendon and ligament all heal by the body laying down collagen fibers and bridging the gap between the torn or stretched fibers. Surgery is performed to bring torn ends closer together, making it easier for those collagen fibers to bridge the gap but the time to return to play isn’t set in stone. Some people heal faster, some slower and the range is often measured in days and weeks, not hours.

For the weekend warrior or the person hurt at work or at home, there may not be the need for x-ray and CT with their associated cost in radiation and dollars. The goal of treatment will be the same as the elite athlete; returning to the level of function present before the injury. The physical therapy and exercises may follow the same plan as the elite athlete, but the difference is often frequency, duration and intensity. It is the pro athlete’s job to recover and they will devote hours each day to rehab. The regular person may do home exercises and see a physical therapist a couple of times a week. It’s likely that the pro would recover sooner.

The take home point for mere mortals and pro athletes is that just because it isn’t broken doesn’t mean that it isn’t hurt. Sprains and strains should be taken seriously. A torn knee ACL is a third degree sprain of that knee ligament and takes months to recover from surgery. LisFranc sprains of the foot can take months to heal, with or without surgery. Hamstring strains take weeks to recover.

Andy Reid and Marty Mornhinweg need to remember it’s never just a sprain.

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