one hit to the jaw…two injuries

Tuesday, April 8, 2014

It takes the blink of an eye for a fastball to travel the 60 feet 6 inches from pitches hand to home plate…literally, less than a half second for each. It takes instinct for the batter to decide whether to swing at a strike and survival to duck out of the way of a wayward pitch. Yesterday, a blink of an eye wasn’t fast enough for Omar Infante of the Kansas City Royals to get out of the way of an errant pitch that hit him in the jaw. The extent of the injuries are to be determined but there are concerns for a broken jaw and a concussion.

In boxing, the purpose of a cross or jab to the jaw is to inflict a concussion and a blow to jaw can aggressively rattle the brain. The jaw is semi-circular bone that attaches to the skull at the temporomandibular joint or TMJ. While the mandible or jaw bone is fixed, the TMJs move and can be felt just in front of the ear. The TMJ allows the mouth to open and close and do important things like chew. When hit in the jaw, the diagnosis of concussion may be very easy to make or it may be challenging. It is all about history and there is no specific test that can confirm or deny the diagnosis. A person who is knocked unconscious, even briefly, or is dazed and confused has obviously had his brain rattled. It is the person who has minimal initial symptoms that is the challenge. The symptoms of brain injury might be subtle and not be recognized for hours or days. It is hard to quantify difficulty with concentrating, being irritable or moody and having trouble with sleep. The best that medicine can do is image the brain looking for structural changes in the brain, perhaps with CT or MRI, but proving that a concussion does not exist is very difficult.

Deciding whether a jaw is broken is somewhat easier. Physical exam looks for tenderness or swelling along the mandible. It’s important to remember that the jaw forms a circle and like a pretzel, it’s hard to break in just one place. For that reason, if one fracture is present, another on the opposite side might be missed. The mandible also holds teeth in place and when broken there may be a sense that the teeth upper and lower don’t quite fit quiet right or are shifted. The inside of the mouth needs to be evaluated as well, looking for lacerations or damage to gum tissue or teeth. Feeling the TMJs is relatively easy because the can be palpated or felt in front of the ear. As well, a finger in the ear canal almost touches the joint. While fractures can occur near the TMJ, a blow to the jaw can cause damage within the joint. Bleeding or torn cartilage can cause significant swelling and pain preventing the jaw from opening appropriately.

While concussion may be tough to visualize, a jaw injury can be imaged in a variety of ways. Plain x-rays are sometimes done, but good pictures require the skill of a good x-ray tech and still may be difficult to interpret. A panorex is a curved x-ray that is often performed in a dentist or oral surgeon’s office that allows the whole jaw bone to be seen in one picture, a panorama type effect. Should plain films be less than helpful, the next method to look at the bone is by CT scan, but if it’s available, CT is often the first imaging choice for many doctors.

While the anatomy and function of the jaw can be determined with a few x-rays or scans, it’s the concussion that becomes the injury that will potentially sideline Mr. Infante for a prolonged period of time. The healing of broken bones can be monitored but concussions are different. Just as there is no specific test to confirm the presence of a concussion, there is no test that confirms when the brain is completely healed. Guidelines exist that can help decide when a person is ready to resume activity, but every brain is different and while one patient might take a few days to return to “normal”, it might take weeks or longer for another. It’s just another reminder that for all the technology available to inflict upon a patient, in some instances, the art of medicine remains less than precise.



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