Is it October yet? Part 2: Trent McCleary

This is the second in a series of posts looking at historic hockey injuries, intended to keep me busy and you interested while we wait for October to get here.

The history was provided by Jen aka @NHLhistorygirl. Jen is a librarian and graduate student at the University of North Dakota in the last stage of her MA in history: writing her thesis on the 1972 Summit Series, media, and notions of national identity.

 

Trent McCleary, huge frigging badass.

The history…

It’s a play we’ve seen hundreds of times: a player winds up for a shot, another player attempts to block it. The puck slides away, the players skate after it. No harm done. Every once in a while though, something goes wrong, and a player ends up bruised or needing a few stitches.

And in the case of Trent McCleary, it went horribly wrong.

On January 29, 2000, the Habs were playing the Flyers at the Molson Centre. Habs right wing Trent McCleary hadn’t logged much ice time (only 4:02) but he played aggressively. It was no surprise that he attempted to block defenceman Chris Therien’s shot.

The shot hit him directly in the throat, and McCleary fell to the ice, unable to breathe. He struggled on the ice for a few moments, then his instincts drove him to skate to the bench, where he tried to tell the trainer he couldn’t breathe before collapsing.

Not quite unconscious, McCleary’s throat was filling with blood and every breath became more difficult, causing him to thrash about frantically. His adrenaline level was so high that when Habs therapist Graham Rynbend tried to hold him down for examination, he threw Rynbend over the table.

When the doctor could not get a breathing tube down McCleary’s throat, he was then rushed to the hospital and directly to an operating table. McCleary had a collapsed right lung and a complex fracture of the larynx, two life-threatening injuries that required an emergency tracheotomy and putting him on a respirator.

Events happened so quickly that of none of McCleary’s equipment had been removed before emergency surgery. It was the first time the doctors had ever operated on someone still in skates. Had events not moved as quickly as they did, according to the surgeons, McCleary would have died. “It was a matter of seconds,” said Dr. Mulder.

Two days later, unable to speak, he wrote a note to his teammates (who were about to play the Hurricanes): “Doing well. Here’s $500 on the board for the win. I’ll be listening. Battle Hard. Go Habs. Trent no. 6”

After three surgeries and months of therapy, McCleary was able to regain his voice and resume a normal life. However, the tracheotomy site formed enough scar tissue to reduce his breathing capacity, and he was forced to retire.

 

The medicine…

Every patient assessment algorithm begins with the ABCs – airway, breathing, and circulation. If one of these elements is compromised, you can’t proceed until you’ve fixed it. McCleary’s injury brought the assessment algorithm to a screeching halt at A. When Therien’s shot hit him in the throat, it fractured his larynx, and almost completely occluded his airway. Without A, there’s no B. Without B, C quickly stops.

The Larynx

Bonus pro tip: Don’t pronounce this lair-nix. That’s wrong, and you’ll sound stupid. It’s lair-inks.

The larynx is a complicated combination of cartilage, muscles, and ligaments that sits just below the base of the tongue. It forms the topmost segment of the trachea (windpipe), and protects the vocal cords. It’s also an invaluable player on the airway team with a limited no-trade clause. With very, very few exceptions, you can’t live without it.

 

So THAT's where my larynx is!

 

What you know as your Adam’s apple is actually the front of your thyroid cartilage. Just below that you’ll feel a little gap, which is the cricothyroid membrane. That’s of huge significance in an injury like McCleary’s, as it’s an easily identified way of getting into the airway in a hurry.

 

The Larynx: It doesn't want to go to Edmonton either.

 

When Trent McCleary took a puck in the throat and fractured his larynx (i.e. the cartilage), two things immediately happened: He started bleeding, and he started swelling. The only method of getting air to his lungs was rapidly filling up with things air doesn’t like to go through. McCleary had the presence of mind to get up and move towards the bench, and with assistance made it off the ice before he collapsed. We have to assume that he was moving some air, as the brain won’t last longer than 4-6 minutes without it, and McCleary suffered no brain injury as a result of this incident.

A is for airway

McCleary was moved to the dressing room where team doctor David Mulder (a cardiothoracic surgeon) and trainer Graham Rynbend very quickly began trying to establish an airway. The usual way of doing so is intubation – sticking a plastic tube into the trachea (through the larynx) to provide a secure way of ventilating the patient. McCleary’s fractured larynx, along with swelling and bleeding, made tube placement impossible. Worse yet, the injury meant that the tissues of McCleary’s neck were beginning to fill with air that was leaking from his damaged trachea. This is called subcutaneous emphysema (if you’re a professional), or rice krispies (if you’re a paramedic or ER doc) because it really feels like there’s a layer of them under the skin.

With no way to intubate McCleary and what was left of his airway rapidly disappearing, some sources state Dr. Mulder performed a needle cricothyroidotomy with the assistance of Dr. David Fleizser, a surgeon who was a spectator at the game. Remember that little gap below your Adam’s apple? That’s the cricothyroid membrane, and a needle cric (say it like crikey without the y) involves punching through it with a big needle to provide a (very) temporary way of getting air into the lungs. The needle used is generally 14 gauge, which is about 2mm wide. To put it into perspective, 2mm is REALLY DAMN SMALL. Smaller than a drinking straw. The information we have doesn’t tell us if they stopped at the needle cric, or if they widened it to accomodate a larger tube. We do know that McCleary arrived at the emergency room 17 minutes after the puck hit his throat, and was immediately taken to the OR.

Dr. Mulder performed an emergency tracheotomy, a common surgical procedure that involves cutting a hole into the trachea at the base of the neck between the cartilage rings (which you can see in the figure above). The trach saved McCleary’s life by providing him with a way to get air past the horrendous damage in his throat. The A portion of the ABCs was complete.

B is for Breathing

Somewhere along the way, Trent McCleary also suffered a collapsed lung (pneumothorax). Pneumothoraces can happen in any number of ways – blunt trauma, penetrating trauma, and even spontaneously. McCleary’s pneumothorax could well have been a consequence of the air escaping his mangled larynx looking for places to go. The basic premise is that instead of filling the lung, air fills the cavity between the lung and the chest wall, keeping the lung from inflating and preventing proper ventilation. Keep in mind also that throughout this ordeal, McCleary was being aggressively ventilated, with air being forced into his mouth and nose by way of a BVM (bag-valve mask, or ‘bag’ – you’ve seen it on ER, and they’re always using it completely wrong).

Note the arrow pointing at the edge of the collapsed lung (which is conspicuously nowhere near where it should be)

A pneumothorax is a condition that can quickly become fatal. It’s not hard to figure out that if you fill your chest cavity with air, the heart and lungs end up getting shoved out of the way. Much as the brain is touchy about getting pushed around, the heart and lungs aren’t fans of it either. Your breathing suffers, your heart can’t fill or pump efficiently, and organs that need oxygen stop getting it.

Dr. Mulder inserted a thoracostomy tube (what you and I have lovingly come to know as a chest tube), which allows trapped air to escape the chest cavity and the lungs to reinflate. The tracheostomy was a more permanent answer to the B of the ABCs, and the chest tube ensured that the C of the ABCs wasn’t compromised.

The Aftermath

Once McCleary’s airway had been re-established, he was still left with the problem of a badly damaged larynx. He spent a few days on a ventilator, which is not surprising considering the extensive swelling and damage to his airway. It also takes practice to learn how to breathe with a trach, and patients who are intubated and on a vent usually take a little time to transition back to breathing on their own.

Several surgeries were required to repair the fracture (most likely with wire sutures), and his voice was restored with the final procedure (yes, you can suture vocal cords). Over the course of his recovery McCleary received his nutrition first by way of TPN, or total parenteral nutrition – essentially a solution of fat, glucose, amino acids and vitamins that’s administered via IV. He eventually graduated to a small-bore (narrow) feeding tube that was placed through his nose into his stomach. In time the tube was removed, as was the trach.

McCleary attempted a comeback with the Habs the next season, but scarring had narrowed his airway by approximately 15% and he found himself so out of breath that he couldn’t complete a shift.

Things I don’t believe:

In an incredibly boring video featuring Swift Current’s 5 most fascinating people of 2009, McCleary says that Mulder dislocated his jaw in his attempts to establish an airway. The way you open the airway of a patient who may have a spinal injury is by using a jaw thrust – placing the thumbs behind the angle of the lower jaw and pulling it forwards. This serves to straighten out the airway, making intubation easier, and limits movement of the c-spine. There’s plenty of yapping about whether or not this actually results in a jaw dislocation. All I can offer is that in 11 years of performing this maneuver, I’ve never dislocated a jaw (nor heard of one being dislocated). A search of the literature yielded very little on the topic, suggesting that mandibular dislocation isn’t entirely uncommon, but is generally seen in patients under general anesthesia. So is it possible? Sure. Do I think it happened? No, probably not. It takes a lot of force to dislocate someone’s jaw, especially if they’re not sedated. Does it matter? No. McCleary is fine now, and Drs. Mulder and Fleiszer and Mr. Rynbend are total badasses.

Speaking of badasses…

Note Trent McLeary’s gigantic cojones as he gets up and skates off the ice with a shattered throat. Absolutely amazing. Most of the credit in this situation probably needs to go to McLeary for getting up and getting help. Had he stayed on the ice and waited for the medical staff, his outcome might not have been as good as it was.

Enjoy a trip back to 2000 with this truly terrible quality video:

Kesler: Terrible hip pun available on request.

The Vancouver Canucks announced today that interview-bombing center Ryan Kesler has had a successful repair on his hip labrum. Kesler is no stranger to hip injuries, having had a labrum repair once already in 2007. Frantic googling and help from @ArtemChubarov via @BotchonCanucks seems to indicate that the repair in 2007 was on the right hip, and today’s procedure was on the left.

 

What’s a hip labrum?

Back it up. First let’s look at how the hip is built. The hip joint is a ball-and-socket joint, which is exactly what it sounds like. There’s a socket on the side of the pelvis, and a ball on top of the femur (thigh bone) that fits in there. The femoral head (the ball) and the acetabulum (the socket) are both covered in cartilage. The cartilage provides cushioning as well as allowing the bones to articulate – bone on bone doesn’t slide too well (and hurts like a bitch). In addition to the articular cartilage of the bones that make up the hip joint, there’s a ring of fibrous cartilage around the outside of the acetabulum (that’s the labrum) that adds to the stability of the hip joint. The labrum deepens the socket, provides extra surface area to spread out the load the hip is carrying, and essentially provides a seal around the joint that keeps the femoral head in place (with help from a whole lot of ligaments).

 

The hip joint

 

So how do you tear your labrum?

Labral tears are common in sports with a lot of hip flexion (that’s the motion you get when you pull your leg up to your chest), external rotation (rotation of the leg so the toes point out) and twisting (duh). The usual culprits are hockey, soccer, dance (not a sport, I don’t care what the IOC says) and golf (the twistiest of the twisty sports).

 

Oh look, hip flexion.

 

How do I know if I’ve torn my labrum?

The most common symptom of a torn labrum is hip pain – most often in the front of the hip. There can also be limitation of range of motion of the joint, as well as joint weakness, clicking, catching and locking. Frequently labral tears go undiagnosed for a while (typically as much as two years), as the symptoms can be very non-specific and there’s usually not one particular incident that the patient can identify as the cause of the injury.

When Kesler had his hip problem in 2007, he was having issues with joint stiffness and locking, and was said to have been unable to walk up a flight of stairs prior to his repair. This time the Canucks revealed after the playoffs ended that he’d been playing with a hip injury sustained in game 5 of the series with the Sharks. Kesler had been trying to avoid surgery with therapy, but team management and medical staff decided that a repair now was better than compounding problems later.

The diagnosis is usually made with an MRI, although in 2007 Kesler’s hip was diagnosed with an MRI arthrogram – where dye is injected into the joint.

 

So how do you fix a labrum?

The definitive treatment is surgery, and there are several options. Depending on the extent of the damage, it could be as simple as an outpatient arthroscopy (little cameras poked through little holes) to trim off the torn cartilage. Other options would be a repair using sutures or other anchoring devices (similar to what we saw in Huselius’ pectoral repair). The worst case scenario involves damage to the articular cartilage, and not just the labrum. In that case, there could be a need for what’s called microfracture surgery – where small holes are drilled in the bone underlying the cartilage, stimulating the growth of new cartilage. Microfracture requires no weightbearing for 6 to 8 weeks after the procedure, and 4 to 6 months before a return to play can even be contemplated. The worst WORST case scenario would be a total hip replacement.

 

Torn labrum

 

In the picture above you can just see the smooth femoral head on the left, and the labrum hanging off the acetabulum (which the probe is hooked around). This is bad.

 

What’s ahead for Kesler?

It takes about 4 to 6 weeks for the repaired cartilage to really re-attach to acetabulum. Generally you’d be looking at anywhere from an 8 week to 6 month recovery time, but Kesler came back in only 10 weeks last time (only to break his finger 3 days later). The earliest you could reasonably expect him to be back would likely be mid to late October.

It’s also a safe assumption that Kesler’s injury and surgery won’t be keeping him from his finely-honed interview bombing techniques.