My ship: USS Independence CV-62 (now retired)
When I was in the Navy, we had pithy expressions for just about everything.
“That makes as much sense as a screen door on a submarine.” (self-explanatory)
“I want you guys to make this place shine like a diamond in a goat’s ass.” (Really clean this place up!)
“That (machine) is tits up.” (That means a device is broken or “dead.”)
“Are we gonna go ugly-early? Or are we gonna drink’em pretty tonight?”
Colorful stuff! 🙂
Join the Navy… See the world… Piss people off… and get your ass kicked
In the dental clinics, we’d occasionally get sailors the day after a night out on the town suffering from “Two Dudes Syndrome.” 
Broken teeth. Avulsed teeth. Lacerated lips. Even the occasional fractured mandible. The story was the same, every time. “I was walking down the street… minding my own business… and these TWO DUDES JUMPED ME from out of nowhere!”
They always denied instigating anything. They were always innocent. One guy told me 30 guys jumped him. I figured he was lucky to be alive. 😉 In reality, most just didn’t want to admit they got their asses kicked (by one guy).
Meanwhile in the civilian sector…
On Sunday, I got a call via my emergency phone number. New patient found me with a web search. The girlfriend called on his behalf. He had been in an altercation in the wee hours of Sunday morning (out Saturday night). A tooth was knocked out. He found it and went to the ER. They put the tooth back in. (I reassured her that was a good thing.) But, was still in a lot of pain.
I generally don’t go into the office after hours for strangers I’ve never seen as patients before. So, I told her to call the office first thing in the morning (Monday) and we’ll get a look at him. I told her we may need to stabilize the tooth to let it heal, and it might need a root canal. In many cases the tooth can be saved.
Sure enough she called back in the morning, and we got him in as the first patient. The tooth that was avulsed was #24. And, oddly enough it was located / crowded to the lingual of the other anterior teeth. So, how on Earth does a lower tooth that’s crowded out to the LINGUAL get knocked out in a fight? Maybe his teeth slammed together in a funny way? Weird.
Nothing good happens after midnight
Oh… it was two dudes that did this to him. No kidding. At 5:00 am on Sunday morning after a night of partying. Two dudes jumped him for “no reason.” I later learned he previously served in the Army, not that it means anything. 🙂 But, he and his girlfriend actually seemed quite nice.
He reported that his whole jaw hurts. Hmmm… I palpated the TMJ areas… “How about here?” Nope. He pointed to the angle of the mandible and then swept forward to his chin, “It hurts everywhere.” I asked him to open. He managed to open about an inch and winces in pain. That was as far as he could open. I observed ecchymosis on the floor of his mouth in the anterior area. Hmmmm… Let’s get a panoramic x-ray.
See anything? It’s not on the left (L) side by the wizzie. That’s an artifact.
The size and format of the image is small, so let’s zoom in.
Patient’s right side. See anything here?
Patient’s left side. How about here? Ouch!
Two fractures. One at the right angle of the mandible. The other in the left body of the mandible diagonally extending to the midline. No wonder he’s in pain! He must have taken a heck of a shot!
My new theory of how the lingually crowded #24 came out: It squirted out like a grape seed when the mandible fractured in that area.
I called my oral surgeon down the street. Turns out the patient has no insurance and no money, so he suggested he return to the E.R. I later found out from there, he went to the V.A. hospital. And, from there he was sent to the V.A. in Miami. He’s scheduled for surgery later this week.
Some day, I hope those two dudes retire.
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Ha! When I was in residency we used to get all kinds of inner-city patients with a similar story…”I was just sittin’ on my porch watchin’ the cars go by when the bullet hit me!” Crazy how that happens!
There were similar presentations I’ve seen when working in a prison. I would never want to be incarcerated, if for no other reason than it seems like those folks are the most prone to fall in the shower, trip on the stairs or fall in the yard and incur a Lefort I, bilateral ZMC fx’s and bilateral symphysis fractures! Watch that last step…it’s a doosie!
Another salient point is that the ER apparently didn’t take a radiograph, or did and it wasn’t read by the radiologist (after hours? No T1 connection?) -OR- they simply dismissed it to, “just a tooth knocked loose,” and thus not important to overall systemic health. Good pickup on your part…if you find one fracture, keep looking! There’ll be more!
Thanks for your comments, Sherman. I found two fractures in this case. I believe the dark line on the left angle is an artifact. But, two fractures for sure.
According to the patient, they did not take any x-rays at the ER.
Sorry…that didn’t read right. I was complimenting you on diagnosing both!
A surgeon when I was in residency told me once that the, “ring,” shaped or, “u-shaped,” bones like the pelvic girdle and the mandible rarely fracture in only one area, due to the direction of the initial (impact) force. There is almost always a contralateral fracture…he called this, “the pretzel phenomenon,” in that it is damn near impossible to break a pretzel in only one place. Any kind of displacement, by definition, causes more than one fracture. I logged that one away and have seen it many times since.
Makes sense, when you rewind back to the Physics courses, and think about where the mandible goes during and following impact.
Would you mind if I use your radiograph and case presentation to show this to my residents?
“Pretzel phenomenon.” That’s a great metaphor.
Feel free to use this with your residents. 🙂
And the ER…my office is attached to a Level III hospital. I see A TON of patients from the ER both there and in the office. I can say with a clear conscience and honest heart that the observation/knowledge of odontogenic and jaw/oral and peri-oral tissues stops at the nares, and reconvenes at the tonsillar pillars. Almost anything that goes on, “in there,” is dental territory. The ER Docs HATE dealing with anything that we deal with regularly. Ordering a pan or head/neck CT (for fascial space infections or fractures) is as foreign to them as podiatry is to us. It sounds silly, as toothaches and odontogenic infections were the primary cause of death in many people not too many years ago, and still is in the 3rd world. It still qualifies as an emergency, yet the ER’s (at least in my experience) are horribly suited to treat them.