Jack Reacher versus a gang of prison inmates… 1 vs 5? The odds are definitely in Reacher’s favour–
Reacher is an intimidating presence… In the novels he stands about 6 foot 5 inches and weighs 250
lbs. He’s a retired Military Police Officer with years of real world experience and training under
his belt, and in the new Amazon adaptation, Alan Ritchson is well suited (and sized) for the role.
If it were anyone else facing down 5 angry inmates (some of them armed), I might be worried for them.
But Reacher is anything but average, and these guys are in for a rude awakening.
The leader of the gang motions for all the men in the bathroom to leave… Cocky move. He seems
very sure of himself. But when Jack Reacher starts counting, his opponents start dropping like flies…
Okay, Jack– pause right there! [speaking to Jack]
Thank you so much for giving me so many opportunities to talk
about blunt force facial trauma. You are a friend of medical educators everywhere.
Whether it be a headbut, a jab, a backhand, a forehand, a kick or an industrial-steel
prison bathroom sink, a blow to the bridge of the nose is problematic for many reasons:
This type blow can cause significant facial trauma whose extent depends on
the amount of force used in the blow and the type of object used to strike with.
In this case Reacher strikes two different inmates in the same area, one with his forehead,
and the other with his fist. In the case of the headbutt, the forehead is a broad surface
that is quite hard so the force of impact is spread out over a larger area. The impact would
involve the bridge of the nose, but would also involve the cheeks or maxillae, the nose itself,
and possibly also the orbitals bilaterally. In the case of the right cross, the fist presents
a much smaller striking surface, so the impact would be more concentrated. Consequently, I
would anticipate the zone of injury to be smaller correlating with the smaller striking surface,
although the constellation of injuries associated with the punch would be similar to that seen
with the head butt. A study has shown that the average impact velocity for a headbutt, 4.7 m/s,
is considerably less than that of a punch, 12 m/s. So, a typical headbutt is not likely to lead
to life-threatening injuries, but bony injuries of the face such as those described, can easily
occur. Under certain circumstances potentially lethal injuries could also occur. However,
the lethality of a given strike ultimately depends on what was used to strike the head,
how hard the strike was delivered, and where the strike landed. Facial fractures, if present, would
be stabilized with open reduction and internal fixation using contoured stabilization plates
inserted through incisions whose location would be determined by the particular fracture pattern.
An uppercut is also troublesome, though the resultant injuries differ slightly:
In this case, with the blow angled upward
rather than directly to the face, the jaw or the mandible is the primary point of impact.
If delivered with enough force, the mandible would be fractured. However, a dislocation of the jaw,
of which there are four types, might also occur. The types of dislocation that could be associated
with a powerful uppercut include posterior, superior, and lateral dislocations, with the names
describing the respective directions in which the jaw could travel after being struck. Although
these dislocations are potentially rare, the superior dislocation in particular is significant
for its potential for injury to the facial and vestibulocochlear nerves and the temporal lobe
as a result of the superior migration of the condyle into the middle cranial fossa. Ouch!
Now, Jack… If you don’t mind continuing the demonstration. Can
you show us all what happens to people who approach you wielding a weapon?
Thank you, Jack. An excellent demonstration of the relative softness of the eyeball compared
to the bones of the face. It looks like your thumb has entered that man's eye socket up to
the level of the Metacarpophalangeal joint– You’ve got fairly large hands
so I think it’s safe to assume at least a couple inches of penetration. Now just as
I explained in my last video explaining the shot glass attack in the Equalizer,
this henchman is probably going to lose his eye. No doubt about it.
Here, REacher’s thumb causes a blunt force injury to the globe. This is very likely to
cause a rupture of the globe, since it is really difficult for the henchman’s
eyeball and Reacher’s thumb to occupy the space available in the orbit at the same time otherwise.
A rupture of the globe can be caused by a laceration of the globe, or by blunt force,
such as with Reacher’s thumb. Patients presenting with a ruptured globe typically have
decreased vision which is not really good for remaining fight-worthy.
The eyeball itself is often visibly distorted, and the pupil may be shaped like a teardrop.
Occasionally, fluid will leak from the eye whicH I am pretty much guaranteeing here.
Excessive bleeding under the conjunctiva, the thin mucous membrane that covers the cornea,
can also be a symptom of a ruptured globe. Laceration to the globe requires immediate
evaluation by an ophthalmologist. CT is typically performed to confirm the diagnosis, and to rule
out the presence of any foreign material inside the eye or the presence of any further damage
around the eye. However, even after all possible medical and surgical treatment has been performed,
serious eyeball laceration or globe rupture may still result in partial or total loss of vision.
Great, but what if that isn’t enough to incapacitate your attacker? Would you
mind demonstrating some other techniques one might apply to more robust opponents?
Impacts like this to the spine and back of the neck would be sufficient to:
cause significant injuries to the back and the head. Blunt force trauma to the back
is a fantastic way to break ribs, fracture the scapulae on the back of the chest wall,
and injure intra-thoracic organs such as the lungs (pneumothorax,
hemothorax, or pneumohemotherorax). It is also possible to fracture a vertebral
spine or the posterior aspect of the skull when being thrown against a concrete wall.
With an impact that is caused by a whipping motion, there is the real possibility of a
skull fracture at the back of the skull or occiput. This could be an isolated injury,
but more than likely would be associated with a closed head injury as well. This could be
simply a concussion that would be caused by the impact of the brain on the back of the skull,
of it more serious would be a brain contusion. If the damage is more severe, it might occur
with bleeding inside, or around the outside of the brain. These different kind of bleeds could
cause increased pressure within the skull and consequent compression of the brain. With enough
pressure on the brain over a long enough period, permanent brain damage or even death could occur.
But the leader of the gang is tenacious and follows up with a couple blows of his own.
In a prison fight, anything goes. And this swift kick to the family jewels stunned our
gang leader long enough for Jack to work some magic on his arm: With this injury,
Reacher bends the head henchman’s arm over his knee at the elbow.
Not really a problem, you say. Except that it is not designed to bend sideways…at the elbow.
The elbow is a hinge joint whose primary plane of movement is in the sagittal plane. It has robust
ligaments, the collateral ligaments, that prevent sideways opening either medially or laterally.
However, even these collateral ligaments can be overcome by the might of a 6’5” angry ex-marine
warrant officer. This injury mechanism would cause a complete or near complete circular disruption of
capsuloligamentous stabilizers starting with the lateral collateral ligament or LCL first,
and working around the capsule to the medial collateral ligament or MCL. This would result
is gross instability of the elbow, which would make it difficult for said henchman to use his
shank-holding arm. And with Jack Reacher, that is a problem that you don’t want to have.
Now remember what I just said about back injuries? To
my eyes, these two impacts are a little more intense than the previous one;
a 300 style front kick, and then a cross-the-room back into the wall slam: A Leinidis kick to the
chest can easily result in an injury to the sternum or the breast bone. The sternum is a
structure that connects the anterior ribs to one another in a semi-rigid manner to create
a flexible cage in which the heart, lungs, and major vessel are contained. The ribs are connected
to the sternum by cartilage articulations at sternocostal joints, and the sternum is
stabilized between the ribs by its attachment to the clavicles, at the two sternoclavicular joints
above. Dislocation of the sternum would require failure of several of the articulations, either
at the sternocostal joints, the sternoclavicular joints, or both. With an impact from the front,
we would anticipate that the sternum would be dislocated posteriorly, or in other words, pushed
backwards into the chest. The mediastinum is the space that is located in the middle of the chest,
behind the sternum. The mediastinum contains the heart, aorta, esophagus, thymus, trachea,
lymph nodes and some nerves. Dislocation of the sternum is generally not desirable, and if severe,
can cause injury to any one of the structures located behind it. This would be bad, so generally
I advise people not to get kicked…correction, heel stomped in the chest. Combine this with the blunt
force trauma caused by being punted into the wall, and I suspect that this henchman will have serious
trouble breathing for an extended period of time. And in case you didn’t get enough of the back
smash from earlier in the scene, Reacher demonstrates it again with another henchman.
Jack
continues smashing faces…
Hm, more blunt force facial trauma– obviously effective approach Jack,
but perhaps for the sake of medical education you could give us something different?
Excellent, pause right there. That’s the kind of stuff we
need– In depth explanation of heel step leg snap. Here Reacher stomps on a henchman’s lower leg
just above the level of the ankle. Of course, since the knee and the ankle are hinge joints,
they can’t really accommodate sideways bending…in the middle of the tibial
shaft. This leaves the tibial shaft alone to resist the bending force applied to it.
If you’ve watched this channel long enough, you will know that bones are great in compression,
but that they suck in rotation and don’t fare too well in bending.
This injury mechanism would result in a fracture of the tibia at the junction of the middle and
distal thirds. This would be expected to be a transverse fracture of the tibial shaft
with an associated fracture of the distal fibula. If the baddie
were fortunate this would be a closed injury, but if his luck were otherwise engaged, which
if you are fighting Jack Reacher likely is, it would be an open fracture where the bone
fragments had perforated the soft tissue envelope and become exposed to the external environment.
Open fractures, would carry an added risk of infection,
and would be more likely to be delayed in healing. But whether open or closed,
this fracture would require operative stabilization in a surgical setting.
Generally, there are three ways to fix a lower extremity fracture surgically. An external
fixator, plate fixation, or an intramedullary nail. An external fixator is a frame that is
placed outside the leg and attached to the leg with pins to stabilize the fracture externally.
It is typically only used for temporary fixation and is usually replaced by internal fixation when
the leg is more amenable to repair. Plate fixation is a form of internal fixation that may be used
for definitive, or permanent, fixation. It is applied at the fracture site directly through
a formal incision and spans the fracture site on the surface of the bone. It is secured with
a number of screws above and below the level of the fracture. Intramedullary nail fixation is
another type of internal fixation that may be selected for definitive fixation. It is
inserted away from the fracture site through the knee, but spans the fracture site within
the bone. It is secured with a number of screws above and below the level of the fracture. Here,
if the fracture is very close to the level of the ankle, a plate will be used. However,
if the fracture is sufficiently distant to the ankle joint an intramedullary nail will be used
for fixation. I suppose that is one way to get a break from day to day prison life.
Okay, that about wraps up today’s class. Thanks again to our guest
educator, Jack reacher. Let me know in the comments what you’d like me to react to next.