Here's Bergeron, clearly not suffering at all.

Here’s Bergeron clearly not suffering at all.

Teams are always cagey about injuries during the playoffs, but Boston took it to entirely new heights this year when they revealed that Patrice Bergeron had a body injury. Not upper body, not lower body, just body. The injury turned out to be multiple upper body injuries (a broken rib, torn cartilage, a separated shoulder, and a pneumothorax) none of which could be considered minimal by any standards, and none of which prevented him from finishing the series.

Cartilage! Ribs!

The fun started in game four when Bergeron tore cartilage in his chest on a check from Michael Frolik. He then left game five in the second period, due to what was later revealed was a broken rib and concerns for a spleen inury. The cartilage in your chest has an important job, namely holding your ribs onto your sternum. The cartilage is highlighted in red below to point out just how heinous the pain is when you tear it. Generally people with costochondral injuries (costo = rib, chondral = pertaining to cartilage) sit very still, breathe very shallowly, and try not to do anything that would move their chest in any way. Try that. It’s impossible. What do you do for the injury? Nothing. Seriously, nothing. You wait it out, you take pain pills, and you suffer.

The red parts hurt when you rip them.

The red parts hurt when you rip them.

 

It was his spleen! Just kidding, it wasn’t his spleen.

The Bruins were worried enough about Bergeron’s pain to take him out of game five after six minutes for a visit to a Chicago hospital to ensure that his rib fracture and the trauma that caused it hadn’t affected any of the important bits that live under the ribs – namely the spleen. The spleen, as you may recall from Peter Forsberg’s experience in the 2001 playoffs is an important little organ that filters out and recycles old blood cells, so of course it has a massive blood supply. In blunt trauma it’s the most often injured organ, and it can kill you in a hurry when it bleeds. Wisely the team elected to get Bergeron to a hospital for further evaluation when he skated off the ice with pain to the left side of his chest. Obviously his spleen was fine, because he was released and flew home with the team. That hospital visit kicked off speculation about what exactly Bergeron’s injury was. Anything from spleen to kidney stones to concussion, but he was kept day-to-day by the team, so at that point it seemed clear at least that it wasn’t a life threat.

 

This wasn't Bergeron's problem (sorry, Kypreos).

This handsome little fellow wasn’t Bergeron’s problem (sorry, Kypreos).

 

Game six really, really hurt!

Before game six, Bergeron had an intercostal block for the pain from his broken rib. A needle is inserted under the rib in question, and anesthetic is injected. It works quickly, and reducing the pain makes it easier to move and breathe. The theory has been floated that the nerve block is what could have caused Bergeron’s pneumothorax, which is a collection of air between the lung and the chest wall. The problem with that theory is that it’s likely incredibly wrong. The needle used to do the block is a small one, and the rate of pneumothorax after intercostal block is about 1% for each nerve blocked. Not to mention Bergeron has said he had a chest x-ray after the initial block that was normal, and he didn’t start to have problems until the third period.

 

It's so tiny and cute!

It’s so tiny and cute!

 

The other theory is that Bergeron’s broken rib poked a hole in his lung. I’d like to call bullshit on that as well. While a pneumothorax can absolutely be caused by rib fractures (and they frequently are), a broken rib would have to be really, really broken to punch a hole in a lung. So broken that the ends don’t line up. So broken that if anyone saw that on an x-ray there’s no way Bergeron would be playing, Stanley Cup or not. And again, Bergeron himself has said that he didn’t start getting short of breath until after game six – well after the initial rib fracture which happened in game five. The term “punctured lung” is getting thrown around a lot, which is problematic because it implies that Bergeron’s lung had a huge, gaping hole in it. Huge gaping holes in lungs tend to cause something called a tension pneumothorax, which is quickly deadly. Air gets into the space between the lung and the chest with every breath, and it can’t get out. This causes tension on the lung, heart, and all the important chest things, causing them to shift away from the pneumo as it gets bigger. That quickly leads to a heart that can’t pump, lungs that can’t fill, and death. The treatment is to let the air out of the chest via a pleural decompression (sticking a big needle in there to drain it) followed by a chest tube – a big tube inserted between the ribs that keeps that air from getting back in, and drains any blood or other fluid that might have accumulated. Eric Lindros ended up with a chest tube after a pulmonary contusion led to a hemothorax, which is the same as a pneumothorax except blood is filling the space instead of air.

 

Tension pneumothorax: Bad, bad, bad.

Tension pneumothorax: Bad, bad, bad.

 

Not a tension pneumothorax, but still bad.

Not a tension pneumothorax, but still bad.

 

A simple (non-tension) pneumothorax is air between the lung and the chest wall. It’s fairly common in blunt chest trauma, and often pneumothoraces that are a result of non-penetrating chest trauma happen with no rib fracture at all. The mechanism is thought to be that the sudden increase in pressure in the lung from compression of the chest during the hit blows out some alveoli (the tiny little chambers at the ends of the airways where gas exchange happens), causing an air leak. If the patient is healthy, has stable vital signs, the pneumothorax isn’t getting bigger, and it isn’t huge to begin with, it can be treated with observation and supportive care alone. If those conditions aren’t met, then the chest tube comes back into play. In Bergeron’s case, his pneumo ended up being big enough to buy him a chest tube. He had a second nerve block during the second period of game six, and after the game began feeling short of breath. X-rays at TD Garden were inconclusive, which I’ll interpret as meaning he didn’t have a huge tension pneumo that was shoving his heart over onto the wrong side of his chest.  He was taken to Mass General Hospital where they found out his lung had “collapsed” (another misleading term I hate) and he had the chest tube placed. The chest tube you usually get when you’re acutely dying from a tension pneumothorax tends to be the size of a thumb, and gets forcefully shoved between the ribs after a hole is sliced in the chest wall with a scalpel. The chest tube you get in a more controlled setting for a simple pneumothorax is likely to be a pigtail catheter, which not only has an adorable name, but is small, flexible, and doesn’t require giant holes or fingers being poked inside your chest. Considering Bergeron is out of the hospital after three days, didn’t require surgery, and is saying he’ll be ready for training camp would seem to indicate he won the chest tube lottery with a pigtail (which is still a truly crappy prize).

Fun pneumothorax side note: A spontaneous pneumothorax is a different beast than what we’re talking about with Bergeron. That’s a pneumothorax that happens spontaneously (whoever named this really nailed it), usually in tall slim young men or people with COPD or other lung pathology. It’s non-traumatic, and is a result of problems with the lung tissue itself as opposed to damage from outside forces. It’s quite similar to traumatic pneumothoraces in that it also sucks hard.

 

Oh yeah, the shoulder too.

Torn cartilage, broken rib, pneumothorax, no Stanley Cup, and a shoulder separation to cap it all off. In the first period of game six, Bergeron fell on his right shoulder and separated it. According to him, he fell awkwardly because he was trying to protect the broken rib on his left side. A shoulder separation, also known as an acromioclavicular or AC separation is when the end of the clavicle (collar bone) is pulled away from the acromion, which is the part of the scapula (shoulder blade) that makes up the front part of the shoulder. Most commonly AC separations are just simple sprains involving stretching of the ligaments that hold the two bones together, and don’t require anything more than standard rehab – antiinflammatories, physiotherapy, and not doing anything to aggravate it.

 

Those parts outlined in blue shouldn't be that far apart.

Those parts outlined in blue shouldn’t be that far apart.

 

Disclaimer!

Is it possible that the second intercostal block caused the pneumothorax? Sure. Is it likely? No. Is it possible his rib poked a hole in his lung? Sure. Is it likely? No. Is it possible he had a tiny pneumo that slowly developed into a big pneumo as a result of the nerve block/second nerve block/broken rib/any number of hits to the chest area/a fall that didn’t start to really bother him until after the game? Sure. But I don’t know. I wasn’t there. All of this is speculation, but generally speaking a pneumo from a nerve block is rare, and a pneumo from a rib lacerating a lung is serious enough that you don’t get out of the hospital after three days.

 

“Playing through it”

As usual there’s been plenty of squawking about how careless it was to let Bergeron play with these injuries. I can easily argue either side. I’m a notorious bleeding heart. It kills me to see players lose their careers over preventable injuries, and I hate seeing players on the ice that aren’t 100% healthy. I’m also a realist in that I know you can’t force a competent adult to do something they don’t want to do. So while the Bruins could have shut Bergeron down, they no doubt had on their hands a player who was telling them the pain isn’t that bad, just give me a shot and I’ll be fine. It’s not like they knew he was going to develop a pneumothorax, or separate his shoulder. On the other hand, the NHL is badly broken in terms of weighing out player safety versus the importance of GOING FOR IT. That’s a huge discussion we’ve had a million times before, and will continue to have until something changes. Hopefully it will be a policy change before it’s a catastrophic injury.