PALATE CLEANSER 1: Zorro and Ankle Fracture

BELIEVABILITY IS WHAT COUNTS

I never thought I'd be able to write a post that mentions Terminator Salvation and Zorro, The Gay Blade in the same sentence, but here we are. What could these two movies possibly have in common? Ankle fracture, sort of.

As was discussed in a previous post, in Terminator Salvation, giant robots are manually dumping humans into "transport vehicles" (who talks like that?). Once released from the grip of the robot, those people are falling from a height significant enough(1) to cause one of two types of fracture-dislocation of the foot; either Pott's fracture, Dupuytren's fracture, or any variation thereof.

Here's an x-ray of Dupuytren's fracture a.k.a Paratrooper's fracture. You can see the way the foot bones have been driven up, between the two bones of the lower leg. As a point of interest, any dislocation is also going to involve sprain because ligaments will be torn.

Terminator Salvation's relationship to ankle fracture is that of missed opportunity. A little hobbling and deformity on the part of a minor character would have given this film about machines and cybernetic organisms taking over the world a lot more credibility. Too bad. It's really the little things in explosive, apocalyptic, science fiction movies that can make or break them.

How does this relate to Zorro, the Gay Blade? Here's the quick plot synopsis from Anonymous at the IMDb site: "In 1840's Mexico, wealthy landowner Don Diego Vega adopts the persona of his late father's secret identity as Zorro, the masked folk hero. But when Vega is incapacitated by an injury, he asks Ramon, his very gay, long lost twin brother (now calling himself 'Bunny'), to replace him as the caped hero, who makes some drastic changes his Zorro persona." That Anonymous sure can write. For a more complete story, see Wikipedia.

The key phrase here is "incapacitated by an injury." Diego(George Hamilton), disguised as Zorro, attends a costume ball, flirts with the ladies, angers the bad guy, gets in a fight and (through a little slapstick comedy) stumbles backward off of a balcony, to land on his feet, at the edge of a fountain, injuring his ankle. He hops to his horse and rides home.

Zorro, before the fall.

At home, Diego accurately cares for his acute injury with R.I.C.E. therapy(2). We see a shot of his foot. It is puffy and bruised. Now I'm no doctor (I watch one on TV), but for that amount of swelling and ecchymosis, I'm willing to bet Diego has at least a 2nd degree ankle sprain(3), or possible 3rd degree sprain, perhaps with fracture of the fibula or medial malleolus (lateral and medial ankle bones).

I couldn't find an image from the film of Diego's injured foot, but it looked quite like this.

In one of his finest acting moments, George Hamilton, who has been hobbling about and wincing in a most convincing way, is confronted Captain Esteban (Ron Leibman) who suspects his identity. Esteban tells Diego that Zorro escaped, but his ankle is "sprained, possibly fractured." Diego, to prove that he is not Zorro, dances and hops about on his injured foot, trying to disguise his acute pain from Diego. The ruse works and Diego leaves. It's actually funny if you think about the additional damage he would be doing to an injury like that. He would probably pass out from the pain.

I don't know if it was Hal Dresner, Johnston McCulley, or one of the other writers who decided to use this device, but it works well. Orthopedists watching the film probably pee their pants with laughter.

ONWARD

I am putting together cyborg research. If anyone would like to suggest any films featuring cyborgs (not androids, clones, or robots) beyond the usual suspects of the Terminator series, Robocop (a misnamed film if ever there was one), Star Trek: First Contact, Cyborg, Universal Soldier, or I, Robot(4), please do.

1. In the movie it seems that they are being dropped into these cages from a height of 12-15 feet onto a solid floor.

2. Rest, Ice, Compression, Elevation.

3. A sprain is the over-stretching, or tearing of a ligament. In a 2nd degree sprain, as much as 99% of a ligaments fibers can be torn. For more on sprains and R.I.C.E. therapy visit the Merck Manual Online.

4. Will Smith's character qualifies as a cyborg because of his prosthetic arm and its capabilities.

TERMINATOR SALVATION - Spoiler Alert #4

MARCUS' HEART

The dialogue of the film reminds us on occasion of Marcus' heart. Blair (Moon Bloodgood, Rowr!) mentions it beating strongly when she seductively snuggles up to him and lays her head on Marcus' chest. Connor tells Marcus he sees his "heart beating a mile a minute." However we never see it directly, only through Terminator-vision at the end of a fight, so we don't know it's a human heart. Marcus' metallic skeleton at his chest is exposed but his heart is never visible to us.

Marcus' naughty parts

Here's a picture of Marcus' skeleton that I got off of Rotten Tomatoes. You can see that Marcus either has an organic heart encased in that metal skeleton, or perhaps he doesn't have a heart at all. Maybe the machines gave him some kind of mechanical pump that only sounds like a heart in case he has to snuggle with a human female.

Everyone mentions his heart. We all get it. Marcus has a strong heart. It's robust, can pump blood through an organism made of a combination of organic and manufactured materials, and is the symbol of his emotions, values, and humanity. Marcus' heart is the key to the final action, his redemption, and John Connor's life (so that there can be another movie -- spoiler alert #4.5!). The way the film works this material is both irritating and entertaining.

MARCUS TO THE RESCUE

In the factory during the final big action scene, Connor defribillates Marcus with industrial cables not because he is a being of value, but because Connor can use him as a weapon against a Terminator. Connor needs a weapon, and Marcus is it. But before the revived Marcus can stop it, the Terminator shoves a pipe through Connor's chest, where his heart would be if he had one(1). That is a great moment! It's shot really well, the welling blood suits their palette, and the action is well timed. Marcus then saves Connor and helps get him back to the base.

Getting to the 'copter

YOU KNOW THORAX

Back at base, Connor is dying because "his heart is too weak." Really? That's it? How about a collapsed lung, massive loss of blood, perhaps a sucking chest wound, fractured ribs splintering into everything, and insane amounts of bleeding around the mediastinum?

Below are some pictures of the chest. The mediastinum is essentially the area between the lungs, housing the heart in the "pericardial cavity". The lungs, heart, and other tubes are partitioned off from one another by sheets of connective tissue, sometimes referred to as membranes.

Mediastinum, anterior view

Here we see the heart and its vessels nestled in the mediastinum, between the lungs.

Mediastinum, cross cut

This is similar to an aerial view. The sternum is at the top of the picture, the vertebral column at the bottom, center. We see the lungs (right and left) and many of their blood vessels. We also see the top of the heart and the vessels from the lungs leading into the heart (in blue... yes, blue); these are essentially located within the borders of the mediastinum.

If bleeding happens within a partitioned area, the membranous walls keep blood from going everywhere. If one lung collapses due to blood in the chest (hemothorax[2]), the other lung can function because the blood won't leak into its space unless these partitions are compromised.

Hemothorax

After Marcus rescues him, Connor seems to be able to breathe and is not hacking up blood loogies, so the pipe and splintered ribs have obviously not pierced his lungs or their cavity (the plural cavity for you trivia buffs). His breathing would be pretty labored if he had a hemothorax or pneumothorax(3) situation. So what the heck happened? What is the scenario to fit the shot of the pipe emerging from Connor's chest, with all that blood welling up?

The only thing we can assume is there is bleeding (and swelling) around Connor's heart, causing compression to its chambers. This is called cardiac tamponade(4). The pressure from the blood build-up would reduce the amount of blood that could get into the heart, reducing cardiac output. To compensate, the heart would have to beat faster to try and get enough blood around the body. This condition would indeed weaken and exhaust the heart. This is the only condition I could possibly come up with to support the action and the script. I'd be curious to know what the writers were thinking...

Here's an illustration of cardiac tamponade from a World War II surgical manual. It's comforting to know that traumatic injuries suffered in the 20th century will still be around well into the 21st century...

Cardiac Tamponade

I LEFT MY HEART IN SAN FRANCISCO...OR WAS IT L.A?

So, Marcus tells them to take his heart and transplant it into Connor's body. It is Marcus' chance to redeem his criminal life and sacrifice himself for a higher cause. What does Marcus get from Connor for his heart? A curt nod. No "thank you" or, "I guess you're human after all" or anything. Obviously Connor will never need a penis transplant. He's a big enough one as it is.

Then they perform transplant surgery out of doors under a netted camouflage tent. Grit and dust aren't sterile. There is a lot of bacteria in dirt, you know. As an example, anthrax bacteria can live in dirt for years and years. Wind can blow all sorts of bacteria into a wound. They should also do some blood and tissue typing before wasting Marcus' heart, if he even has one. If Connor doesn't die of infection, he may die of tissue rejection(5), which means... no sequel!

Anthrax Bacteria (the rod-shaped things)

CYBORGS AT LARGE

Thinking about Marcus (only professionally, of course) as the first human-based cyborg to show up in a Terminator film, I started thinking about cyborg films, generally. Expect the next entries to be an exploration of the meat/metal interface.

1. Connor's character is so self-centered! Let's face it, if I grew up with a mother who taught me to use firearms and told me I was destined to be the savior of the world, I'd be pretty stuck up, too.

2. Hemo = blood, thorax = chest. Put it all together, and there you have it.

3. Pneumo = air. I sense a pattern. Pneumothorax might happen if the chest wall and/or lung was punctured. As Connor struggled to breathe, air could get into the space around the lung, collapsing it.

4. Tamponade can refer to both the accumulation of blood around the heart or "the act of using a tampon." Thank you, Taber's Cyclopedic Medical Dictionary.

5. For more on transplantation feel free to peruse the Face/Off! entries from March of 2009.

TERMINATOR SALVATION - Spoiler Alert #3

The terminator that had Arnold Schwarzenegger's features before they were burned away. Note the sternal and costal pectoralis major fibers still clinging to the left chest and shoulder.

CANT' TAKE THE CREDIT FOR THIS ONE

My husband, the cartoonist, suggested that perhaps Governor Schwarzenegger was one of the unfortunates captured and experimented on by Skynet, in the early years. Despite his history of steroid use, the former Mr. Universe is a healthy specimen for his age. Obviously, humans trust their politicians more than they ought. The machines probably considered him an obvious choice when it came to making a human prototype.

TERMINATED BY THE TERMINATOR

Marcus has a big fight with the metallic core of a terminator that had the visage and physique of the governor of California. The "living tissue" doesn't last long on this particular Terminator. It is flayed off of him in an explosion. Marcus and the faceless Terminator are duking it out in the factory where the girl finds the power cells, by the by.

The Terminator punches Marcus in the chest with enough power to cause his human heart (encased in a metallic superstructure) to go into ventricular fibrillation. (I'm assuming his heart is fibrillating based on what happens next.) Marcus collapses, of course. Ventricular fibrillation is the cause of many massive deadly heart attacks in this country.

VF

Ventricular fibrillation essentially means that the muscle of the heart starts to quiver instead of contracting rhythmically. I believe I've read somewhere that severe trauma to cardiac muscle (such as a crushing blow to the chest) could cause VF. The cardiac muscle cells are still contracting, but the contractions are uncoordinated so blood can't be pushed out of the heart.

Connor is left to fight the Terminator alone. He tries, but the terminator is a Terminator, so it doesn't go well. In desperation, Connor goes to the still form of Marcus and tries to revive him. As is appropriate with ventricular fibrillation, Connor gives Marcus a "precordial thump ... (delivered with a clenched fist raised 10 to 30 cm [about 8 to 12 in.] above the sternum and brought down firmly)(1)."

Image of precordial thump technique from the great blog, Medgadget.com.

The precordial thump doesn't seem to work. No surprise since Marcus' heart is encased in super-hard metal, and Connor is a puny human, not the god he thinks he is. (More on the possible types of metal in a future post.) What is Connor to do? In true MacGyver fashion, he uses the materials at hand.

Connor pulls two electrical cables from the wall of the factory and uses them as a cyborg defibrillator. Ventricular fibrillation is treated by direct current defibrillation(2). We see this in moves all the time. For example, in Casino Royal, Vesper Lynd (Eva Green) defibrillates James Bond (Daniel Craig) after he's been poisoned by digitalis.

Connor gives Marcus a huge jolt of electricity from the cables. I admire this gimmick because it is exactly the kind of thing I might suggest for a movie of this type. Which is not to say that it would work, or that I understand anything about electricity. I'm not sure if Marcus' heart would have remained a lump of raw meat, or if Connor would be smelling barbecue.

If he was a normal person, Marcus' heart would have to be revived within 4-6 minutes in order to prevent brain damage from lack of blood and oxygen to his brain. We assume Connor makes the deadline, Marcus revives and saves the day. However, Marcus can't prevent the terminator from driving a big piece of metal through Connor's chest. The spike appears to penetrate from back to front, and emerges just next to the sternum around ribs 5 or 6.

Even with this wound, Connor can breathe and remain conscious. Here he is escaping to the helicopter with Marcus. He looks pretty good, doesn't he? Very alert, no palor, doesn't seem to be burbling blood...

Next time, ruminations about Marcus' heart.

1. Once again, my bedside Merck Manual, 16th Edition, p 524, comes in handy. Okay, it's not really bedside.

2. Sources vary on the amount of electricity needed to re-establish heart rhythm. According to Merck Online, a fibrillating patient is given a jolt of 120-300 joules. A really interesting article on the history of defibrillators describes an automatic emergency defibrillator as packing a 100 kilowatt punch in its charge, with a quick reverse current at the end. I went to Unitconversion.org to see if I could put joules and kilowatts in context for myself. I got confused trying to figure out volts, joules, watts, etc. I never watch an electrician on TV. I gave up trying to understand this stuff after about 15 minutes. Any help, anyone?

TERMINATOR SALVATION - Spoiler Alert #2

TWO CORTICES? Or is it cortexes...?

Apparently the cyborg, Marcus (the dreamiest cyborg yet!), has been given a "hybrid nervous system" as well as a metallic skeleton. According to dialogue, Marcus has a human cortex and a machine cortex in his brain. The cortex of the cerebrum is the outer, gray part. The cortex interprets and processes the sensory information coming into the brain, controls voluntary movements and functions in intellectual and emotional processing, including memory.

The cortex is called the cortex because it's the outermost part. Your adrenal glands have cortices, too. Guess where they are? Yup, they are the outer shell of the gland. So the conversation distracted me for a moment because I was trying to imagine how a brain has two outer casings. I wondered if they meant the extra "cortex" was labeled that way as a functional structure instead of an extra cap around Marcus' brain. Once I decided that was the case, I could keep moving with the film(1). The question remains as to whether the "control chip" placed at the back of Marcus' head is this second cortex.

Lobes of the Cerebrum

It does make sense that Marcus would have enhanced processing and voluntary motor control. Later, after I saw half his face taken off, I realized that he must have a metal skull. This would certainly help protect his brain from injury although injury from brain sloshing(2) would still be an issue. Perhaps the machines had invested Marcus' brain with so many fine, mesh-like wires that it would hold it in place during agitation. Let's face it: skipping across water like a stone, as Marcus does in the movie, would shake a non-augmented person's brain into a liquid bloody pulp. I get distracted by trivia like this. I think it's a sign I need to get out more...

An illustration of a contrecoup injury scenario. No big surprise, I found it on a site for a attorney's office.

FLAME RESISTANT HAIR

Has anyone noticed how characters in movies can survive the flaming backlash from an explosion with all their hair? It's maddening. Most people can't even get their locks within 6 inches of a candle flame. And yet 98%(3) of all movie characters retain their hair in the presence of fireballs.

Marcus (Sam Worthington) and Blair (Moon Bloodgood) have fire proof hair.

MACHINES DON'T WORRY ABOUT SAFETY STANDARDS

The girl, Star (Jadagrace), discovers a tray containing a number of nuclear fuel cells for the T800 series. I don't imagine that the machines have the same intolerance for radioactivity in the workplace as do people. Shouldn't someone pull that kid's pretty face away from a nuclear fuel cell before her skin bubbles away, or she's set up for cancer at an early age? Instead everyone goes over to stick their own faces next to the radiation, too. If John Connor is about to be a father, he better start thinking like one.

Star And The Gang

Next time, the big defibrillation scene!

1. I really had to resolve this issue! This is sooo important to my enjoyment of the film.

2. One of the (understandable) major oversights movies make is that a person can sustain a fatal brain injury even if their skull is intact. Acceleration/deceleration injuries can happen from violent shaking, striking the head, or if the head strikes something. The brain's axons and its blood vessels can get torn, leading to direct destruction, and damage from bleeding and swelling. A contrecoup injury means that the brain is damaged at the point of impact as well as the area opposite the point of impact. This happens because the brain is very liquidy and will "slosh" in the skull if forces permit.

3. These statistics cannot be verified because I made them up.

TERMINATOR SALVATION - Spoiler Alert #1

Being a science fiction fan and a lover of the first and second Terminator movies, I went to se Terminator Salvation with my screenwriter friend, Todd Alcott, who was in town for the weekend. I'll leave script analysis to the experts, but since I watch a doctor on TV, I consider myself fully qualified to probe the parameters of cyborg medicine.

Here's the basics of the plot from the Sony Pictures Official Website. My commentary is in italics:

"'Terminator Salvation' is set in post-apocalyptic 2018, where John Connor (Christian Bale - His character is a self-important jerk.) is the man fated to lead the human resistance against Skynet and its army of Terminators. But the future that Connor was raised to believe in is altered in part by the appearance of Marcus Wright (Sam Worthington - Yummy!), a stranger whose last memory is of being on death row. Connor must decide whether Marcus has been sent from the future, or rescued from the past (Connor doesn't care about Marcus' past. It's not an issue for him). As Skynet prepares its final onslaught ("Final" indeed!), Connor and Marcus both embark on an odyssey that takes them into the heart of Skynet's operations, where they uncover the terrible secret behind the possible annihilation of mankind. (Yes, there's a "secret", but it's established pretty early. "Possible" annihilation doesn't seem that exciting, does it?)

The movie has lots of good action, but lacks in plot. It's not entertaining enough to keep me from dwelling on trivia that wouldn't even get my notice on a better film. Like the dweeb that I am I took notes in the theater - for my blog, which makes me dweeb-concentrate. Today's entry covers the first entertaining distraction I encountered in the film.

Giant Robot

DROPPING PEOPLE INTO CAGES CAUSES INJURY - Don't try this at home!

Giant humanoid-shaped robots scoop people (like Jane Alexander) up in their mighty, bone crushing hands and drop them into cages on "human transport vehicles." The puny humans are dropped from a height of a minimum of 15 feet, to either land on other people (ouch!), or land on the floor of what looks like a cattle car. The citizens of the future have incredible righting reflexes and manage to land on their feet more often than not.

Human Transport Vehicle

Landing on one's feet from extreme height can result in a fracture-dislocation, where the lower bone of the ankle, the talus, is driven up between the two leg bones, the tibia and fibula. Usually there is some breakage of the fibula, and if you try hard enough, you can break your tibia, too! Depending on the direction of the force, the foot can also be displaced to the side(1). This type of injury is incredibly painful. Suddenly, a person with this type of fracture is a few inches shorter when standing on his broken foot, as compared to the healthy side.

Ankle Anatomy

Above is a picture of normal alignment between the tibia, fibula, and talus at the right ankle.

Here (below) is a dislocation-fracture of those bones. Notice the way the talus is now in between the bones of the lower leg. The fibula, on the left, is also broken but the break is not visible in this xray(2). Gruesome, isn't it?

Another variation can happen when the foot is displaced laterally (eversion) and the fibula is broken. This is called a Pott's fracture, pictured below. When comparing the two photos, be aware that the fibula is on the left side, and the tibia is on the right side in the xray above. In the illustration below, the fibula is on the right and the tibia is on the left. These are both right feet, but xrayed from the front and drawn from the back.

You'll notice that when the people are dumped out of the transport cars (in a scene vaguely reminiscent of Soylent Green with Charlton Heston) no one is limping, visibly in pain, or three inches shorter on one side because his foot has been shoved up his leg. Let's face it, Jane Alexander looks great but she is getting older, and she should be a little gimpy at this point in the film.

Is there more than ankle fracture to this movie? Oh yes! So much more! Next time, I write about Marcus' cybernetic brain, hair that will not burn, and child safety.

1. Dupuytren's fracture and Pott's fracture both present as variations on this scenario. I remember being told by a professor that one of these injuries is nicknamed "Paratrooper's fracture" because these types of injury are common if you land wrong when sky diving. This is, providing your parachute opens. If it didn't then you would really be "landing wrong!"

2. Xray is from the article by: Adla, Deepthi Nandan, Rachael Joanne Hutchinson, and Ian R. Scott. "An Unusual Fracture-Dislocation of the Ankle." Journal of Bone & Joint Surgery, American Volume 86.10 (Oct. 2004): 2287-2289.