August 8, 2011

Collateral Damage

Nicasio's Neck

by Corey Dawkins and Ben Lindbergh

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Juan Nicasio, COL (Neck surgery—C1 fracture) [AGL: TBD, ATD: TBD] (Explanation)

Even though catastrophic injuries don't happen often in baseball, they aren’t unheard of. The line drive that rocketed off Ian Desmond's bat struck Nicasio on the right side of the head before ricocheting towards the first base dugout. It appeared that Nicasio very briefly lost consciousness, but we can't be completely sure. In that brief instant, Nicasio collapsed, with his head hitting the ground at the top of his forehead. That caused an axial load similar to those warned about with spearing in football and likely caused the fracture to the first vertebrae in his spine. The fracture could also have resulted from the quick rotation of the neck and head after the ball struck his head, although that’s less likely.

There are seven cervical (neck) bones in the spine, and Nicasio injured C1, known as the atlas, which was displaced from its anatomical position. C1 is a ring that sits on C2 allowing stable rotation of the head on the spine and can best be visualized here. Even though he suffered the fracture and ended up having surgery—we'll discuss this later on—he was extremely lucky, given the potential consequences of a fracture this high in his neck. With any axial loading of the head/neck, there is an increased risk of fractures and/or spinal cord injuries. When the injuries to the spinal cord are above C5, the nerves innervating the diaphragm can become compromised and lead to difficulty breathing, which is the leading cause of death associated with spinal cord injuries.

Rockies head athletic trainer Keith Dugger briefed everyone about the events that transpired, including the surgery. We saw that the ball struck Nicasio on the right side of his head, and Dugger thought he was unconscious  as he was going to the ground (but couldn’t be sure). By the time Dugger reached Nicasio, Nicasio was alert and able to communicate that his neck hurt. At that time, the emergency protocol was initiated. Every precaution was taken in spine boarding and transporting Nicasio to the hospital, where a CT scan revealed the C1 fracture. In addition to the fractured spine, he also suffered a skull fracture. Every option was discussed with Nicasio before he decided to have surgery without delay to give him the best chance of a full recovery.

During the surgical procedure, two screws and a plate were placed into Nicasio’s neck to stabilize the area. The hardware is incredibly small, and since it is so close to the spinal cord, that's a risky surgery in and of itself. There is no record of a MLB pitcher requiring this surgery from a C1 fracture, so the long-term prognosis is unknown. Any time a plate and screws are inserted, motion will be limited at that segment. It's unclear how this will affect his mechanics, if at all.

It’s probably pure speculation, but the doctors and Dugger felt the absolute best-case scenario would call for Nicasio to return in time for spring training.

Jose Reyes, NYN (Left hamstring strain) [AGL: 4 (27DL), ATD: -.018 (-.008DL)]
It's no secret that Reyes has had his fair share of lower extremity injuries, so any inkling of leg troubles gets everyone concerned. On Sunday, he was removed in the second inning with a left hamstring strain, although there was no clear injury during the game. We later found out that he felt the hamstring pull as he ran down the line in the first inning. This is the same hamstring that put him on the disabled list earlier in July, causing him to miss 16 games. Back in July, there was some doubt about whether he would placed on the disabled list at all, and the Mets aren't giving a clear indication one way or the other at this point either. Hamstrings are more prone to injuries than the quadriceps because of the muscle imbalances and also the two-joint nature of the muscle group. Throw in a history of hamstring strains—some severe—and the resultant scar tissue increases the chances of injury even more. The Mets did not release the results of an MRI last night, but those results will certainly give us an idea of the true severity of the injury.

Daniel Murphy, NYM (Left knee MCL sprain) [AGL: 24, ATD: -.001]
About four innings after losing Reyes, the Mets had to conjure up another middle infielder out of thin air after Murphy went down with a left leg injury. Jose Constanza was bearing down on him during a stolen base attempt when Constanza slid into Murphy's lower leg. Murphy was basically unable to put any weight down on it and had to be helped off the field. Murphy missed almost all of 2010 with a sprained MCL in his right knee, and a recurrence could certainly be a possibility. The replay shows how awkwardly his knee bent, and reports say it's a grade II sprain, which ends Murphy's promising season.

Ike Davis, NYM (Left ankle sprain and bone bruise) [AGL: 29, ATD: -.003]
After a follow-up visit on Friday, it appears that the bone bruise has shown minimal improvement, and Davis will back off rehabilitation for a month. If it does not show significant improvement by then, he will reportedly undergo microfracture surgery. Regardless of whether he has surgery, it’s unlikely that he’ll play again in 2011, since it will be the beginning of September before he’s even able to begin baseball activities. The cartilage damage is supposedly not to a large area, but depending on the exact location, even small areas of damage can lead to a lot of problems. Microfracture surgery in the ankle is no different than microfracture surgery in the knee and still requires a lengthy rehab for the fibrous clot to form and become a smooth cartilage-like surface. It looks like Davis' season is probably over at this point.

Jair Jurrjens, ATL (Right knee inflammation) [AGL: 28, ATD: -.063]
Jurrjens was placed on the disabled list with right knee inflammation following Saturday's game. This is the same knee that has pained him over his last four starts, and also the same knee that required surgery last year for a torn meniscus. He and Atlanta's staff both came to the conclusion that this would not improve without a break, and so a move to the disabled list was made.

It is uncommon to have soreness this far out from trimming out a torn meniscus, so this should really be considered a new injury. Whether it resulted from altered biomechanics or something entirely unrelated, this certainly isn’t the usual post-surgical soreness. It doesn't sound like Jurrjens will miss much more than the minimum, but it remains to be seen how the knee will react after being injured for the second season in a row.

Chase Headley, SDN (Left pinkie finger fracture) [AGL: 6 (30DL), ATD: -.011 (-.052DL)]
Headley has dealt with several nagging injuries over the course of the season, and the list of injuries now includes the left little finger he fractured on Saturday. Headley was trying to steal second base in the first inning when he slid headfirst and—accordingto Headley—bent the finger backward. He taped it up and continued playing, so the fracture does not appear to be a major one, although it was confirmed by a CT scan after the game. Fractures to the fingers don’t automatically result in trips to the disabled list, especially when there is no displacement, but that option always remains a possibility.

Alex Cobb, TBA (Right hand numbness) [AGL: 5 (TBD DL), ATD: -.002 (TBD DL)]*
Despite several tests, there is no clear reason at this point why Cobb has numbness in his middle finger. The possibilities generally include cervical disc injury, entrapment of a peripheral nerve, blood clots, or thoracic outlet syndrome. Most of these would show up on various exams, and Cobb was indeed checked for clots Saturday after the game. He first felt a dead-arm sensation after his July 30th appearance that wasn't isolated to his hand, as it involved his whole arm.  The only guarantee that we have until we determine the root cause of his symptoms is that he will be out until at least August 22nd, the first day he is eligible to return.

*The AGL and ATD are for day-to-day injuries only. The other cases of numbness in a pitcher’s hand or fingers were caused by other things and classified as such. Once the reason for Cobb's numbness is determined, the AGL and ATD will be updated.

Flesh Wounds: Wandy Rodriguez is dealing with a stiff neck and may be skipped this time through the rotation... Cesar Izturis, fresh off the disabled list, strained his left groin yesterday and will undergo more tests to determine the severity of the injury... Craig Breslow is dealing with tightness in his shoulder and was unavailable yesterday... Jed Lowrie is to be activated today after doing well on his rehabilitation assignment... Alex Presley will begin his rehabilitation in Florida and prepare for a subsequent assignment... Yonder Alonso hurt his right ankle by stepping on a sprinkler head. Apparently, the game has not changed too much since the days of Mickey Mantle... Chris Heisey was placed on the disabled list with a strained left oblique, and teammate Miguel Cairo was dealing with soreness in his oblique as well... Zach Britton was placed on the disabled list with a left shoulder strain after originally feeling pain over a month ago... Chris Denorfia was placed on the disabled list with a right hamstring strain... J.J. Hardy's left ankle still is bothering him, but a CT scan was negative. He's day-to-day… Brandon Phillips was diagnosed with a right ankle sprain Saturday after colliding with Drew Stubbs and is also day-to-day...Ryan Spilborghs was placed on the disabled list with plantar fasciitis and Enerio Del Rosario was placed on the disabled list for a right shoulder strain.

Roy Oswalt and Carlos Gonzalez were both activated over the weekend... Brad Hawpe had Tommy John surgery on his left elbow. He was officially on the disabled list for a right finger strain, but his elbow was clearly the bigger problem... Placido Polanco is falling apart in front of our eyes. He's been dealing with left hip soreness for about a month and has not been actively treating it. He's going to have an MRI of the hip to determine the extent of the injury... Teammate Joe Blanton will see Dr. Andrews today for his elbow impingement, with surgery being a real possibility... Mike Cameron sprained his left wrist on Friday but came in on Saturday as a pinch-hitter... Nate McLouth will miss about six weeks after suffering a sports hernia surgery... Derrek Lee is still dealing with a left hand contusion after being plunked in Wednesday's game. This far out from the injury, the concern for a small fracture increases... Hanley Ramirez isn't sure when he will be back, because he is not getting his motion back as quickly as he expected. It's not something that just happens overnight, either...Adrian Beltre aggravated his hamstring injury while running the bases on Saturday and is expected to miss another three weeks... Victor Martinez sprained his left knee on Saturday while trying to avoid being tagged out at the plate. It looked bad, considering he wouldn't put any weight on it, but it started to feel better immediately, and he may not miss too much time... Carlos Beltran sprained his right wrist yesterday and is day-to-day, according to the Giants.

Corey Dawkins is an author of Baseball Prospectus. Follow @CoreyDawkinsBP
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Ben Lindbergh is an author of Baseball Prospectus. Follow @benlindbergh
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