BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 3. - Jaw problems
RADIO 4
TUESDAY 23/05/06 2100-2130
PRESENTER:
MARK PORTER
CONTRIBUTORS:
IAIN HUTCHINSON
ROBERT JAGGER
NAHEEM ALI
PETER BRENNAN
PRODUCER:
ERIKA WRIGHT
NOT CHECKED AS BROADCAST
MORGAN-ELPHICK
I couldn't eat properly, I'd never eaten an apple as everyone else eats it, I couldn't eat crusty bread. My bottom jaw, I could bring that over my top jaw and the jaw could meet with the nose and touch. So I just couldn't bite into things normally, I'd have to cut my food up really, really small. My lisp had become more marked. I looked a bit like the comic moon face - like the crescent moon shape with an awfully big nose where people used to make fun of me, call me anteater, call me Concorde.
My face was extremely long.
PORTER
Sue Morgan-Elphick talking about her abnormally shaped jaw - a problem that required a drastic solution.
MORGAN-ELPHICK
The surgery was quite intensive. He folded back the top layer of my face, broke the bones from below my eye sockets downwards, didn't touch the bottom jaw but all the bones in the face were broken and rebuilt. They used bone from my hip plus titanium plates - I've got six titanium plates and screws in my face. The surgery took about six hours. Eighteen hours after surgery I'd had a few wires removed from me, even though I looked like something off Planet of the Apes I could see the change in my face. My nose is smaller and my face had reduced in length by - it must have been at least two inches. Now it's quite ironic, I look more like my parents now after surgery than I did before. Now I feel like the true me.
PORTER
More about that type of surgery later in today's programme, which is all about the jaw, and a wide range of problems associated with it - from tooth grinding and facial pain, to fractures and cancer. My guest today is Mr Iain Hutchinson, he's a maxillofacial surgeon at the Bart's and London Hospitals. And he runs the facial surgery research charity - Saving Faces.
Now I suppose we should start with some basic anatomy.
HUTCHINSON
Right. Well the jaw is a unique bone in the body, you look at it and if you look at it on an x-ray its shape is bizarre - it has two right angles at the end leading up to the jaw joint and then a horizontal piece that joins on to that. It's got teeth in it, which again makes it unique. So actually most bones have a joint at either end, the jaw bone has the joints at either end but in addition it has this infinite number of joints between the teeth. So if people bite their teeth together a lot then they start rocking their jaw joints and get inflammation of their jaw joints, get pain in the jaw joints and get pains in the muscles around the jaw joint - these very, very powerful closing muscles, the masticatory muscles - and so they get this very, very common problem of jaw joint pain and muscle pain around it associated with periods of stress. There have been studies which suggest that at least three quarters of the population may get jaw joint symptoms at some stage in their life, those symptoms may only last for a day and it may be that they just can't open their jaw, for some inexplicable reason they can't open their jaw, which settles down.
PORTER
Because it is a slightly unusual joint in its shape as well, because it's not just a straightforward hinge is it.
HUTCHINSON
No, it's got a disc in the middle of it, a bit like a knee joint. And part of the problem is that the disc is attached to a muscle and if we start using that muscle abnormally it pulls the disc out of position and then you can get problems with the disc flicking in and out of position and not protecting the head of the jaw. And so what that means is that the patient gets pain because the jaw - the head of the jaw is contacting with the socket in which it's meant to lie without the protection of the disc of cartilage between. And also that disc can lock out of position permanently or it can flick in and out so it makes noises - clicking - which can be very loud, so some people ...
PORTER
It's right next to the ear of course.
HUTCHINSON
Yeah and some people get these noises that are so huge that interfere with their social contacts, so people when they're eating they hear this great big loud crunching noises coming from their jaw joint which upsets them.
PORTER
We talk about function there but of course it's not just about function, it's an important part of the face too.
HUTCHINSON
Yeah, I mean of course facial skin is very important, we'd be lost without it, but really if you look at the face it's a bit like a sofa - you've got the facial skin, which is the sofa cover, but underneath you've got the skeleton of a sofa which describes the appearance of the face. So if you have a jaw that's abnormal in shape or not present your face looks absolutely ridiculous because it's the kind of scaffold under which the facial skin is draped. And your facial skin can be perfect, it can be peach like, but if your jaw is the wrong shape you'll look very odd indeed.
PORTER
And by wrong - we're talking about this a little bit later on - but are we talking a jaw that's too small or too big or can you get asymmetry of the jaw?
HUTCHINSON
Well you can get all three, and of course we've got names for them haven't we - we've got lantern jaw, we've got the people who are regarded as being thugs because their jaw is too big, they may not be violent at all or the people who are regarded as being thick or weak because their jaw's too small. Actually ...
PORTER
The chinless wonder.
HUTCHINSON
The chinless wonder - exactly, exactly. And of course also if you have a very small jaw that means your tongue is forced back into your throat which means it can interfere with your breathing which leads on to the problem of - which is now given a flashy title - obstructive sleep apnoea but basically snoring but that can actually be quite a serious problem, it can actually impeded the airway so you can't breathe properly and can't eat properly.
PORTER
Well we'll come back to jaw positional problems later if we may. First of all, I want to go back to tooth grinding that you mentioned there. It's generally the sort of problem that's more likely to be picked up by a dentist than a GP like me. Robert Jagger is a consultant and senior lecturer at the University of Bristol's Department of Oral and Dental Science, and I caught up with him during a busy afternoon clinic to find out more.
JAGGER
Bruxism is a term that's used to describe the habitual clenching or pressing of the teeth, it's very, very common, as many as 20% of people are believed to clench their teeth habitually during the day, approximately 14% of people clench or grind the teeth during the night. The results of bruxing and clenching the teeth and grinding the teeth are widespread, it can result in muscle pain in the face, it can result in muscle contraction headaches, it can also cause damage to the teeth in the form of wear of the incisal or biting surface of the teeth, splitting of the teeth, breaking of fillings, breaking of dentures and displacement of temporary crowns and bridges. So the consequences are many.
PORTER
And is it related to any other underlying problems, is it more common in people who are anxious for instance?
JAGGER
Anxiety's been closely associated with the disorder and the daytime clenching is one we've described as a parafunction or a purposeless movement that's believed to be similar to nail biting. The cause of the nocturnal grinding is actually unknown, it's believed to be a sleep disorder that people are born with, the bruxism is more common amongst children and tends to reduce with age.
PORTER
What harm can we come to?
JAGGER
Well there are lots of ways that grinding can express itself, most commonly perhaps is facial pain, what we call tempromandibular disorder but also very commonly is loss of the surface of the tooth and even leads to tooth loss on many occasions.
PORTER
So once you've identified somebody as having a problem with bruxism at night, let's say, what can we do to help them?
JAGGER
The most important thing is probably the provision of a night guard or a bite splint. This is a plastic appliance which can be placed between the teeth so that any wear occurs on the plastic rather than on the enamel itself.
PORTER
And this is essentially a gum shield is it?
JAGGER
Yes.
PORTER
But how does that stop the clenching of the muscles and the facial pain and the headache?
JAGGER
It doesn't stop the clenching in all people, it can help in some people but what it will do is to reduce the tooth surface loss and it is possible that the facial pain will be reduced, possibly because the force of the contraction will be reduced as well.
PORTER
And, as fortune would have it, one of the people in the clinic waiting room had come back for a check-up after being given one of those bite splints.
PATIENT
I just wake up occasionally at night with sort of pain in my jaw. Didn't really know what it was, so went to the dentist. I was then sort of given a soft gum shield which I wore when I was grinding, so it relieved the symptoms a little bit, from then on when I woke up at night it was okay. But I started then to realise that during the day sometimes I seemed to be subconsciously doing it, especially at times when I'm stressed or feeling a little bit tense.
PORTER
Looking back do you think you've been grinding for some time?
PATIENT
I have noticed that sort of my jaw muscles have just got more and more prominent over the years and from what the dentist said I mean I've managed to grind sort of facets in my teeth, which obviously must have happened over a longer period of time than the last year.
PORTER
Do you find yourself stopping yourself grinding your teeth now?
PATIENT
Yeah, I think once you've been made aware of it you just seem to consciously think about it and if you feel yourself clenching or grinding then consciously you'll stop yourself.
PORTER
One of Robert Jagger's patients at the Dental School in Bristol.
You are listening to Case Notes, I'm Dr Mark Porter and I am discussing the jaw, and jaw related problems, with my guest surgeon Iain Hutchinson.
Iain, given that stress often makes it worse I suspect the next few weeks - with exams and of course the World Cup - we're going to see a lot more people complaining of tooth grinding.
HUTCHINSON
Absolutely, it's a problem of teenagers very often coming up to exams. I don't know how many England players are going to suffer with jaw grinding at the moment, they seem fairly relaxed and laid back.
PORTER
Well their fans might and I know football's a particular interest of yours isn't it.
HUTCHINSON
Yes, I felt that a lot of professional footballers were getting treatment when they had broken jaw bones and facial bones being told that they had to take six weeks off. And so I have revolutionised that concept by saying well you know you can go back training within a week and you can play matches in a week.
PORTER
So what sort of injuries do you see in the footballers then, because presumably they're just representative of the sort of injuries that can happen to the jaw full stop?
HUTCHINSON
Yes, footballers don't get as many injuries as rugby players to the face but fractured jaws, fractured noses, fractured cheek bones and a few cuts and lacerations but usually not really severe injuries, just straightforward simple fractures, not the kind of beaten up with a sledgehammer or car crash into a tree type of injury, it's an isolated fracture.
PORTER
Is the jaw a fragile bone?
HUTCHINSON
It's got points of weakness, it's got - the point of weakness - the greatest point of weakness is the neck of the head of the jaw which is quite thin.
PORTER
So the angle in front of the ear.
HUTCHINSON
In front of the ear, it's not exactly described as the angle, it's above the angle, and that often resolves of its own accord, doesn't need to be - have any open reduction or wiring, it's usually not displaced. Probably the next commonest fracture is through the wisdom tooth, which is a point of weakness, at the angle and that does require plating of the jaw and then mid-line is probably the next point of fracture.
PORTER
And what sort of injuries are people - is it a sideways blow or a knee in the ...?
HUTCHINSON
It's - well we did a study in 1998 on facial injuries in the UK and we looked at over 6,000 facial injuries that occurred in a week in the UK, the most serious facial injuries - facial fractures - occurred in the 15-25 year old age group. Friday and Saturday nights, 11.00 p.m. to 2.00 a.m. in association with alcohol, either being assaulted or just falling flat on their face on the point of their chin. So that is the cause of facial injuries in the UK - falling flat on your face or getting into fights and getting beaten up. And so we actually - Saving Faces with the Department of Health and with the British Association of Oromaxillofacial Surgeons - are launching a national campaign where we go into schools, show kids pictures of patients with facial injuries, ideally take a young patient along with us, and say if you get drunk this is what happens. And actually we're not saying to kids - we're talking to 14 year olds - and we're not saying to kids don't drink, we're saying we know that you drink but drink slowly and drink sensibly, have a soft drink in between your alcoholic drinks.
PORTER
I want to go back to the positional problems with the jaw now. Twenty-six-year-old
Mark Redfern's upper jaw hadn't grown in proportion with his lower jaw, affecting both his bite and appearance. After years of struggling with the problem, maxillofacial surgeon Naheem Ali arranged to operate on Mark to correct the deformity. And, after a quick pre-op chat with Mark on the ward, we joined Mr Ali in the theatres at Barts Hospital last week to watch him perform the surgery.
ALI
Mark's problem is that his upper jaw hasn't grown as far forward as it should have done. When your face is growing, usually during your early teens, the different parts of it can grow in a disproportionate manner and in him the upper jaw hasn't grown far forward enough. What this means is that the teeth, which are carried on the jaw bone, are not in the right position, he therefore has an abnormal bite. When he tries to eat food, for example a sandwich, he'll leave the ham or the filling behind. Also he has a very slight lisp because he can't make a seal at the front of his mouth with his tongue and his teeth.
REDFERN
I can remember that I used to be able to bite my nails, that's when I remember back to, I can't remember when the last time I bit my nails was but in my teens probably and I could tell the gap was getting wider and it was getting harder to eat and stuff - like sandwiches. And when you're out in public and you're trying to eat sandwiches and the filling's going all over the place, it's not very good. I can push out my tongue - if I just close my teeth together in the normal position I can stick my tongue through it. So if I had a pen in my mouth and bit it, it would kind of flip up.
ALI
Mark's main concern really was about his function, his inability to eat and whilst some people may say well is it really such a big deal that you can't eat a sandwich but for those individuals who suffer with this problem it can be quite a lot of social embarrassment and distress, there may be avoiding behaviour, for example not going out, not eating in public. And certainly their quality of life suffers.
PORTER
So what exactly are you hoping to do this afternoon?
ALI
The surgical procedure that we're going to carry out on Mark comes under the term orthognathic surgery, which means same or even jaws. What we do is make a cut through the upper jaw bone and then separate the upper teeth, together with the palate, the upper jaw bone, we then move this jaw bone to the position where it should be and hold it in place with some metal plates and screws, these are like a small titanium Meccano set. Once we've held the jaw in place there we will then close the wound and allow the bone to heal.
PORTER
And how quickly is he likely to recover?
ALI
That process takes about four to six weeks for the bone to knit and then three months in total for the bone to become as solid as it was before. During that time Mark will be able to eat soft food, he'll be able to speak normally. When the operations were first carried out years ago the jaws were wired together for a period of anything up to six weeks, now with the titanium screws and plates we are able to have jaws free straightaway.
REDFERN
I'm looking forward to it. It's been a long time, it's been three years since I first went to see a dentist about this problem. They're going to break the upper jaw, that's the maxilla, and they're going to move it forward, they said, eight millimetres.
ALI
We've just made a cut on the inside of the upper lip and we're just lifting up the skin overlying the cheek. The most amazing thing about this operation is that it's done entirely from inside the mouth, so there's no external scars or incisions at all. And we're lifting the muscles of the face off from the underlying bone. We then mark out where we want to make our cuts in the jaw bone and then we'll make those cuts using a surgical saw.
PORTER
I've got to admit this is the bit I'm not looking forward to.
ALI
What we're doing now is the nose is attached to the top of your upper jaw bone, the nasal septum, which is the dividing piece of cartilage in the centre of your nose, and we're just separating that off. So that's the last thing holding the upper jaw bone to the rest of the face. You can see now that the upper jaw, the teeth, the palate and the lower part of the upper jaw bone are free in my hand. The blood supply for this piece of bone comes from the back of the jaw, so that's still keeping it well nourished. And what we'll do now is move the jaw forwards and then put it in the place where it originally belonged.
PORTER
Naheem Ali operating on Mark Redfern, who I am pleased to say has now been discharged and is recovering well at home.
Iain, Mark's main complaint was that he couldn't bite properly, but we've already mentioned appearance is often a factor too?
HUTCHINSON
Yes. Well you heard the woman at the beginning of the programme talking about how people felt about her face and described her as having a crescent moon and looking miserable and she didn't feel that she had any of those characteristics but people looked at her and thought she was like that. So of course it's pretty straightforward that if somebody's jaw is in the wrong place, in relation to - whether it be the upper jaw in relation to the lower jaw or the lower jaw to the upper jaw - their teeth aren't going to meet properly, they're going to have problems with speech, maybe lisping, they're going to have problems with biting. But that isn't the whole story, it's also about appearance. And Naheem Ali, who you've had on your programme led a study that I started in schools and in medical schools and what he did with us was a very clever project where he mixed up photographs of patients before and after this type of surgery with ordinary everyday people. And he asked the watchers - the 200 people in the lecture theatre - to fill out a form saying what they thought of the person they were looking at - the photograph - and they had about 30 seconds to a minute, I can't remember exactly, how much to judge those people ...
PORTER
First impressions.
HUTCHINSON
First impressions. And so they judged their appearance but they were also asked to say do you think this person is violent, do you think this person is intelligent, happy, do you think they're promiscuous, do you think - all sorts of subjective things that don't relate to the person's appearance at all. And what was clear was that - and they didn't know that they were the same people before and after surgery because they were all mixed up and they all looked different as well - wearing different clothes and looking different. So it's quite clear what happened, you'll guess what happened. Of course they looked more attractive afterwards but they were perceived as being more honest, more intelligent, less violent, more friendly. So that's one study which has definitely shown that people who have facial appearances with this kind of protruding lower jaw or receding chin are perceived in a prejudicial manner by the general population, so it means they don't get as good jobs, never mind about getting a life partner, they don't get as good jobs. And from studies in the States we also know that people who look less attractive doing the same job earn less money. So there are significant issues about appearance that are important.
PORTER
Mark there had his operation done mainly on the grounds of functionality, it was done on the NHS, is it possible to have the same operation done purely on cosmetic grounds, if your function was acceptable?
HUTCHINSON
Well we start to get into - it's ...
PORTER
It's a grey area.
HUTCHINSON
It's a grey area. On the one hand if you've got somebody who's got two noses or a forehead that goes up to the ceiling or eyes that are on the side of their head or ears that are missing or asymmetry of their face, then quite clearly that's not a cosmetic problem. If you've got somebody like me, an ageing face and I want to get rid of a few wrinkles because I don't want to look 57, I want to look 27 again, then that's cosmetic. But these people are in the middle, they are teased, they are disadvantaged and it's quite clear that - of course they have functional problems - but also their appearance is disabling them and if they get their appearance sorted out they will function much better in society, they will achieve much more and of course that's beneficial for society. Going back to the woman first on the programme she said that after her operation she looked more like her parents, so maybe there was some growth factor that just didn't kick in when it was mean to kick in and her face never grew to how it was meant to grow.
PORTER
Okay, I want to leave appearance there for the moment, I want to move on to another problem with the jaw that can require radical surgery - cancer. To discover more I travelled to meet Professor Peter Brennan - he's the maxillofacial surgeon at the Queen Alexandra Hospital in Portsmouth. Peter started by showing me a picture of the inside of a 55 year old man's mouth. Now his problems started when he noticed a strange lump around his back lower teeth - he booked in to see his dentist, who promptly referred him on to the hospital.
BRENNAN
It sort of shows a fairly nasty looking whitish horrible mass really doesn't it, two or three centimetres in size, around the lower molar teeth, just looks very, very unpleasant.
PORTER
That looks suspicious, so the dentist will have taken one look at that presumably and thought right needs to be referred to you?
BRENNAN
Yes. And looking at this patient straightaway I thought this was something unpleasant like a cancer.
PORTER
Now in my clinical career I've never seen anything like that, how unusual are these types of tumours, tumours of the jaw?
BRENNAN
Well mouth cancer itself we see about three and a half thousand new cases per year. In terms of cancer of the jaw it's much rarer, so I would say it's probably three or four hundred cases a year.
PORTER
And do we know why some people get it - are there recognised risk factors?
BRENNAN
Yes there are yes, people that smoke, people that consume alcohol - particularly spirits. The worst scenario is people that smoke and consume spirits as well because one of the problems with jaw cancer is that usually what happens is that it's a cancer in the lining of the jaw itself which then grows into the jaw.
PORTER
Is the challenge primarily one of a localised problem or do these tumours tend to spread?
BRENNAN
They tend to spread locally, so they'll spread into the neck, if they do spread into the neck then the chance of eradicating the problem actually falls by 50%, so the cure rate will fall by half. This is an x-ray showing a fairly dark area around the teeth and the teeth are effectively floating on air, aren't they really, the bone has been lost around the teeth there, as you can see.
PORTER
Probably about the size - I'm guessing here - about the size of a golf ball I would say.
BRENNAN
Oh it's at least that, yeah it's probably more like a lemon - four or five centimetres in size, a couple of inches at least.
PORTER
And so the tumour there has dissolved away the bone effectively.
BRENNAN
Yeah the tumour dissolves away the bone, so he's at very serious risk of breaking the jaw actually.
PORTER
Can tumours sometimes present with that sort of symptom that somebody literally breaks their jaw after minor trauma or perhaps eating something?
BRENNAN
Yes, yes, some tumours grow very, very rapidly indeed and some grow quite slowly but in this chap's case you could almost see it growing by the week.
PORTER
So the first tell tale sign for him might have been - I mean if you'd been looking inside the mouth you might have seen some form of ulcer presumably?
BRENNAN
Yes that's right, I mean it's very important with all these cases if you spot anything to go and see your doctor or dentist as soon as possible.
PORTER
But mouth ulcers are a common problem, I mean lots of people get them. What differentiates a normal mouth ulcer from one that you would regard as suspicious?
BRENNAN
Yeah, that's a very good question, what we'd say is an ulcer that lasted for more than about three weeks and that didn't resolve and that got progressively larger and usually cancerous ulcers are not painful at all, whereas the typical mouth ulcer that we've all had is exceedingly uncomfortable. Cancer tends not to be painful.
PORTER
So this gentleman appears to have a large possibly fast growing tumour in a difficult place, it's nearly grown all the way through his jaw...
BRENNAN
It has.
PORTER
... how can you help him?
BRENNAN
Well his only option really is an operation and we have to remove half of the jaw on that side and that's a huge undertaking, I mean if you imagine you use the jaw for eating, chewing, it forms part of your face, so he needs a fairly massive operation. So here's a picture, as you can see, this is taken of the jaw bone removed at the time of the operation, and you can see it's five or six inches.
PORTER
So effectively the patient has lost half the side of his face. What's happened to the soft tissue that overlies that - the cheek and the skin?
BRENNAN
Well we have to take that as well, if it's involved, so he will have lost a good inch or two around the jaw bone itself. So another couple of inches has been lost.
PORTER
So there are two things you have to - one you have to replace the functionality of the jaw bone, give him some form of formal replacement, but then you've got to cover it?
BRENNAN
Yes that's right, yeah, there's a number of options we can use, we can take bone from various parts of the body, for example the leg, we can take the shin bone and use that to reconstruct the jaw, we can take that with some skin on it as well. You don't actually need that bone really I mean it forms one part in terms of the ankle but as long as you take it above the ankle you can use that bone with very good effect.
PORTER
So that's the thinner of the two bones that goes from the knee to the ankle.
BRENNAN
Yes the outside one.
PORTER
But one technical hitch - it's dead straight.
BRENNAN
It certainly is, so what we can do is we can make some cuts using a saw - a very fine saw - and actually make some cuts through the bone, almost like a branch on a tree actually and fracture it round to actually make the shape that we want.
PORTER
But how do you actually fix those joints?
BRENNAN
Well here you can see is another photograph of a Meccano plate, in simple terms, it's a titanium plate, it's very lightweight metal and very strong metal and then in between that we fit the shin bone and then we screw it in with some screws.
PORTER
And that titanium plate, I mean it really looks a bit like a bicycle chain doesn't it, running along the jaw with the screws going through the links.
BRENNAN
It does doesn't it, it does, but it's extremely strong, it doesn't move like a bicycle chain, it's completely rigid.
PORTER
So here's the patient many months after the surgery, I mean I've got to say that even as a doctor, he's looking straight at the camera here, I mean I can't see anything at all, it's remarkable that he's had such a large piece of his jaw removed.
BRENNAN
He's got a scar in the neck, as you can see, which extends from the chin point right up to his ear. But we've actually tucked that in to one of the natural skin creases, so it hardly shows.
PORTER
Professor Peter Brennan talking to me at the Queen Alexandra Hospital in Portsmouth.
Iain, what is the long term outlook in cases like that?
HUTCHINSON
The outlook has improved dramatically. Over the past 20 years we've been able to take out huge swathes of the face, so take out very, very large cancers successfully because we now have the ability to reconstruct something that wasn't available say 30 or 40 years ago. We use microscopes and special instruments, micro-instruments, to join up blood vessels from the area that we've taken the tissue into the neck, and that's enabled us to be much more radical which means that even with large cancers we can achieve cure rates of up to 60%. But obviously if we catch the cancer earlier, and that's the key, if we catch the cancer when it's at a very early stage we've got a 90% cure rate and we don't need to do such heroic surgery.
PORTER
So perhaps we could recap on the signs that Peter Brennan was talking about earlier, the suspicious ulcers for instance.
HUTCHINSON
Right, well the rule is if you've got an ulcer in the mouth that hasn't gone away after three weeks, if you've got a lose tooth that really there's no explanation for, if you've got numbness of any part of your face that you can't explain, if you've got a bleeding point in your mouth that's just not getting better, if you've got a white or red patch that's not going away, if you've got a persistent one sided sore throat or a persistent neck lump that's no going away get yourself to your local oromaxillofacial surgeon immediately.
PORTER
And that's via your GP or dentist presumably.
HUTCHINSON
Yeah either, either will do.
PORTER
Well Iain, I'm afraid we're going to have to leave it there, that's all we've got time for.
Thank you very much.
If you would like more information on any of the issues raised today then do call the Radio 4 Action Line, that's 0800 044 044, or you can visit the website bbc.co.uk/radio4, where you can also listen to any part of the programme again.
Next week I'll be finding out about the latest in the management of broken bones - including an expert opinion on whether Wayne Rooney's fractured foot will keep him out of the World Cup.
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