X-ray differential diagnosis of traumatic and malignant vertebral compression fractures. Healing time for rib fractures

As a manuscript, Elena Andreevna KIREEVA FORENSIC DETERMINATION OF THE DISTANCE OF RIB FRACTURES 14.00.24. – Forensic medicine Abstract of the dissertation for the candidate’s scientific degree medical sciences Moscow 2008. The work was carried out at the state institution 3 thanatological “Russian Center Department of the Federal Forensic Medical Examination of Roszdrav”. Scientific supervisor: Doctor of Medical Sciences, Professor V.A. Klevno Official opponents: Honored Scientist of the RSFSR, Doctor of Medical Sciences, Professor V.N. Kryukov Candidate of Medical Sciences O.V. Lysenko Leading institution: Military Medical Academy named after. CM. Kirov The defense of the dissertation will take place on April 10, 2008 at 13-00 at a meeting of the Dissertation Council D 208.070.01 at the Federal State Institution “Russian Center” forensic medical examination Roszdrav" (125284, Moscow, Polikarpova St., building 12/13). The dissertation can be found in the library of the Federal State Institution “Russian Center for Forensic Medical Examination of Roszdrav.” The abstract was sent out on March 6, 2008. Scientific secretary of the dissertation council, candidate of medical sciences, associate professor O.A. Panfilenko 4 General characteristics of the work Relevance of the study One of the pressing issues in forensic medicine is to establish the lifetime and duration of a mechanical injury (V.A. Klevno, S.S. Abramov, D.V. Bogomolov et al, 2007). Most of the research in this direction has been devoted to studying reactive changes soft tissues and internal organs(A.V. Permyakov, V.I. Viter, 1998, V.S. Chelnokov, 1971, 2000). Assessing the lifetime and duration of bone fractures using x-rays (S.B. Maltsev, E.H. Barinov, M.O. Solovyova, 1995, P.A. Machinsky, V.V. Tsykalov, V.K. Tsykalov, 2001, A.V. Kovalev, A.A. Rubin, 2004), histological (I.I. Angelov, 1902, A.V. Saenko et al., 1996, 1998, 2000, T.K. Osipenkova, 2000, Yu. I. Pigolkin, M.N. Nagornov, 2004), electron microscopic (L. Harsanyi, 1976, 1981, V.A. Klevno, 1994), and biophysical methods (A.M. Kashulin, V.G. Baskakov, 1978, V.F. Kovbasin, 1984), dedicated to single works. Most of the listed works are descriptions of the results of preliminary research and are not suitable for practical use (L. Harsanyi, 1976, 1981, A.M. Kashulin, V.G. Baskakov, 1978, S.B. Maltsev, E.H. Barinov, M O. Solovyova, 1995, A. V. Saenko et al., 1996, 1998). The remaining works are not sufficiently detailed, and their practical application is difficult (L. Adelson, 1989, R. Hansmann et al., 1997, S. Bernatches, 1998, P. Di-Ninno et al., 1998, C. Hernandez-Cueto, 2000). To establish intravitality, a fractographic method was used to study traces of dynamic sliding on the fracture surface of rib fragments; morphological changes surfaces of fractures during active breathing (I.B. Kolyado, 1991, V.A. Klevno, 1991, V.A. Klevno, 1994), however, this method was not used to establish the age. Thus, the issue of determining the age of fractures has not been studied enough and its solution is possible through a comprehensive analysis of the changes occurring in the biotribological system, which is a rib fracture, with continued breathing, as well as to develop criteria for diagnosing the age of rib fractures. The purpose of the study is to develop criteria for judicial medical diagnostics age of rib fractures. To achieve this goal, the following tasks were set: 1. Conduct qualitative analysis pathomorphological changes in the area of ​​the ends of fragments and surrounding soft tissues of rib fractures of various ages. 2. Conduct a quantitative histomorphological analysis of signs in the area of ​​the ends of fragments and soft tissues of rib fractures of various ages. 5 3. Conduct a semi-quantitative fractographic study of rib fractures to establish morphological features, reflecting their age. 4. Based on the results of pathomorphological, histological and fractographic studies, develop criteria for forensic medical diagnosis of the age of rib fractures. Scientific novelty The fractographic method was used for the first time to identify and semi-quantitatively evaluate fractographic features that can serve as criteria for forensic diagnostics of the age of rib fractures; the dynamics of these signs is described for the first time. A set of fundamentally new histomorphometric parameters was used, reflecting the dynamics of fracture healing. For the first time, the features of necrotic, inflammatory and regenerative processes in the area of ​​rib fractures were revealed, which consist in the fact that necrotic changes tissues, hemolysis of erythrocytes, leukocyte and macrophage reaction, proliferation of fibroblasts and the formation of granulation tissue unfold faster, and the vascular reaction later than with damage of other locations and types. Practical significance The results of the dissertation can be used for forensic medical diagnosis of the age of rib fractures. Based on the data obtained, it was developed complex method forensic medical determination of the age of rib fractures, including regression equations based on histological and fractological characteristics, as well as a table of qualitative characteristics. The proposed method is simple to implement, does not require special preparation and the proposed use of expensive forensic consumable materials. makes it possible to increase the accuracy and objectivity of forensic medical diagnosis of the age of mechanical chest trauma. Introduction into practice The results of the study were introduced into the practical activities of the Federal State Institution “Russian Center for Forensic Medical Examination of Roszdrav”, into the practical activities of the Main state center forensic and forensic examinations of the Ministry of Defense of the Russian Federation; to the work of thanatology department No. 6 of the Bureau of Forensic Medical Examination of the Moscow Department of Health. 6 Approbation of the work The dissertation materials were presented and discussed at scientific conferences of the Federal State Institution “RC SME Roszdrav”. Approbation of the work took place on November 15, 2007 at the expanded scientific and practical conference of the Federal State Institution “RC SME of Roszdrav”. Publications 3 published on the topic of the dissertation scientific articles, 1 of which is in the journal “Forensic Medical Examination”. Structure of the dissertation The dissertation consists of an introduction, a literature review, a description of the materials and methods used, 2 chapters of the results of one’s own research, their discussion, conclusion, conclusions and bibliography (258 sources, of which 236 domestic and 22 foreign). The text is presented on 199 pages of computer typesetting, illustrated with 33 microphotographs, 9 tables. The main provisions put forward for the defense: 1. The degree of severity of changes in the contact zone of rib fragments, identified by the fractographic method (traces, rubs, grinding) can be used for forensic diagnostics of the age of fractures. 2. Necrotic, inflammatory and regenerative processes in the area of ​​the rib fracture have the peculiarities that necrotic tissue changes, hemolysis of erythrocytes, leukocyte and macrophage reaction, formation of granulation tissue and proliferation of fibroblasts develop faster, and the vascular reaction occurs later than with injuries of other locations and types. 3. A comprehensive method has been developed for determining the age of formation of rib fractures, based on semi-quantitative fractographic, quantitative and qualitative histological assessment of signs of injury age, which makes it possible to increase the accuracy and objectivity of determining the age of injury. Materials and methods of research Material of research 203 (213 fractures) ribs and soft tissues from the fracture area were used as research material, from which 213 bone preparations and 179 histological sections were prepared. The material was obtained as a result of a sectional forensic medical study of 84 corpses (59 men and 25 women 25-89 years old) with a chest injury duration ranging from 30 minutes to 27 days (according to the accompanying EMS sheet (time of receiving the call) and from decisions on the appointment of forensic medical examination of the 7th corpse). The cause of death in 8 cases was cardiovascular and neurological diseases, in the rest – mechanical injury. 25 people were intoxicated: 2 women, 23 men, maintenance ethyl alcohol in the blood varied from 0.739 to 3.2‰, and in the urine (kidney) from 0.5 to 3.3‰, in 6 cases there was a protocol in the medical records of the inpatient medical examination to establish the fact of alcohol consumption and intoxication with a conclusion - alcohol intoxication, without the results of blood tests for alcohol. Sectional research method Forensic medical examination of corpses was carried out on the basis of traditional sectional techniques (A.I. Abrikosov 1939, G.G. Avtandilov, 1994). Fractographic research method To study the morphology of rib fractures, I.B.’s technique was used. Kolyado and V.E. Yankovsky 1990, then carried out a detailed study of the fracture surface to identify expert - diagnostic criteria lifetime of rib fractures (Klevno V.A., 1991, Kolyado I.B., 1991), using a LEICA EZ4D stereomicroscope (with x 8x magnification), the data obtained were recorded in the columns: 1. TRACES (represent traces of dynamic mutual influence rib fragments with continued breathing) (in points): 1 - barely noticeable (Fig. 1) 2 - pronounced (Fig. 2), 0 - none (Fig. 3); Fig.1. Inconspicuous tracks (1 point), if the injury is 55 minutes old; x8 Fig.2. Pronounced marks (2 points), barely noticeable shiny rubs (1 point) when the injury is 5 hours 40 minutes old; x 8 2. RUBES (or shiny area - a section of bone tissue polished to a shine. Shiny areas are formed in areas of actual contact and are located isolated from each other, both on the fracture surface and in the area of ​​​​the marginal areas of fragments, depending on their conditions of initial sliding .) the presence and severity of shiny areas were noted (in points): 3 – maximally pronounced (Fig. 4), 2 – pronounced (Fig. 3), 1 – barely noticeable (Fig. 2), 0 – none; 8 Fig.3. Severe rubbing (2 points) when the injury is 3 days old; x8 Fig.4. The most pronounced chafing (3 points) when the injury was 7 days old; x8 3. GRINDING (Grinding of the edge of a fracture occurs as a result of erasing and smoothing one edge of the fracture by merging several areas with each other due to an increase in the area of ​​actual contact.): 3 - maximum pronounced (Fig. 7), 2 - pronounced (Fig. 6), 1-inconspicuous (Fig. 5), 0-no. Fig.5. Slight grinding (1 point) of the fracture surface when the injury was 19 hours 20 minutes old; x8 Fig.6. Pronounced grinding (2 points) of the fracture surface when the injury was 5 days old; x8 Fig.7. The most pronounced grinding (3 points) of the fracture surface when the injury was 6 days old; x8 9 Microscopic method of examination Soft tissues from the fracture area were taken from the area of ​​adjacent undamaged tissues. The samples were fixed in a 10% solution of neutral formalin and subjected to standard paraffin wax (D.S. Sarkisov, Yu.L. Perov, 1996). Paraffin sections 5-10 µm thick were stained with hematoxylin and eosin and Weigert. The bone was first decalcified in a 7% nitric acid solution for two weeks, then washed in running water and also subjected to standard paraffin embedding, followed by hematoxylin-eosin and Weigert staining of the sections. We applied a number of new methodological principles: 1. study of all reactions associated with blood vessels (plethora, leukostasis and diapedesis of white blood cells) separately for arteries, veins and capillaries, 2. taking into account the number of vessels of each type in the preparation when assessing the reactions associated with them, 3. standardization of all qualitative and semi-quantitative indicators in the form of clear unified definitions of each of them, 4. assessment of not only the timing of appearance, but also the timing of maximum development and disappearance of each sign, 5 . quantitative assessment of all stages of migration of white blood cells (stasis, passage through the wall, perivascular location, perivascular clusters, couplings, tracks, clusters at the border of hemorrhage) separately, 6. quantitative assessment of the number of white blood cells not only at the border of hemorrhage, but also in it thicker, 7. quantitative assessment of parameters such as the degree of hemolysis and thickness of the periosteum, 8. analysis of all observations that do not fit into general patterns, in order to establish their number and the reasons for the increase or decrease in the reaction under study. The preparations were studied using a CETI Belgium microscope. The studies were carried out in all fields of view of the histological section, except for counting cells in the thickness and at the border of hemorrhage; these signs were observed in 1 field of view. Signs – area of ​​the histological section; number of arteries, veins, capillaries; number of full-blooded arteries, veins, capillaries; the number of empty arteries, the number of arteries with spasm, the number of collapsed veins, capillaries; Track couplings, fibrin, hemolysis, necrosis, leukocyte breakdown, vascular proliferation, lacunae, periosteum were described and measured at 100x magnification, other signs at 400x magnification. 10 Based on the primary data, the following calculated characteristics were obtained: 1. RATIO OF THE NUMBER OF NEUTROPHILS PER THE LUMEN OF ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of neutrophils in the lumens of arteries, veins, capillaries / to the total number of arteries, veins, capillaries) 2. RATIO OF THE QUANTITY MACROPHAGES PER THE LUMEN OF ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of macrophages in the lumens of arteries, veins, capillaries / per total number of arteries, veins, capillaries) 3. RATIO OF THE NUMBER OF LYMPHOCYTES PER THE lumen of ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number lymphocytes in the lumens of arteries, veins, capillaries / per total number of arteries, veins, capillaries) 4. RATIO OF THE NUMBER OF NEUTROPHILS IN THE WALL OF ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of neutrophils in the wall of arteries, veins, capillaries / per total number of arteries, veins, capillaries) 5. RATIO OF THE NUMBER OF MACROPHAGES IN THE WALL OF ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of macrophages in the wall of arteries, veins, capillaries / per total number of arteries, veins, capillaries) 6. RATIO OF THE NUMBER OF LYMPHOCYTES IN THE WALL OF ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of lymphocytes in the wall of arteries, veins, capillaries / to the total number of arteries, veins, capillaries) 7. RATIO OF THE NUMBER OF NEUTROPHILS NEAR ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS UDOV (general number of neutrophils near the walls of arteries, veins, capillaries / per total number of arteries, veins, capillaries) 8. RATIO OF THE NUMBER OF MACROPHAGES NEAR ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of macrophages near the walls of arteries, veins, capillaries / per total number of arteries, veins, capillaries) 9. RATIO OF THE NUMBER OF LYMPHOCYTES NEAR ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of lymphocytes near the walls of arteries, veins, capillaries / to the total number of arteries, veins, capillaries) 10. RATIO OF THE NUMBER OF FIBROBLASTS NEAR ARTERIES, VEINS, K APILLARIES TO THE NUMBER OF VESSELS (total number of fibroblasts near arteries, veins, capillaries / per total number of arteries, veins, capillaries) 11. PROPORTION OF FULL-BLOODED, EMPTY, SPASMATED ARTERIES (number of full-blooded, empty, spasmodic arteries / per total number of arteries) 11 12. PROPORTION FULL-BLOODED, EMPLOYED, COLLECTED VEINS (number of plethoric, empty, collapsed veins / per total number of veins) 13. PROPORTION OF FULL-BLOODED, EMPTY, COLLOWED CAPILLARIES (number of full-blooded, empty, collapsed capillaries / per total number of capillaries). Statistical method In the process of collecting information, a computer database was created based on the Microsoft Access-97 program. Many of our parameters were of a ranking nature, since they represented assessments of features in points. Others had a distribution other than normal. Therefore, multivariate correlation analysis of the obtained data was carried out according to Spearman. When studying the correlation of fractographic signs with the duration of injury, it was carried out for the entire range of duration of the post-traumatic period, and cases studied histomorphologically were, in addition, divided into ranges from 30 minutes to 27 days and from 30 minutes to 1 day, and a correlation analysis was carried out also on each band separately. After selecting the parameters that most strongly correlated with the duration of injury, a multivariate analysis was also carried out. regression analysis, which resulted in regression equations that can be used to determine the duration of injury. At statistical research used: - operating shell Microsoft Windows XP Professional 2002; - software tool for statistical analysis SPSS for Windows v.7.5 (SPSS Inc.). Research results Results of fractographic research Traces are the most early sign dynamic sliding of bone fragments, which, according to our data, is clearly visible 30 minutes after the injury and can be observed until the end of 1 day. The presence of traces in the absence of other signs of dynamic sliding indicates that the post-traumatic period is up to 5 hours old. From 5 hours to 1 day, tracks are detected only in combination with shiny areas. This combination may appear earlier, starting 30 minutes after the injury. Therefore, the absence of shiny areas proves that the injury was less than 5 hours old, but their presence does not mean that the post-traumatic period was longer than this value. Starting from 70 minutes to 24 hours, one can observe a combination of traces also with grinding of the fracture edge. The first mild rubbing (shiny areas, 1 point) appears when the injury is 30 minutes old. Their weak expression can be observed for up to 8 days, 12 significantly pronounced shiny areas (2 points) were detected when the injury was from 3 to 27 days old. Shiny areas visible to the naked eye (without a microscope - 3 points) were noted by us in the period from 6 days to 27 days. Polishing (weakly expressed - 1 point) was observed together with traces and rubs; in the period from 1 hour 20 minutes to 7 days, weakly expressed rubbings (1 point) were combined with mild grinding (1 point). Pronounced grinding (2 points) was noted by us in the range of injury duration from 19.3 hours to 11 days, always with equally pronounced shiny areas, both on the surface and on the fracture edge. The grinding of the fracture edge, visible to the naked eye (3 points), was detected in the period from 6 to 16 days after injury and was always accompanied by equally pronounced rubbing (3 points) and complete absence trass (0 points). Signs of dynamic sliding are less pronounced: - with incomplete fractures; - on the other side chest where it's broken large quantity ribs; - on the upper (from 1 to 2 ribs) and lower ribs (starting from 7); - for fractures occurring at the border of bone and cartilage tissue. Application of multivariate correlation and regression analysis signs (fractographic and histological) of the age of injury, taking into account factors influencing the dynamics of healing, and, accordingly, the severity of the sign, made it possible to develop criteria for the age of rib fractures. It was found that the following fractographic features have the highest correlation coefficients with the duration of the injury over the entire studied range of duration of the post-traumatic period: traces, rubs, grinding, rolling. Based on them, an expert model was developed for determining the duration of rib fractures in the form of a regression equation (No. 1), which has the form: T=k0+k1 R1+k2R2+k3 R3, where T is the predicted duration of damage in minutes; k0, k1, k2, k3 - regression coefficients calculated when studying the fracture surface of a rib with a known history of damage, where k0 = -1359, 690; k1=3.694; k2=1538.317; k3=3198.178; R1, R2, R3, - severity of the trait in points, where R1 - traces, R2 - rubs, R3 sanding. Thus, T= -1359.690+3.694R1+1538.317 R2+3198.178 R3, (correlation coefficient for this model r = 0.736, standard error 3198.73, significance p< 0,001). 13 Результаты гистологического исследования. По нашим данным, реакция организма на перелом ребер в динамике развертывается in the following way. An increase in blood supply to the arteries, veins and capillaries develops within 1 hour after a chest injury, but in the arteries the plethora persists for up to 7 hours, in the capillaries for up to 6 hours, and in the veins only for up to 1.5-2 hours. In the post-traumatic period from 1 to 27 days, vascular plethora increases again: veins - from 7 to 11 days after injury, arteries - from the beginning of the second day to 8 days after injury, capillaries - from 7 to 16 days after injury. Hemolysis of red blood cells can begin as early as half an hour after injury and increases as the post-traumatic period increases. When the injury is more than 10 days old, hemolysis occurs in almost 100% of the red blood cells located in the hemorrhage area. Necrosis of muscle, fat, connective and bone tissue develops approximately 1 hour after injury. The leukocyte reaction to a rib fracture can be characterized as follows. An increase in the number of neutrophils in the vessels and their marginal standing is noticeable already 30 minutes after injury (in capillaries - after 1 hour), but in arteries it reaches its maximum severity in the period from 1 to 3 hours, in capillaries - by 3-4 hours, in veins about 5-7 hours after injury. Diapedesis of neutrophils in the tissue begins already when the injury is 35 minutes old and is most pronounced in the arteries, where leukocyte couplings and tracks form an hour after the injury. It ends in the arteries after 12 hours, in the walls of the veins after 4.5 hours, and in the walls of the capillaries after 2 hours. Perivascularly, neutrophils are found near veins up to 6 hours after injury, near capillaries up to 11 hours, and near arteries, single neutrophils and perivascular couplings can be detected even 24 hours after injury. At the border of hemorrhage, leukocytes appear no earlier than 1 hour after injury. Their number reaches a maximum in the period from 6 to 24 hours, and from 16 hours a leukocyte wave can already be traced. At the same time, multiple leukocyte tracks can be seen running from the vessels to the hemorrhage. When the injury is more than 1 day old, the reaction of leukocytes becomes very variable and depends on the preservation of the body’s reactivity and on the presence of leukocytosis as a reaction to a purulent-inflammatory process (pneumonia, meningitis, etc.). Nevertheless, some patterns can be traced. Small leukostasis in vessels of various types can be detected up to 11 (capillaries), 16 (veins) and 27 days (arteries). Leukodiapedesis, however, is absent or insignificant from day 2 - in the form of single cells and only through the arteries. Single neutrophils near the vessels can be detected up to 27 days after injury, but leukocyte couplings in preparations with an injury duration of more than 1-14 days are not detected. Leukocyte tracks cease to be observed when the injury is more than 2 days old. The leukocyte count can be determined up to 5-10 days. Later, only single neutrophils can be detected in the thickness of the granulation tissue formed at the site of hemorrhage, but not at the border. The breakdown of leukocytes begins when the injury is more than an hour old and continues up to 14 days, after which it ceases to be detected due to the attenuation of the leukocyte reaction. On the first day, only single monocytes can be observed in the lumens of blood vessels. The reaction of monocytes becomes clear (in the form of an increase in their number in the lumens of the veins) no earlier than 4-6 hours after the injury and not in all cases. Diapedesis of monocytes in tissue can begin as early as 1 hour after damage in the arteries and only after 4 hours in other vessels. The bulk of monocytes exits the blood into tissues through arteries. The appearance of single macrophages at the border of the hemorrhage and in its thickness is also noted within 1 hour after the injury, but their number increases slowly, and its slight increase becomes noticeable only by the end of 1 day. Monocytes accumulate in blood vessels (mainly arteries) mainly during a period of 5 to 10 days. For veins, this interval is longer - from 2 to 14 days - but the reaction of monocytes in them is less constant. Diapedesis of monocytes is observed mainly in the period 2-6 days. Later, only single macrophages may be found near the vessels or they are completely absent. Accordingly, from 5 to 10 days after injury, the largest number of macrophages is found in the thickness of the hemorrhage, and from 2 to 7 days - at its border. During the first day, the reaction of lymphocytes to injury is insignificant and is not always detected. However, the first lymphocytes emerging from the vessels into the tissue can be detected within 1 hour after injury. By the end of 1 day, individual lymphocytes are clearly visible at the border of the hemorrhage and in its thickness. Diapedesis of lymphocytes is less intense than other blood cells, occurring mainly through arteries and to a lesser extent through veins in the period from 1 to 10-11 days after injury, reaching a maximum at approximately 5 days. At the border of the hemorrhage and in its thickness, lymphocytes also appear 1 day after the injury, reach a maximum by 5 days, and when the injury is more than 10 days old, they cease to be detected at the border and become few in number or disappear completely in the thickness of the hemorrhage. Repeated waves of increased lymphocyte diapedesis are possible in observations with a trauma duration of 14 and 27 days, but due to the rarity of such cases, it is impossible to explain them. There are no reliable signs of fibroblast proliferation or other manifestations of regeneration in cases with an injury up to 24 hours old. 15 Proliferation of fibroblasts occurs mainly around the arteries (5-10 days after injury) and in connective tissue in the thickness of the hemorrhage (starting from 3 days after injury). At the border of hemorrhage, single fibroblasts appear no earlier than 3 days after the injury, and after 7 days after the injury they are no longer detectable. In contrast, the number of fibroblasts in the thickness of the hemorrhage increases as granulation tissue develops. The thickness of the periosteum can increase to 3 cells after 35 minutes after injury and continues to increase up to 27 days, however, there is no direct relationship between the duration of the injury and the number of layers of cambial cells in the periosteum. Granulation tissue in the form of a cluster of thin-walled vessels, between which there are macrophages, lymphocytes and fibroblasts, was found when the injury was from 5 days to 27 days. Thus, the formation of granulation tissue begins already from 5 days after injury. Rice. 8. Formation of cartilage, injury duration 8 days x200 Fig. 9. Formation of injury 16 days x 200 cartilage, age When the injury is more than 9 days old, chondrocyte proliferation is observed in the area of ​​the fracture, and developed cartilage tissue is detected when the injury is old and the post-traumatic period lasts 27 days (Fig. 8-9). Studies have shown that the highest correlation coefficients with the duration of the injury over the entire studied range of duration of the post-traumatic period have the following signs: the proportion of full-blooded arteries, the proportion of collapsed veins, the number of macrophages, lymphocytes and fibroblasts near the arteries and veins, the number of macrophages near capillaries, the number of macrophages, lymphocytes and fibroblasts in the thickness of the hemorrhage, the number of macrophages at the border of the hemorrhage, the presence and severity of fibrin deposits, vascular proliferation. 16 Based on them, an expert model was developed for determining the duration of rib fractures in the time period from 30 minutes to 27 days in the form of a regression equation (No. 2): T=k1+k2Q1+k3Q2+k4Q3+k5Q4+k6Q5+k7Q6+k8Q7; where T is the predicted duration of damage in minutes; k1,k2,k3,…. k8 – regression coefficients calculated from histological examination of individuals with a known history of chest injury; Q1 – number of macrophages near arteries; Q2 – number of fibroblasts near arteries; Q3 - number of fibroblasts near veins; Q4 – number of macrophages in the thickness of the hemorrhage; Q5 – number of lymphocytes in the thickness of the hemorrhage; Q6 – degree of fibrin loss; Q7 – degree of manifestation of proliferation vessels; Thus, the duration of injury in minutes can be determined by the following formula: T=711.241+158.345Q1+277.643Q2+331.339Q3-7.899Q483.285Q5+681.551Q6+4159.212Q7, (correlation coefficient for this model r = 0.877, standard error 2783.82, significance p< 0,001). С учетом того, что leukocyte reaction increases mainly in the first day after the injury; for differential diagnosis, we tried to study this time interval in more detail. Based on the data of the correlation analysis, a strong correlation was identified between the duration of mechanical injury to the ribs (up to 1 day) and the severity of accumulations and breakdown of leukocytes, as well as the percentage of hemolysis of erythrocytes, the proportion of full-blooded capillaries, the number of macrophages in the thickness of the hemorrhage, and a moderate correlation between the duration of mechanical trauma to the chest and the ratio of the number of neutrophils and macrophages near the arteries to the number of these vessels in the preparation, the ratio of the number of neutrophils and macrophages near the capillaries to the number of these vessels in the preparation, the number of lymphocytes in the thickness of the hemorrhage, the number of macrophages at the border of the hemorrhage. Based on them, an expert model was developed for determining the duration of rib fractures in a time period from 30 minutes to 24 hours in the form of a regression equation (No. 3): T=k1+k2G1+k3G2+k4G3+k5G4+k6G5+k7G6+k8G7+k9G8+k10G9 +k11G10+k12G11; where T is the predicted duration of damage in minutes; k1,k2,k3,…. k12 – regression coefficients calculated from histological examination of individuals with a known history of chest injury; 17 G1 – ratio of the number of neutrophils near the arteries to the number of arteries; G2 – ratio of the number of macrophages near the arteries to the number of arteries; G3 – proportion of full-blooded capillaries; G4 – ratio of the number of neutrophils near capillaries to the number of capillaries; G5 – ratio of the number of macrophages near capillaries to the number of capillaries; G6 – degree of severity of the leukocyte shaft; G7 – number of macrophages in the thickness of the hemorrhage; G8 – number of lymphocytes in the thickness of the hemorrhage; G9 – number of macrophages at the border of hemorrhage; G10 – percentage of hemolyzed erythrocytes; G11 – degree of destruction of leukocytes; Thus, T=-8.311+86.155 G1-636.281 G2-72.130 G3+49.205 G4+610.529 G5+148.154 G6+18.236G7-12.907G8+9.446G9+x.488G10+61.029G11, (correlation coefficient for of this model r = 0.819, standard error 174.05, significance p< 0,001). Результаты нашего исследования показывают принципиальную возможность установления давности травмы ребер по комплексу количественных и полуколичественных гистологических показателей с помощью разработанного нами уравнения регрессии. На основе параметров, полученных обоими методами (гистологическим и фрактографическим) была разработана экспертная модель определения давности переломов ребер в промежуток времени от 30 минут до 27 суток в виде уравнения регрессии (№4): Т= k1+k2G1+k3G2+k4G3+k5G4+k6G5+k7G6+k8G7 +k9G8+k10G9 (коэффициент корреляции для данной модели r = 0,877, стандартная ошибка 2783,82, значимость р < 0,001); где Т – прогнозируемая давность повреждения в минутах; k1,k2,k3,…. k8 – коэффициенты регрессии, вычисленные при гистологическом исследовании лиц с известной давностью травмы груди; G1 , G2, G8, G9 - выраженность признака в баллах, где G1 – трасы, G2 – зашлифованность, G8 – фибрин, G9 – выраженность сосудов пролиферации, G3 – общее количество макрофагов около артерий к числу артерий, G4 - общее количество фибробластов около артерий к числу артерий, G5 – общее количество фибробластов около вен к числу вен, G6 – количество макрофагов в толще кровоизлияния, G7 – количество лимфоцитов в толще кровоизлияния; 18 Таким образом, давность травмы в минутах можно определять по следующей формуле: Т=695,552-24,265G1+1144,272G2+224,902G3+2398,025G4+3913,304G5-0,654G6189,837G7 +1151,347G8+2523,297G9. Полученные результаты убедительно доказывают эффективность фрактографического и гистологического исследования переломов ребер в качестве объективного основного метода при судебно-медицинской диагностике давности переломов ребер и дифференциальной диагностике прижизненности переломов ребер, в случаях, когда получение травмы произошло в условиях неочевидности. Выводы 1. Выявляемые фрактографическим методом изменения отломков ребер в зоне контакта (трасы, натиры, зашлифованность) могут использоваться для судебно-медицинской диагностики давности переломов. 2. Обнаруживается сильная корреляция давности переломов ребер со степенью выраженности натиров и зашлифованности и корреляционная зависимость medium degree between the duration of the injury and the severity of the symptoms. 3. Fractological signs of age are less pronounced in incomplete fractures, on that side of the chest where more ribs are broken, on the upper (1 to 2) and lower ribs (starting from 7), with some comminuted and oblique transverse fractures, with fractures passing along the parasternal line and at the border of bone and cartilage tissue. 4. Features of necrotic, inflammatory and regenerative processes in the area of ​​rib fractures are that hemolysis of erythrocytes, leukocyte and macrophage reactions, necrotic tissue changes, proliferation of fibroblasts and the formation of granulation tissue develop faster, and the vascular reaction occurs later than with damage to other localizations and types. 5. On the first day, a strong correlation with the duration of the injury is found for the following histological parameters: the percentage of hemolysis of red blood cells, the proportion of full-blooded capillaries, the average number of neutrophils near the arteries and capillaries, the number of neutrophils at the border of hemorrhage in the x400 field of view, the severity of the breakdown of leukocytes, the average number of macrophages about arteries and near capillaries, the number of macrophages at the border of the hemorrhage in the x400 field of view, the number of macrophages and lymphocytes in the thickness of the hemorrhage in the x400 field of view. 6. Throughout the entire range of injury duration, a strong correlation with the duration of rib injury is found for the following histological parameters: the proportion of 19 full-blooded arteries, the proportion of collapsed veins, the average number of macrophages, lymphocytes and fibroblasts near arteries and veins, the average number of macrophages near capillaries, the number of macrophages, lymphocytes and fibroblasts in the thickness of the hemorrhage in the x400 field of view, the number of macrophages at the border of the hemorrhage in the x400 field of view, the presence and nature of fibrin deposits, the severity of vascular proliferation. 7. A comprehensive method for forensic medical determination of the age of rib fractures is proposed, which includes regression equations based on histological and fractological characteristics, as well as a table of qualitative histological features. Practical recommendations 1. For forensic medical diagnosis of the age of rib fractures, it is recommended to use a comprehensive fractological study of the fracture area and histological examination of the bone and soft tissue from the fracture zone. 2. Since the formation of signs of intravital origin of rib fractures is based on friction processes, it is necessary to exclude rough manipulations in the area of ​​fractures when preparing preparations: - broken ribs are removed entirely by dissecting the intercostal spaces and isolating their heads, and are marked; - removed rib fractures along with soft tissues are preliminarily placed for at least three days in a 10% solution of neutral formalin; - fixed rib fragments are washed from formalin for one day in running water and cleaned of soft tissues with a scalpel, without touching the edges of the fracture; - the ribs are again placed in running water for 1-2 hours and carefully cleaned of remnants of the periosteum, and the spongy substance is washed from the blood; - cleaned fractures are degreased in an ethereal alcohol solution (1:1), dried at room temperature, and labeled. 3. For more precise definition prescription is indicated: - subtype of fracture and its features: complete or not, location of the fracture plane relative to the long axis of the rib; - serial number ribs and side; - localization of rib fractures relative to anatomical lines. For direct microscopy, a stereomicroscope (with x 8x magnification) is used, rotating the edge under the microscope lens to identify signs of age along the edges (traces, rubs, sanding). Having discovered them, it is necessary to fix the rib on the object table using 20 pieces of plasticine and continue the examination, paying attention to the following points: - degree of expression of the traces: 2 - pronounced, 1 - subtle, 0 - none; - degree of severity of rubbing: 3 – most pronounced, 2 – pronounced, 1 barely noticeable, 0 – none; - degree of severity of polishing: 3 - maximum pronounced, 2 - pronounced, 1 - barely noticeable, 0 - none. 4. Substitute the obtained results into the developed expert model for determining the duration of rib fractures in the form of a regression equation (No. 1). 5. For histological examination of signs of age of chest injury: - soft fabrics from the area of ​​the fracture are taken with the area of ​​adjacent undamaged tissue. Samples are fixed in a 10% solution of neutral formalin and subjected to standard paraffin wax (D.S. Sarkisov, Yu.L. Perov, 1996); - paraffin sections 5-10 microns thick are stained with hematoxylin and eosin; - the bone is decalcified in a 7% nitric acid solution for two weeks, then washed in running water and also subjected to standard paraffin wax, followed by staining of the sections with hematoxylin and eosin. 6. Area of ​​histological section; number of arteries, veins, capillaries; number of full-blooded arteries, veins, capillaries, number of empty arteries, number of arteries with spasm, number of collapsed veins, capillaries, couplings, tracks, fibrin (severity of the sign in points: 0-none, 1-fibrin strands, 2-granular fibrin), hemolysis , necrosis, breakdown of leukocytes (0-none, 1-few, 2-many), vascular proliferation (0no, 1-few, 2-many), lacunae, periosteum, described at 10x magnification, other signs: number of neutrophils, macrophages, lymphocytes in the lumen / in the wall / near the arteries, veins, capillaries, the number of fibroblasts near the arteries, veins, capillaries, the number of neutrophils, lymphocytes, macrophages, fibroblasts in the thickness / at the border of the hemorrhage - with a 40-fold increase. 7. Based on the primary data, obtain calculated characteristics (see chapter “Material and research methods”). 8. Substitute the obtained results into the developed expert models for determining the duration of rib fractures (in the time period from 30 minutes to 27 days No. 2, No. 4 or the time period from 30 minutes to 24 hours - No. 3). 9. For a more accurate forensic medical diagnosis of the duration of rib fractures, you should use Table No. 1 of qualitative histological signs characterizing the duration of the injury. 21 Table No. 1. Qualitative histological signs of the age of rib fractures. Name of the sign Plethora of the arteries Plethemia of the veins Plethemia of the capillaries Neutrophils in the lumen of the arteries Neutrophils in the lumen of the veins Neutrophils in the lumen of the capillaries Neutrophils in the walls of the arteries Neutrophils in the walls of the veins Neutrophils in the walls of the capillaries Neutrophils near the arteries Neutrophils near the veins Neutrophils near the capillaries Leuko cyte couplings Leukocyte tracks Leukocyte shaft Neutrophils at the border hemorrhages Neutrophils in the thickness of the hemorrhage Monocytes in the lumen of the arteries Monocytes in the lumen of the veins Monocytes in the lumen of the capillaries Monocytes in the wall of the arteries Monocytes in the wall of the veins Monocytes in the wall of the capillaries Macrophages near the arteries Macrophages near the veins Macrophages near the capillaries Macrophages at the border of the hemorrhage Macrophages in the thickness of the blood effusions of lymphocytes in the lumen of arteries Lymphocytes in the lumen of capillaries Lymphocytes in the wall of arteries Lymphocytes in the wall of veins Lymphocytes in the wall of capillaries Lymphocytes near arteries Lymphocytes near veins Lymphocytes near capillaries Lymphocytes at the border of hemorrhage Lymphocytes in the depth of hemorrhage Necrosis of fat, muscle and connective tissue Hemolysis erythrocytes Fibrin Time of symptom onset 30 minutes 30 hours 30 minutes 30 hours 30 minutes 30 hours 30 minutes 30 minutes 1 – 6 hours 2 days 35 minutes 1 hour 1 hour 10 minutes 35 minutes 80 minutes 1 hour 55 minutes 30 minutes 16 hours 1 hour 30 minutes 30 minutes 30 minutes 1 -24 hours 1 hour 10 minutes 16 hours -24 hours a 1 hour 25 minutes 1 hour 3 hours 4 hours 1 hour 1 hour 30 minutes 1 hour - 24 hours 1 hour -24 hours 24 hours and 5 days 1 hour - 24 hours 35 minutes - 24 hours 5 hours 25 minutes - 24 hours 1 hour 1 day 1 day 55 minutes Sign disappearance time 7-24 hours 8-27 days 6-24 hours 7-27 days 1-6 hours 16-27 days 27 days<= 16 суток >6 hours > 11 days 2-14 days 4 hours 40 minutes 2 hours 14 days over 6 hours 11 hours >24 hours 2 days 5-10 days 10 days 10 days up to 27 days 10-27 days 5 days 5 days 5 days 24 hours 14 days 27 days 27 days >7 days< 27 суток 1-10 суток 30 минут 1 сутки 10 суток 27 суток 2, 5, 7 суток 1 - 11 суток 2 – 10 суток 24 часа, 14 и 27 суток 10 суток < 10 суток 27 суток 22 Пролиферация фибробластов вокруг артерий Фибробласты в толще кровоизлияния Фибробласты на границе кровоизлияния Грануляционная ткань Пролиферация хондроцитов 2 суток >10 days 3-5 days 3 days 5 days 9 days 7 days 27 days 27 days List of works published on the topic of the dissertation 1. State of the problem of forensic medical determination of the lifetime and duration of bone fractures (according to the literature) // Materials of the final scientific conference Russian Center forensic medical examination. –M. -2006. – P.70-74. (co-author Suvorova Yu.S.). 2. Possibilities of forensic medical determination of the age of rib fractures (preliminary study) // Current issues of forensic medicine and expert practice on modern stage. –M. -2006. –P.39-41. (co-author I.N. Bogomolova). 3. Forensic definition prescription of rib fractures // Forensic medical. expert. – 2008. - No. 1. – P. 44-47. (co-author V.A. Klevno, I.N. Bogomolova).

When describing what a fracture looks like on an x-ray, it is impossible to offer readers a standard diagram. Each radiologist has his own algorithms for setting a conclusion based on x-rays. Radiology has the potential to detect bone pathology during traumatic, destructive, and malignant processes.

When analyzing an image for a fracture, many factors should be excluded - etiology, distribution, nature of displacement, number of fragments. There are many parameters, but x-rays do not always allow us to establish the correct conclusion.

With minor damage, which is popularly called “cracks,” specific signs may not be visualized. If there is a history of trauma, clinical symptoms pathology is prescribed CT scan. A magnetic resonance scan is performed to determine changes in soft tissues.

What does a fracture look like on an x-ray: types, description

On an x-ray, the fracture looks specific. Classic signs are a linear area of ​​clearing, displacement of fragments, angular position of fragments.

A large variety of traumatic injuries requires a thorough analysis of all the symptoms of the pathology.

To begin with, we propose to divide all fractures into simple and complex, closed and open. With a simple form, a line of clearing is observed with no displacement or small divergences (convergence) of the fragments.

The complex variety is characterized by the presence of wedge-shaped areas of destruction with individual fragments and various types of displacements.

To determine treatment tactics, it is important for the traumatologist to know the nature of the fracture in relation to the articular surface. Extra-articular fractures heal faster and are characterized by fewer complications.

Intra-articular fractures are accompanied by bone damage localized inside the joint. With this nosology, in most cases mobility is limited. If healing occurs with the formation of excess callus, pronounced immobility is possible.

Towards skin There are 2 types of fractures:

1. Closed;
2. Open.

In the latter form, skin damage occurs and the bones protrude outward through the defect. Fractures are accompanied heavy bleeding. Trauma with an open skin defect increases the risk of bacterial infection due to contamination of the wound from the external environment.

Children have a fracture of the left wrist joint in the area of ​​metaepiphysiolysis through germinal zones takes a long time to overgrow. After healing, shortening is often observed upper limb due to improper fusion of the radius or ulna bones.

On day 20, the healing area does not look like a light stripe of clearing, but the appearance of foci of darkening in the fracture area due to the deposition of calcium salts. On X-ray photographs, consolidation of the fracture area due to an increase in the number of bone beams indicates healing of the defect.

When analyzing an x-ray, a specialist should pay attention to the separation of muscle fibers and the appearance of gas bubbles indicating the presence of air between the muscles. Magnetic resonance scanning for this pathology shows the destruction of muscle-ligamentous structures.

Radiographs to determine callus growth are performed to dynamically monitor the condition of the bone tissue. The callus is characterized by intense foci of darkening.

Features of fractures on x-ray during healing

The first decade of healing is accompanied by a pronounced defective gap. Enlightenment intensifies over the course of 1-2 weeks. The process is caused by the resorption of bone beams. Connective tissue grows between the fragments. It is not visible on the picture, so it is almost impossible to assess healing until the 20th day.

Osteoid tissue can be seen in the image starting from the second decade. It does not contain bone beams, so it is not clearly visible on an x-ray. If you compare images in the first and second decades, a more “cloudy” spot will be visualized in the area of ​​clearing. At the same time, osteoporosis forms at the articular ends of the bones - restructuring of the structure.

A dense callus forms in the 3rd decade. Complete calcification is formed within 2-5 months. Long-term reconstruction causes hardening of the damaged area. This is how large tubular bones grow together.

The traumatologist or surgeon who is treating the patient will be able to determine when to perform repeated radiographs for dynamic tracking. Sometimes it is necessary to check the fixation of metal pins and plates. Images are also prescribed to monitor complications.

If callus formation is weak, there is no need to think about impaired bone fusion. Connective, osteoid tissue grows between the fragments, which firmly fuses the fragments together. With this pathology, radiologists suggest false joint, but its presence, if the clearing line is preserved for a long time on an X-ray image, is not necessarily recorded. Fusion of fragments is ensured by osteoid tissue. Ending plates of bone in the absence foreign bodies capable of ensuring the healing process.

Is the fracture visible on x-ray?

Patients who ask the doctor whether a fracture is visible on an x-ray most often encounter the problem of visualizing the fracture on an x-ray during their initial consultation. medical care. Install correct diagnosis Either a repeat image after a while or a computed tomography helped.

Let us give an example of a specific medical history.

A 14-year-old child had an X-ray of his hand after an injury. The radiograph did not reveal clearing, displacement of fragments, or discrepancies of fragments. After examination by a traumatologist and analysis x-ray A diagnosis of soft tissue contusion was made.

Treatment for a week did not bring relief. A bandage was applied, but no casting was performed. After repeated X-rays, a fracture of the 1st metacarpal bone of the right hand was revealed.

Patients in such a situation often write complaints against doctors, because they worry that the diagnosis was not made on time. For a week, the child was not provided with qualified assistance. Is there a mistake made by specialists, and what harm is caused from the “incorrect” treatment of a bruise rather than a fracture? Let's figure it out.

The x-ray did not show a fracture due to a small defect that was not visible on the x-ray due to an oblique beam or incomplete bone damage. In children, bone tissue contains a large number of cartilage tissue.

In the repeated image, the clearing line appeared due to greater divergence of the bone fragments. If we assume this situation, then the fracture is not visible on X-ray. Popularly, such damage is simply called a “crack.”

Even with a CT scan, a diagnosis cannot be made accurately for such injuries. The assumption is confirmed by the traumatologist's lack of alertness when examining the patient.

A visible break is not always a fracture, since clearing lines create blood vessels and hemorrhages. The absence of a defect is not a guarantee that damage will not occur bone structure.

If a CT scan was performed, the child would receive a dose of radiation. To avoid it, traumatologists did not prescribe additional examination. Within a week, in the absence of displacement of the fragments, the defect could not have increased.

In such a situation, the most correct decision by the doctor is to limit mobility, even in the absence of visible signs of damage on the x-ray. When analyzing the medical history of the child described above, it is necessary to find out how the mobility of the arm was limited, since in the second week, during a repeat X-ray, a clearing line appeared.

If the x-ray does not show a fracture, a dynamic examination should be performed. A series of subsequent radiographs will allow a thorough assessment of the nature of traumatic injury.

X-ray signs of a fracture due to birth trauma

X-ray signs of a fracture birth trauma are not studied at institutes for further training of doctors. The pathology remains poorly understood, but according to statistical data, it often occurs in newborns, who are subsequently diagnosed with perinatal encephalopathy.

The cause of the pathology in the clinical literature is considered to be damage to the bones of the skull during passage through the birth canal. Only recently have morphological markers of pathology in which biomechanical damage occurs been published nervous system.

According to typical ideas, bone damage in the fetus in the parietal and occipital bone occurs in the following sequence:

The baby's head is pressed against birth canal under the influence of expelling forces. In this case, hemorrhage forms in the periosteum, aponeurosis, scalp heads;
Deflection of the skull bones occurs at the “wire point”, where overextension of the brain is formed, increasing the likelihood of intradural bleeding;
Tension of the spine in the cervical region increases due to synchondrosis of the occipital bone; displacement of the bones leads to compression spinal cord;
Constitutional fractures of the occipital bone change the configuration of the child’s head; stretching of the septal parts of the meninges is formed under increasing pressure and can lead to displacement of the skull bones;
With a further increase in pressure, “shear” fractures occur, deformation and syndesmosis are observed, and hemorrhages appear in the meninges;
Rotation of bones occurs during the period of fetal expulsion;
Simultaneously with the bones of the skull, damage to the spinal cord and cervical spine is possible.

In case of traumatic damage to the nervous system in the fetus, it is impossible to detect a fracture in the image, since radiography is not prescribed.

In case of birth trauma, it is rational to prescribe an x-ray of a fracture if the patient has the following morphological markers of pathology:

1. Cephalohematoma in the area of ​​contact of the skull bones with the pelvic organs;
2. Bleeding under the aponeurosis of the scalp;
3. Changing the head configuration;
4. Damage to the meninges;
5. Bleeding under the area of ​​the ligaments of the atlantoaxial and atlanto-occipital joint;
6. Local epidural hemorrhage into the spinal canal;
7. Spinal deformity;
8. Bleeding in the interarticular ligaments of the cervical spine;
9. Damage to the vertebral arteries;
10. Cracks, fractures of synchondrosis of the base of the skull;
11. Spinal cord injury;
12. Hypoxic conditions;
13. Tear of the septal part;
14. Intradural bleeding.

When performing an X-ray examination, it must be taken into account that the image of newborns will not show a fracture of the skull bones without damage to the periosteum. The radiograph shows a cephalohematoma. The purpose of the study is to determine radiological markers of damage to the nervous system in a newborn.

Primary damage to the skull bones during expulsion of the fetus is accompanied by cracks and stepwise deformation. Expansion of the gap appears due to excess pressure during rotation of the cervical vertebrae. Breaks, tears ligamentous apparatus cervico-occipital joint are markers of the primary lesion.

If a fetal cephalohematoma is detected on an x-ray, a skull x-ray is not necessary. It is more rational to carry out computed tomography or magnetic resonance imaging. Clinical statistics show that birth trauma with cephalohematoma is often accompanied by a fracture of the cancellous bone.

The mechanism of traumatic injury is accompanied by rupture of the bone beams that feed the periosteum. Up to complete bone fractures, displacement of the periosteum and detachment should be analyzed. When moving the head along the birth canal, tangential pressure aggravates the detachment of the periosteum. With such changes, the size of the cephalohematoma increases.

X-ray signs of a skull fracture in a newborn describe deformation of the occipital synchondrosis and lateral basilar structures. It is recommended to schedule an image after identifying 4-5 of the 12 signs described above.

The listed x-ray signs should be consistent with morphological findings, which are pathological markers of trauma to the base of the skull.

In the images of a newborn’s birth trauma, certain signs are observed:

1. Deformation of squama-lateral synchondrosis;
2. Fracture of the occipital bone;
3. Visualization of cephalohematoma;
4. Deformation of the cervical spine;
5. X-ray markers of birth trauma in children;
6. Other biomechanical injuries.

Thus, in the classical course, the fracture looks quite typical on the image. Determining the clearing line, displacement of fragments, and bone divergence determines specific symptoms.

With a small crack or deformation, initial radiography does not always reveal a fracture. Only with repeated examination is it possible to establish the nature of the traumatic injury. If necessary, a computed tomography scan may be prescribed.

When answering whether a fracture is visible on an x-ray, you need to take into account the characteristics of the pathology. The crack is not always visible in the photograph.

The most weakness modern x-ray diagnostics - visualization of changes in birth trauma in children. Due to the low predisposition of doctors to diagnose injuries to the skull and brain in a child, it is rarely possible to clearly establish the nature of fractures when passing through a narrow pelvis on an x-ray.

X-ray of the spine with a compression fracture. The signs are clearly defined - decreased height of the vertebral body, fragments, free bone fragments.

X-ray of the spine with a compression fracture. Signs are clearly defined - decreased vertebral body height, fragments, free bone fragments

X-ray of a fracture of the proximal epiphysis humerus in a child with angular displacement of debris

X-ray of a large focal intra-articular fracture of the right tibia

Main radiological signs of fractures

The main thing in diagnosing fractures is x-ray examination. As a rule, radiographs in two standard projections are sufficient, although in some cases oblique and atypical projections are used, and in case of skull fractures, special projections are used. The diagnosis of a fracture in all cases must be confirmed by objective radiological symptoms. Radiological signs of a fracture include:

1. presence of a fracture line (line of enlightenment in the shadow image of the bone),

2. break of the cortical layer,

3. displacement of fragments,

4. changes in the bone structure, including both compaction in impacted and compression fractures, and areas of clearing due to displacement of bone fragments in fractures of flat bones,

5. bone deformations, for example with compression fractures.

In children, in addition to those listed, signs of a fracture are also deformation of the cortical layer during greenstick fractures and deformation of the cartilaginous plate of the growth zone, for example, during epiphysiolysis.

Indirect symptoms of fractures - changes in adjacent soft tissues - should also be taken into account. These include thickening and compaction of the soft tissue shadow due to hematoma and edema, disappearance and deformation of physiological clearings in the joint area, darkening of the air cavities in fractures of pneumatized bones. Indirect sign fracture, which is at least 2-3 weeks old, is local osteoporosis, caused by intensive restructuring of bone tissue.

The diagnosis of a fracture in all cases must be confirmed by objective radiological symptoms. Its direct signs include the presence of a fracture line (a line of clearing in the shadow display of the bone), a break in the cortical layer, displacement of fragments, changes in the bone structure, including both compaction during impacted and compression fractures, and areas of clearing due to displacement of bone fragments during flat fractures bones, bone deformations, such as compression fractures. In children, in addition to those listed, signs of P. are also deformation of the cortical layer during greenstick fractures and deformation of the cartilaginous plate of the growth zone, for example, during epiphysiolysis. Indirect symptoms of fractures - changes in adjacent soft tissues - should also be taken into account. These include thickening and compaction of the shadow of soft tissues due to hematoma and edema, the disappearance and deformation of physiological clearings in the joint area, darkening of the air cavities with P. of pneumatized bones. An indirect sign of a fracture, which is at least 2-3 weeks old, is local osteoporosis, caused by intensive restructuring of bone tissue.

The fracture line reflects the gap between the fragments and is absent if there is none (with superposition of fragments, impacted and compression P.). To identify this symptom, it is necessary that the plane of the fracture coincides with the direction of the beam of rays over a sufficient length. Often this condition It is not performed along the entire fracture plane, which creates a false impression of an incomplete fracture (crack). The fracture line becomes better visible due to resorption of the edges of the fragments in the first weeks after the fracture. It can be imitated by linear brightenings caused by the tangential effect during bone superposition, birth defects bone tissue, artifacts, canals of feeding arteries, and in the bones of the cranial vault - also vascular grooves and sutures. Marginal avulsions of bone fragments should be differentiated from unfused ossification nuclei, supernumerary bones, paraosseous calcifications and ossifications.

By the number and direction of the fracture lines, one judges its nature - transverse, oblique, spiral, comminuted, T- or U-shaped, etc. Transition of the fracture line to articular surface is the defining sign of an intra-articular fracture. A break in the cortical layer, reflecting a fracture line in the compact substance, is considered to be its reliable symptoms.

Displacement of fragments is also a pathognomonic sign of a fracture. Distinguish the following types displacements: lateral (along the width of the bone), along the length (entry or divergence), angular and rotational (along the axis of the bone). In chest cases, for diagnosis, attention should be paid to minimal lateral displacement with the formation of a step along the contour of the bone.

Each type and localization of P. corresponds to certain displacements of fragments caused by the traction of the muscles attached to them. Tear-off P. in the area of ​​attachment of tendons and ligaments to bones are characterized by displacement of bone fragments in the direction of traction of the corresponding muscle or displacement of the limb as a result of the action of a traumatic force.

For impacted and compression P. the main radiological symptom is bone reformation. Deformations with such P. differ from deformations caused by disturbances in bone formation in that there is a break in the cortical layer and a strip of compaction of the bone structure, which corresponds to compression of bone trabeculae in the zone of wedging of fragments. Thus, a wedge-shaped deformity of the vertebral body during a compression fracture is accompanied by a break in the compact plate along the anterior or lateral contour with a step-like or angular deformation of the latter, a break or depression of the end plate, and a more or less pronounced compaction of the bone structure.

X-ray picture allows us to judge the mechanism of bone damage. A number of features have “overload” fractures, which are regarded by many authors as pathological bone reorganization. It is difficult to overestimate the importance of x-ray examination in recognizing pathological fractures arising from inadequate trauma due to a decrease in the mechanical strength of bones due to local pathological process or systemic damage skeleton. At the same time, changes in the firmness and structure of the bones, periosteal reaction and other symptoms are detected that cannot be explained by the bone damage itself. Most common cause P. with an inadequate nature of injury in old age is Osteoporosis.

X-ray examination is the main method of monitoring the reposition of fragments and the correctness of their position throughout the entire treatment and with its various methods. It makes it possible to evaluate the results of osteosynthesis and other surgical interventions; allows us to judge the healing of fractures, which occurs due to periosteal, endosteal and intermediary callus. With diaphyseal P., the periosteal callus is detected first. Well-matched and securely fixed fragments heal without periosteal callus (the so-called primary healing). Fractures of those parts of the skeleton that are built mainly from spongy substance heal due to endosteal callus. In the process of its formation, the contours of the fragments and the fracture line become less and less distinct, and the compaction of the structure caused by wedging of fragments or compression disappears. Consolidation of fragments is characterized by the restoration of a continuous bone structure, incl. compact records.

Kireeva E.A. Forensic medical determination of the prescription of rib fractures: abstract of thesis. dis. Ph.D. honey. Sciences: 14.00.24 / RC SME. – M., 2008. – 22 p.

Scientific director:

Official opponents:

Honored Scientist of the RSFSR,

Doctor of Medical Sciences, Professor

Candidate of Medical Sciences

O.V. Lysenko

Lead institution: Military Medical Academy named after. CM. Kirov

The defense of the dissertation will take place on April 10, 2008 at 13-00 at a meeting of the Dissertation Council D 208.070.01 at the Federal State Institution “Russian Center for Forensic Medical Examination of the Russian Health Service” (125284, Moscow, Polikarpova St., building 12/13).

The dissertation can be found in the library of the Federal government agency"Russian Center for Forensic Medical Examination of Roszdrav"

Scientific secretary of the dissertation council,
Candidate of Medical Sciences, Associate Professor O.A. Panfilenko

general description of work

The relevance of research

One of the pressing issues in forensic medicine is to establish the lifetime and duration of a mechanical injury (V.A. Klevno, S.S. Abramov, D.V. Bogomolov et al, 2007). Most of the research in this direction was devoted to the study of reactive changes in soft tissues and internal organs (A.V. Permyakov, V.I. Viter, 1998, V.S. Chelnokov, 1971, 2000). Assessing the lifetime and duration of bone fractures using x-rays (S.B. Maltsev, E.H. Barinov, M.O. Solovyova, 1995, P.A. Machinsky, V.V. Tsykalov, V.K. Tsykalov, 2001, A.V. Kovalev, A.A. Rubin, 2004), histological (I.I. Angelov, 1902, A.V. Saenko et al., 1996, 1998, 2000, T.K. Osipenkova, 2000, Yu. I. Pigolkin, M.N. Nagornov, 2004), electron microscopic (L. Harsanyi, 1976, 1981, V.A. Klevno, 1994), and biophysical methods (A.M. Kashulin, V.G. Baskakov, 1978, V.F. Kovbasin, 1984), dedicated to single works. Most of the listed works are descriptions of the results of preliminary research and are not suitable for practical use (L. Harsanyi, 1976, 1981, A.M. Kashulin, V.G. Baskakov, 1978, S.B. Maltsev, E.H. Barinov, M O. Solovyova, 1995, A. V. Saenko et al., 1996, 1998). The remaining works are not detailed enough and are practical use causes difficulties (L. Adelson, 1989, R. Hansmann et al., 1997, S. Bernatches, 1998, P. Di-Ninno et al., 1998, C. Hernandez-Cueto, 2000). To establish intravitality, a fractographic method was used to study traces of dynamic sliding on the fracture surface of rib fragments; morphological changes in the surface of fractures during active breathing were also assessed (I.B. Kolyado, 1991, V.A. Klevno, 1991, V.A. Klevno, 1994) , however, this method was not used to establish prescription.

Thus, the issue of determining the age of fractures has not been studied enough and its solution is possible through a comprehensive analysis of the changes occurring in the biotribological system, which is a rib fracture, with continued breathing, as well as to develop criteria for diagnosing the age of rib fractures.

Purpose of the study- develop criteria for forensic medical diagnosis of the age of rib fractures.

To achieve this goal, the following were set tasks:

1. Conduct a qualitative analysis of pathomorphological changes in the area of ​​the ends of fragments and surrounding soft tissues of rib fractures of various ages.

2. Conduct a quantitative histomorphological analysis of signs in the area of ​​the ends of fragments and soft tissues of rib fractures of various ages.

3. Conduct a semi-quantitative fractographic study of rib fractures to establish morphological characteristics that reflect their age.

4. Based on the results of pathomorphological, histological and fractographic studies, develop criteria for forensic medical diagnosis of the age of rib fractures.

Scientific novelty

The fractographic method was used for the first time to identify and semi-quantitatively evaluate fractographic features that can serve as criteria for forensic diagnostics of the age of rib fractures; the dynamics of these signs is described for the first time.

A set of fundamentally new histomorphometric parameters was used, reflecting the dynamics of fracture healing.

For the first time, the features of necrotic, inflammatory and regenerative processes in the area of ​​rib fractures have been identified, namely that necrotic tissue changes, hemolysis of erythrocytes, leukocyte and macrophage reactions, proliferation of fibroblasts and the formation of granulation tissue develop faster, and the vascular reaction is later than with damage to other localizations and type.

Practical significance

The results of the dissertation can be used for forensic medical diagnosis of the age of rib fractures. Based on the data obtained, a comprehensive method for forensic determination of the age of rib fractures has been developed, which includes regression equations based on histological and fractological characteristics, as well as a table of qualitative characteristics. The proposed method is easy to implement and does not require special training and the use of expensive Supplies. The use of the proposed forensic medical criteria makes it possible to increase the accuracy and objectivity of forensic diagnostics of the age of mechanical chest trauma.

Implementation into practice

The results of the study were introduced into the practical activities of the Federal State Institution “Russian Center for Forensic Medical Expertise of Roszdrav”, into the practical activities of the Main State Center for Forensic Medical and Criminalistic Expertise of the Ministry of Defense of the Russian Federation; to the work of thanatology department No. 6 of the Bureau of Forensic Medical Examination of the Moscow Department of Health.

Approbation of work

The dissertation materials were presented and discussed at scientific conferences of the Federal State Institution “RC SME Roszdrav”.

The work was tested on November 15, 2007 at an expanded scientific-practical conference Federal State Institution "RC SME Roszdrav".

Publications

Dissertation structure

The dissertation consists of an introduction, a literature review, a description of the materials and methods used, 2 chapters of the results of one’s own research, their discussion, conclusion, conclusions and bibliography (258 sources, of which 236 domestic and 22 foreign). The text is presented on 199 pages of computer typesetting, illustrated with 33 microphotographs, 9 tables.

Main provisions submitted for defense:

1. The degree of severity of changes in the contact zone of rib fragments identified by the fractographic method (traces, rubs, grinding) can be used for forensic medical diagnosis of the age of fractures.

2. Necrotic, inflammatory and regenerative processes in the area of ​​a rib fracture have the following features: necrotic tissue changes, hemolysis of erythrocytes, leukocyte and macrophage reactions, formation of granulation tissue and proliferation of fibroblasts develop faster, and the vascular reaction occurs later than with damage different location and type.

3. A comprehensive method has been developed for determining the age of formation of rib fractures, based on semi-quantitative fractographic, quantitative and qualitative histological assessment of signs of injury age, which makes it possible to increase the accuracy and objectivity of determining the age of injury.

Materials and research methods

Research material

As research material, 203 (213 fractures) ribs and soft tissues from the fracture area were used, from which 213 bone preparations and 179 histological sections were prepared. The material was obtained as a result of a sectional forensic medical study of 84 corpses (59 men and 25 women 25-89 years old) with the duration of the chest injury from 30 minutes to 27 days (according to the accompanying sheet of the emergency medical service (time of receiving the call) and from decisions on the appointment of a judicial -medical examination of the corpse). The cause of death in 8 cases was cardiovascular and neurological diseases, in the rest - mechanical injury. There were 25 people in a state of alcoholic intoxication: women - 2, men - 23, the content of ethyl alcohol in the blood varied from 0.739 to 3.2‰, and in the urine (kidney) from 0.5 to 3.3‰, in 6 cases In the medical records of the inpatient, there was a medical examination protocol to establish the fact of alcohol consumption and intoxication with a conclusion - alcohol intoxication, without the results of blood tests for alcohol.

Sectional research method

Forensic medical examination of corpses was carried out on the basis of traditional sectional techniques (A.I. Abrikosov 1939, G.G. Avtandilov, 1994).

Fractographic research method

To study the morphology of rib fractures, I.B.’s technique was used. Kolyado and V.E. Yankovsky 1990, then a detailed study of the fracture surface was carried out to identify expert diagnostic criteria for the lifetime of rib fractures (Klevno V.A., 1991, Kolyado I.B., 1991), using a LEICA EZ4D stereomicroscope (with x 8x magnification) , the received data was recorded in the columns:

1. TRACES (represent traces of the dynamic mutual impact of rib fragments while breathing continues) (in points): 1 - barely noticeable (Fig. 1) 2 - pronounced (Fig. 2), 0 - none (Fig. 3);

Fig.1. Inconspicuous tracks (1 point), if the injury is 55 minutes old; x8

Fig.2. Pronounced marks (2 points), barely noticeable shiny rubs (1 point) when the injury is 5 hours 40 minutes old; x 8

2. RUIN (or shiny area - a section of bone tissue polished to a shine. Shiny areas are formed in the zones of actual contact and are located isolated from each other, both on the fracture surface and in the area of ​​​​the marginal areas of fragments, depending on their conditions of initial sliding.) the presence and severity of shiny areas were noted (in points): 3 – maximally pronounced (Fig. 4), 2 – pronounced (Fig. 3), 1 – barely noticeable (Fig. 2), 0 – none;

Fig.3. Severe rubbing (2 points) when the injury is 3 days old; x8

Fig.4. Maximum pronounced rubbing (3 points) when the injury was 7 days old; x8

3. GRINDING (Grinding of the edge of a fracture occurs as a result of erasing and smoothing one edge of the fracture by merging several areas with each other due to an increase in the area of ​​actual contact.): 3 – maximum pronounced (Fig. 7), 2 – pronounced (Fig. 6), 1 - inconspicuous (Fig. 5), 0-no.

Fig.5. Slight grinding (1 point) of the fracture surface when the injury was 19 hours 20 minutes old; x8

Fig.6. Pronounced grinding (2 points) of the fracture surface when the injury was 5 days old; x8

Fig.7. The most pronounced grinding (3 points) of the fracture surface when the injury was 6 days old; x8

Microscopic research method

Soft tissues from the fracture area were taken from the area of ​​adjacent undamaged tissues. The samples were fixed in a 10% solution of neutral formalin and subjected to standard paraffin wax (D.S. Sarkisov, Yu.L. Perov, 1996). Paraffin sections 5-10 µm thick were stained with hematoxylin and eosin and Weigert. The bone was first decalcified in a 7% nitric acid solution for two weeks, then washed in running water and also subjected to standard paraffin embedding, followed by hematoxylin-eosin and Weigert staining of the sections.

We applied a number of new methodological principles:

1. study of all reactions associated with blood vessels (plethora, leukostasis and diapedesis of white blood cells) separately for arteries, veins and capillaries,

2. taking into account the number of vessels of each type in the drug when assessing the reactions associated with them,

3. standardization of all qualitative and semi-quantitative indicators in the form of clear unified definitions of each of them,

4. assessment of not only the timing of appearance, but also the timing of maximum development and disappearance of each feature,

5. quantitative assessment of all stages of white blood cell migration (stasis, passage through the wall, perivascular location, perivascular clusters-clutches, tracks, clusters at the border of hemorrhage) separately,

6. quantitative assessment of the number of white blood cells not only at the border of the hemorrhage, but also in its thickness,

7. quantitative assessment of parameters such as the degree of hemolysis and periosteum thickness,

8. analysis of all observations that do not fit into general patterns, in order to establish their number and the reasons for the increase or decrease in the reaction under study.

The preparations were studied using a CETI Belgium microscope. The studies were carried out in all fields of view of the histological section, except for counting cells in the thickness and at the border of hemorrhage; these signs were observed in 1 field of view. Signs – area of ​​the histological section; number of arteries, veins, capillaries; number of full-blooded arteries, veins, capillaries; the number of empty arteries, the number of arteries with spasm, the number of collapsed veins, capillaries; Track couplings, fibrin, hemolysis, necrosis, leukocyte breakdown, vascular proliferation, lacunae, periosteum were described and measured at 100x magnification, other signs at 400x magnification.

Based on the primary data, the following calculated characteristics were obtained:

1. RATIO OF THE NUMBER OF NEUTROPHILS IN THE LUMN OF ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of neutrophils in the lumens of arteries, veins, capillaries / per total number of arteries, veins, capillaries)

2. RATIO OF THE NUMBER OF MACROPHAGES PER THE LUMEN OF ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of macrophages in the lumens of arteries, veins, capillaries / per total number of arteries, veins, capillaries)

3. RATIO OF THE NUMBER OF LYMPHOCYTES PER THE LUMN OF ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of lymphocytes in the lumens of arteries, veins, capillaries / to the total number of arteries, veins, capillaries)

4. RATIO OF THE NUMBER OF NEUTROPHILS IN THE WALL OF ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of neutrophils in the wall of arteries, veins, capillaries / per total number of arteries, veins, capillaries)

5. RATIO OF THE NUMBER OF MACROPHAGES IN THE WALL OF ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of macrophages in the wall of arteries, veins, capillaries / per total number of arteries, veins, capillaries)

6. RATIO OF THE NUMBER OF LYMPHOCYTES IN THE WALL OF ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of lymphocytes in the wall of arteries, veins, capillaries / per total number of arteries, veins, capillaries)

7. RATIO OF THE NUMBER OF NEUTROPHILS AROUND ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of neutrophils near the walls of arteries, veins, capillaries / per total number of arteries, veins, capillaries)

8. RATIO OF THE NUMBER OF MACROPHAGES AROUND ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of macrophages near the walls of arteries, veins, capillaries / per total number of arteries, veins, capillaries)

9. RATIO OF THE NUMBER OF LYMPHOCYTES AROUND ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of lymphocytes near the walls of arteries, veins, capillaries / per total number of arteries, veins, capillaries)

10. RATIO OF THE NUMBER OF FIBROBLASTS AREA ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of fibroblasts near arteries, veins, capillaries / total number of arteries, veins, capillaries)

11. PROPORTION OF FULL-BLOODED, EMPTY, SPASMATED ARTERIES (number of full-blooded, empty, spasmodic arteries / per total number of arteries)

12. PROPORTION OF FULL-BLOODED, EMPTY, COLLECTED VEINS (number of full-blooded, empty, collapsed veins / per total number of veins)

13. SHARE OF FULL-BLOODED, EMPTY, COLLAPSE CAPILLARIES (number of full-blooded, empty, collapsed capillaries / per total number of capillaries).

Statistical method

In the process of collecting information, a computer database was created based on the Microsoft Access-97 program. Many of our parameters were of a ranking nature, since they represented assessments of features in points. Others had a distribution other than normal. Therefore, multivariate correlation analysis of the obtained data was carried out according to Spearman. When studying the correlation of fractographic signs with the duration of injury, it was carried out for the entire range of duration of the post-traumatic period, and cases studied histomorphologically were, in addition, divided into ranges from 30 minutes to 27 days and from 30 minutes to 1 day, and a correlation analysis was carried out also on each band separately.

After selecting the parameters that most strongly correlated with injury duration, multivariate regression analysis was also performed to obtain regression equations that can be used to determine injury duration.

The statistical study used:

Operating shell Microsoft Windows XP Professional 2002;

Software tool for statistical analysis SPSS for Windows v.7.5 (SPSS Inc.).

Research results

Results of fractographic research

Traces are the earliest sign of dynamic sliding of bone fragments, which, according to our data, is clearly visible within 30 minutes after injury and can be observed until the end of 1 day. The presence of tracks in the absence of other signs of dynamic sliding indicates that the post-traumatic period is up to 5 hours old. From 5 a.m. to 1 p.m., trails are only discovered in combination with shiny areas. This combination may appear earlier, starting 30 minutes after the injury. Therefore, the absence of shiny areas proves that the injury was less than 5 hours old, but their presence does not mean that the post-traumatic period was longer than this value. Starting from 70 minutes to 24 hours, one can observe a combination of routes also with grinding of the fracture edge.

The first mild rubbing (shiny areas, 1 point) appears when the injury is 30 minutes old. Their weak expression can be observed up to 8 days; significantly pronounced shiny areas (2 points) were detected when the injury was from 3 to 27 days old. Shiny areas visible to the naked eye (without a microscope - 3 points) were noted by us in the period from 6 days to 27 days.

Polishing (weakly expressed - 1 point) was observed together with traces and rubs; in the period from 1 hour 20 minutes to 7 days, weakly expressed rubbings (1 point) were combined with mild grinding (1 point). Pronounced grinding (2 points) was noted by us in the range of injury duration from 19.3 hours to 11 days, always with equally pronounced shiny areas, both on the surface and on the fracture edge. The grinding of the fracture edge, visible to the naked eye (3 points), was detected in the period from 6 to 16 days after the injury and was always accompanied by equally pronounced rubbing (3 points) and a complete absence of traces (0 points).

Less pronounced signs of dynamic sliding:

For incomplete fractures;

On the side of the chest where more ribs are broken;

On the upper (1st to 2nd ribs) and lower ribs (starting from 7th);

For fractures occurring at the border of bone and cartilage tissue.

The use of multivariate correlation and regression analysis of signs (fractographic and histological) of injury duration, taking into account factors influencing the dynamics of healing and, accordingly, the severity of the sign, made it possible to develop criteria for the age of rib fractures.

It was found that the following fractographic features have the highest correlation coefficients with the duration of the injury over the entire studied range of duration of the post-traumatic period: traces, rubs, grinding, rolling.

Based on them, an expert model for determining the duration of rib fractures was developed in the form of a regression equation (No. 1), having the form:

Т=k 0 +k 1 R 1 +k 2 R 2 +k 3 R 3 ,

k 0 , k 1 , k 2 , k 3 - regression coefficients calculated by studying the fracture surface of a rib with a known history of damage, where k 0 = -1359, 690; k 1 =3.694; k 2 =1538.317; k 3 =3198.178;

R 1 , R 2 , R 3 - severity of the trait in points, where R 1 - tracks, R 2 - rubs, R 3 - polishing.

Thus,

T= -1359.690+3.694R 1 +1538.317 R 2 +3198.178 R 3, (correlation coefficient for this model r = 0.736, standard error 3198.73, significance p

Results of histological examination.

According to our data, the body's reaction to a rib fracture unfolds dynamically as follows.

An increase in blood supply to the arteries, veins and capillaries develops within 1 hour after a chest injury, but in the arteries the plethora persists for up to 7 hours, in the capillaries for up to 6 hours, and in the veins only for up to 1.5-2 hours. In the post-traumatic period from 1 to 27 days, vascular plethora increases again: veins - from 7 to 11 days after injury, arteries - from the beginning of the second day to 8 days after injury, capillaries - from 7 to 16 days after injury.

Hemolysis of red blood cells can begin as early as half an hour after injury and increases as the post-traumatic period increases. When the injury is more than 10 days old, hemolysis occurs in almost 100% of the red blood cells located in the hemorrhage area. Necrosis of muscle, fat, connective and bone tissue develops approximately 1 hour after injury.

The leukocyte reaction to a rib fracture can be characterized as follows. An increase in the number of neutrophils in the vessels and their marginal standing is noticeable already 30 minutes after injury (in capillaries - after 1 hour), but in arteries it reaches its maximum severity in the period from 1 to 3 hours, in capillaries - by 3-4 hours, in veins - about 5-7 hours after injury. Diapedesis of neutrophils in the tissue begins already when the injury is 35 minutes old and is most pronounced in the arteries, where leukocyte couplings and tracks form an hour after the injury. It ends in the arteries after 12 hours, in the walls of the veins after 4.5 hours, and in the walls of the capillaries after 2 hours. Perivascularly, neutrophils are found near veins up to 6 hours after injury, near capillaries up to 11 hours, and near arteries, single neutrophils and perivascular couplings can be detected even 24 hours after injury. At the border of hemorrhage, leukocytes appear no earlier than 1 hour after injury. Their number reaches a maximum in the period from 6 to 24 hours, and from 16 hours a leukocyte wave can already be traced. At the same time, multiple leukocyte tracks can be seen running from the vessels to the hemorrhage.

When the injury is more than 1 day old, the reaction of leukocytes becomes very variable and depends on the preservation of the body’s reactivity and on the presence of leukocytosis as a reaction to a purulent-inflammatory process (pneumonia, meningitis, etc.). Nevertheless, some patterns can be traced. Small leukostasis in blood vessels various types can be detected up to 11 (capillaries), 16 (veins) and 27 days (arteries). Leukodiapedesis, however, is absent or insignificant from day 2 - in the form of single cells and only through the arteries. Single neutrophils near the vessels can be detected up to 27 days after injury, but leukocyte couplings in preparations with an injury duration of more than 1 day are not detected. Leukocyte tracks cease to be observed when the injury is more than 2 days old.

The leukocyte count can be determined up to 5-10 days. Later, only single neutrophils can be detected in the thickness of the granulation tissue formed at the site of hemorrhage, but not at the border.

The breakdown of leukocytes begins when the injury is more than an hour old and continues up to 14 days, after which it ceases to be detected due to the attenuation of the leukocyte reaction.

On the first day, only single monocytes can be observed in the lumens of blood vessels. The reaction of monocytes becomes clear (in the form of an increase in their number in the lumens of the veins) no earlier than 4-6 hours after the injury and not in all cases. Diapedesis of monocytes in tissue can begin as early as 1 hour after damage in the arteries and only after 4 hours in other vessels. The bulk of monocytes exits the blood into tissues through arteries. The appearance of single macrophages at the border of the hemorrhage and in its thickness is also noted within 1 hour after the injury, but their number increases slowly, and its slight increase becomes noticeable only by the end of 1 day.

Monocytes accumulate in blood vessels (mainly arteries) mainly during a period of 5 to 10 days. For veins, this interval is longer - from 2 to 14 days - but the reaction of monocytes in them is less constant. Diapedesis of monocytes is observed mainly in the period 2-6 days. Later, only single macrophages may be found near the vessels or they are completely absent. Accordingly, from 5 to 10 days after injury, the largest number of macrophages is found in the thickness of the hemorrhage, and from 2 to 7 days - at its border.

During the first day, the reaction of lymphocytes to injury is insignificant and is not always detected. However, the first lymphocytes emerging from the vessels into the tissue can be detected within 1 hour after injury. By the end of 1 day, individual lymphocytes are clearly visible at the border of the hemorrhage and in its thickness.

Diapedesis of lymphocytes is less intense than other blood cells, occurring mainly through arteries and to a lesser extent through veins in the period from 1 to 10-11 days after injury, reaching a maximum at approximately 5 days. At the border of the hemorrhage and in its thickness, lymphocytes also appear 1 day after the injury, reach a maximum by 5 days, and when the injury is more than 10 days old, they cease to be detected at the border and become few in number or disappear completely in the thickness of the hemorrhage. Repeated waves of increased lymphocyte diapedesis are possible in observations with a trauma duration of 14 and 27 days, but due to the rarity of such cases, it is impossible to explain them.

There are no reliable signs of fibroblast proliferation or other manifestations of regeneration in cases with an injury up to 24 hours old.

Proliferation of fibroblasts occurs mainly around the arteries (5-10 days after injury) and in the connective tissue in the thickness of the hemorrhage (starting from 3 days after injury). At the border of hemorrhage, single fibroblasts appear no earlier than 3 days after the injury, and after 7 days after the injury they are no longer detectable. In contrast, the number of fibroblasts in the thickness of the hemorrhage increases as granulation tissue develops.

The thickness of the periosteum can increase to 3 cells after 35 minutes after injury and continues to increase up to 27 days, however, there is no direct relationship between the duration of the injury and the number of layers of cambial cells in the periosteum.

Granulation tissue in the form of a cluster of thin-walled vessels, between which there are macrophages, lymphocytes and fibroblasts, was found when the injury was from 5 days to 27 days. Thus, the formation of granulation tissue begins already from 5 days after injury.

Rice. 8. Formation of cartilage, injury duration 8 days x200

Rice. 9. Formation of cartilage, injury duration 16 days x200

When the injury is more than 9 days old, chondrocyte proliferation is observed in the fracture area, and developed cartilage tissue is found when the injury is older and the post-traumatic period lasts 27 days (Fig. 8-9).

Studies have shown that the highest correlation coefficients with the duration of the injury over the entire studied range of duration of the post-traumatic period have the following signs: the proportion of full-blooded arteries, the proportion of collapsed veins, the number of macrophages, lymphocytes and fibroblasts near the arteries and veins, the number of macrophages near capillaries, the number of macrophages, lymphocytes and fibroblasts in the thickness of the hemorrhage, the number of macrophages at the border of the hemorrhage, the presence and severity of fibrin deposits, vascular proliferation.

Based on them, an expert model was developed for determining the duration of rib fractures in the period of time from 30 minutes to 27 days in the form of a regression equation (No. 2):

Т=k1+k2Q1+k3Q2+k4Q3+k5Q4+k6Q5+k7Q6+k8Q7;

where T is the predicted duration of damage in minutes;
k1,k2,k3,…. k8 – regression coefficients calculated from histological examination of individuals with a known history of chest injury;
Q1 – number of macrophages near arteries;
Q2 – number of fibroblasts near arteries;
Q3 - number of fibroblasts near veins;
Q4 – number of macrophages in the thickness of the hemorrhage;
Q5 – number of lymphocytes in the thickness of the hemorrhage;
Q6 – degree of fibrin loss;
Q7 – degree of manifestation of proliferation vessels;

Т=711.241+158.345Q1+277.643Q2+331.339Q3-7.899Q4-83.285Q5+681.551Q6+4159.212Q7, (correlation coefficient for this model r = 0.877, standard error 2783.82, significance p

Taking into account the fact that the leukocyte reaction increases mainly in the first day after the injury, for differential diagnosis, we tried to study this time interval in more detail. Based on the data of the correlation analysis, a strong correlation was identified between the duration of mechanical injury to the ribs (up to 1 day) and the severity of accumulations and breakdown of leukocytes, as well as the percentage of hemolysis of erythrocytes, the proportion of full-blooded capillaries, the number of macrophages in the thickness of the hemorrhage, and a moderate correlation between the duration of mechanical trauma to the chest and the ratio of the number of neutrophils and macrophages near the arteries to the number of these vessels in the preparation, the ratio of the number of neutrophils and macrophages near the capillaries to the number of these vessels in the preparation, the number of lymphocytes in the thickness of the hemorrhage, the number of macrophages at the border of the hemorrhage.

Based on them, an expert model was developed for determining the duration of rib fractures in a time period from 30 minutes to 24 hours in the form of a regression equation (No. 3):

Т=k1+k2G1+k3G2+k4G3+k5G4+k6G5+k7G6+k8G7+k9G8+k10G9+k11G10+k12G11;

k1,k2,k3,…. k12 – regression coefficients calculated from histological examination of individuals with a known history of chest injury;
G1 – ratio of the number of neutrophils near the arteries to the number of arteries;
G2 – ratio of the number of macrophages near the arteries to the number of arteries;
G3 – proportion of full-blooded capillaries;
G4 – ratio of the number of neutrophils near capillaries to the number of capillaries;
G5 – ratio of the number of macrophages near capillaries to the number of capillaries;
G6 – degree of severity of the leukocyte shaft;
G7 – number of macrophages in the thickness of the hemorrhage;
G8 – number of lymphocytes in the thickness of the hemorrhage;
G9 – number of macrophages at the border of hemorrhage;
G10 – percentage of hemolyzed erythrocytes;
G11 – degree of destruction of leukocytes;

Thus,

T=-8.311+86.155 G1-636.281 G2-72.130 G3+49.205 G4+610.529 G5+148.154 G6+18.236G7-12.907G8+9.446G9+x.488G10+61.029G11, (correlation coefficient for this model r = 0.819, standard error 174.05, significance p

The results of our study show the fundamental possibility of establishing the duration of a rib injury using a set of quantitative and semi-quantitative histological indicators using the regression equation we developed.

Based on the parameters obtained by both methods (histological and fractographic), an expert model was developed for determining the duration of rib fractures in the time period from 30 minutes to 27 days in the form of a regression equation (No. 4):

Т= k1+k2G1+k3G2+k4G3+k5G4+k6G5+k7G6+k8G7 +k9G8+k10G9 (correlation coefficient for this model r = 0.877, standard error 2783.82, significance p

where T is the predicted duration of damage in minutes;

k1,k2,k3,…. k8 – regression coefficients calculated from histological examination of individuals with a known history of chest injury;

G1, G2, G8, G9 - severity of the trait in points, where G1 - traces, G2 - grinding, G8 - fibrin, G9 - severity of proliferation vessels,

G3 – total number of macrophages near arteries to the number of arteries,

G4 - the total number of fibroblasts near the arteries to the number of arteries,

G5 – total number of fibroblasts near veins to the number of veins,

G6 – number of macrophages in the thickness of the hemorrhage,

G7 – number of lymphocytes in the thickness of the hemorrhage;

Thus, the duration of injury in minutes can be determined using the following formula:

T=695.552-24.265G1+1144.272G2+224.902G3+2398.025G4+3913.304G5-0.654G6-189.837G7 +1151.347G8+2523.297G9.

The results obtained convincingly prove the effectiveness of fractographic and histological examination of rib fractures as an objective main method in forensic medical diagnosis of the age of rib fractures and differential diagnosis of intravital rib fractures, in cases where the injury occurred in conditions of non-obviousness.

conclusions

1. Changes in rib fragments in the contact zone (traces, rubs, grinding) detected by the fractographic method can be used for forensic medical diagnosis of the age of fractures.

2. There is a strong correlation between the duration of rib fractures and the severity of rubbing and grinding, and a moderate correlation between the duration of the injury and the severity of the marks.

3. Fractological signs of age are less pronounced in incomplete fractures, on that side of the chest where more ribs are broken, on the upper (1 to 2) and lower ribs (starting from 7), with some comminuted and oblique transverse fractures, with fractures passing along the parasternal line and at the border of bone and cartilage tissue.

4. Features of necrotic, inflammatory and regenerative processes in the area of ​​rib fractures are that hemolysis of erythrocytes, leukocyte and macrophage reactions, necrotic tissue changes, proliferation of fibroblasts and the formation of granulation tissue develop faster, and the vascular reaction occurs later than with damage to other localizations and types.

5. On the first day, a strong correlation with the duration of the injury is found for the following histological parameters: the percentage of hemolysis of red blood cells, the proportion of full-blooded capillaries, the average number of neutrophils near the arteries and capillaries, the number of neutrophils at the border of hemorrhage in the x400 field of view, the severity of the breakdown of leukocytes, the average number of macrophages about arteries and near capillaries, the number of macrophages at the border of the hemorrhage in the x400 field of view, the number of macrophages and lymphocytes in the thickness of the hemorrhage in the x400 field of view.

6. Throughout the entire range of injury duration, a strong correlation with the duration of rib injury is found for the following histological parameters: the proportion of full-blooded arteries, the proportion of collapsed veins, the average number of macrophages, lymphocytes and fibroblasts near arteries and veins, the average number of macrophages near capillaries, the number of macrophages, lymphocytes and fibroblasts in the thickness of the hemorrhage in the x400 field of view, the number of macrophages at the border of the hemorrhage in the x400 field of view, the presence and nature of fibrin deposits, the severity of vascular proliferation.

7. A comprehensive method for forensic medical determination of the age of rib fractures is proposed, which includes regression equations based on histological and fractological characteristics, as well as a table of qualitative histological characteristics.

1. For forensic medical diagnosis of the age of rib fractures, it is recommended to use a comprehensive fractological study of the fracture area and histological examination of the bone and soft tissue from the fracture zone.

2. Since the formation of signs of intravital origin of rib fractures is based on friction processes, it is necessary to exclude rough manipulations in the area of ​​fractures when preparing preparations:

Broken ribs are removed entirely by cutting the intercostal spaces and isolating their heads, and are marked;

The removed rib fractures along with soft tissues are preliminarily placed for at least three days in a 10% solution of neutral formalin;

Fixed rib fragments are washed from formalin for one day in running water and cleaned of soft tissues with a scalpel, without touching the edges of the fracture;

The ribs are again placed in running water for 1-2 hours and carefully cleaned of remnants of the periosteum, and the spongy substance is washed from the blood;

Cleaned fractures are degreased in an ethereal alcohol solution (1:1), dried at room temperature, and labeled.

3. To more accurately determine the limitation period, indicate:

Subtype of fracture and its features: complete or not, location of the fracture plane relative to the long axis of the rib;

Serial number of the edge and side;

Localization of rib fractures relative to anatomical lines.

For direct microscopy, a stereomicroscope (with x 8x magnification) is used, rotating the edge under the microscope lens to identify signs of age along the edges (traces, rubs, sanding). Having discovered them, it is necessary to fix the rib on the stage using plasticine and continue inspection, paying attention to the following points:

Degree of expression of traces: 2 – pronounced, 1 – subtle, 0 – none;

Degree of severity of rubbing: 3 – most pronounced, 2 – pronounced, 1 – barely noticeable, 0 – none;

Degree of severity of polishing: 3 - maximum pronounced, 2 - pronounced, 1 - barely noticeable, 0 - none.

4. Substitute the obtained results into the developed expert model for determining the duration of rib fractures in the form of a regression equation (No. 1).

5. For histological examination of signs of age of chest injury:

Soft tissue from the fracture area is taken from the area of ​​adjacent undamaged tissue. Samples are fixed in a 10% solution of neutral formalin and subjected to standard paraffin wax (D.S. Sarkisov, Yu.L. Perov, 1996);

Paraffin sections 5-10 µm thick are stained with hematoxylin and eosin;

The bone is decalcified in a 7% nitric acid solution for two weeks, then washed in running water and also subjected to standard paraffin embedding, followed by hematoxylin-eosin staining of the sections.

6. Area of ​​histological section; number of arteries, veins, capillaries; number of full-blooded arteries, veins, capillaries, number of empty arteries, number of arteries with spasm, number of collapsed veins, capillaries, couplings, tracks, fibrin (severity of the sign in points: 0-none, 1-fibrin strands, 2-granular fibrin), hemolysis , necrosis, breakdown of leukocytes (0-none, 1-few, 2-many), vascular proliferation (0-none, 1-few, 2-many), lacunae, periosteum, described at 10x magnification, other signs: quantity neutrophils, macrophages, lymphocytes in the lumen / in the wall / near the arteries, veins, capillaries, the number of fibroblasts near the arteries, veins, capillaries, the number of neutrophils, lymphocytes, macrophages, fibroblasts in the thickness / at the border of the hemorrhage - with a 40-fold increase.

7. Based on the primary data, obtain calculated characteristics (see chapter “Material and research methods”).

8. Substitute the obtained results into the developed expert models for determining the duration of rib fractures (in the time period from 30 minutes to 27 days - No. 2, No. 4 or the time period from 30 minutes to 24 hours - No. 3).

9. For a more accurate forensic medical diagnosis of the duration of rib fractures, you should use Table No. 1 of qualitative histological signs characterizing the duration of the injury.

Table No. 1. Qualitative histological signs of the age of rib fractures.

Feature name	Appearance time sign	Time of disappearance sign
Congestion of the arteries	30 minutes 30 hours
Congestion of veins
Congestion of capillaries		16-27 days
Neutrophils in the lumen of arteries
Neutrophils in the lumen of veins
Neutrophils in the lumen of capillaries	16 hours
Neutrophils in artery walls
Neutrophils in the walls of veins		4 hours 40 minutes
Neutrophils in the walls of capillaries	1 hour 10 minutes
Neutrophils near arteries
Neutrophils near veins		over 6 hours
Neutrophils near capillaries
Leukocyte couplings
Leukocyte tracks
Leukocyte shaft
Neutrophils at the border of hemorrhage
Neutrophils in the thickness of the hemorrhage
Monocytes in the lumen of arteries		up to 27 days
Monocytes in the lumen of veins		10-27 days
Monocytes in the lumen of capillaries
Monocytes in the artery wall	1 hour 10 minutes
Monocytes in the vein wall	16 hours -24 hours a
Monocytes in the capillary wall	1 hour 25 minutes
Macrophages near arteries
Macrophages near veins
Macrophages near capillaries
Macrophages at the border of hemorrhage
Macrophages in the depth of hemorrhage
Lymphocytes in the lumen of arteries
Lymphocytes in the lumen of capillaries	1 hour – 24 hours
Lymphocytes in the artery wall	1 hour -24 hours	2, 5, 7 days
Lymphocytes in the vein wall	24 hours and 5 days
Lymphocytes in the capillary wall	1 hour - 24 hours
Lymphocytes near arteries	35 minutes - 24 hours	1 - 11 days
Lymphocytes near veins	5 hours 25 minutes - 24 hours	2 – 10 days
Lymphocytes near capillaries		24 hours, 14 and 27 days
Lymphocytes at the border of hemorrhage
Lymphocytes in the thickness of the hemorrhage
Necrosis of fat, muscle and connective tissue
Hemolysis of red blood cells
Fibroblast proliferation around arteries
Fibroblasts in the thickness of the hemorrhage
Fibroblasts at the border of hemorrhage
Granulation tissue
Chondrocyte proliferation

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2. Possibilities of forensic medical determination of the age of rib fractures (preliminary study) // Current issues of forensic medicine and expert practice at the present stage. –M. -2006. –P.39-41. (co-author I.N. Bogomolova).

3. Forensic medical determination of the prescription of rib fractures // Forensic medical. expert. – 2008. - No. 1. – P. 44-47. (co-author V.A. Klevno, I.N. Bogomolova).