X-ray differential diagnosis of traumatic and malignant compression fractures of the vertebrae. Healing time for rib fractures
As a manuscript KIREEVA Elena Andreevna FORENSIC MEDICAL ESTABLISHMENT OF RIB FRACTURES 14.00.24. – Forensic medicine Abstract of the dissertation for the degree of Candidate of Medical Sciences Moscow 2008. The work was carried out by the state institution 3 thanatological “Russian Center of the Department of the Federal Forensic Medical Examination of Roszdrav”. Scientific adviser: Doctor of Medical Sciences, Professor V.A. Klevno Official opponents: Honored Worker of Science of the RSFSR, Doctor of Medical Sciences, Professor V.N. Kryukov Candidate of Medical Sciences O.V. Lysenko Lead institution: Military Medical Academy. CM. Kirov The defense of the dissertation will take place on April 10, 2008 at 13-00 hours at a meeting of the Dissertation Council D 208.070.01 at the Federal State Institution "Russian Center for Forensic Medical Examination of Roszdrav" (125284, Moscow, Polikarpova St., house. 12/13). The dissertation can be found in the library of the Federal State Institution "Russian Center for Forensic Medical Examination of Roszdrav". Panfilenko 4 General characteristics of the work Relevance of the study One of the topical issues in forensic medicine is the establishment of lifetime and prescription of 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). Assessment of lifetime and prescription of bone fractures using X-ray (S.B. Maltsev, E.Kh. Barinov, M.O. Solovieva, 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 microscopy (L. Harsanyi, 1976, 1981, V.A. Klevno, 1994), and biophysical methods (A.M. Kashulin, V.G. Baskakov, 1978, VF Kovbasin, 1984), single works are devoted to it. Most of the listed works are descriptions of the results of preliminary studies and are unsuitable for practical use (L. Harsanyi, 1976, 1981, A.M. Kashulin, V.G. Baskakov, 1978, S.B. Maltsev, E.Kh. Barinov, M O. Solovieva, 1995, A. V. Saenko et al., 1996, 1998). The rest of the works are not detailed enough, and their practical application 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 survival, a fractographic method was used to study the traces of dynamic sliding on the fracture surface of rib fragments, and morphological changes in the surface of fractures during active breathing were also evaluated (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 prescription of fractures has not been studied enough and its solution is possible through a comprehensive analysis of changes occurring in the biotribological system, which is a rib fracture, with continued breathing, as well as to develop criteria for diagnosing the prescription of rib fractures. The purpose of the study was to develop criteria for forensic diagnostics of the prescription of rib fractures. To achieve this goal, the following tasks were set: 1. To conduct a qualitative analysis of pathomorphological changes in the area of the ends of the fragments and the surrounding soft tissues of rib fractures of various age. 2. Carry out a quantitative histomorphological analysis of signs in the area of the ends of fragments and soft tissues of rib fractures of various age. 5 3. Conduct a semi-quantitative fractographic study of rib fractures to establish morphological features that reflect their age. 4. Based on the results of pathomorphological, histological and fractographic studies, develop criteria for forensic diagnostics of the prescription 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 medical diagnosis of the prescription of rib fractures; the dynamics of these signs is described for the first time. A set of fundamentally new histomorphometric parameters reflecting the dynamics of fracture healing was used. For the first time, the features of necrotic, inflammatory and regenerative processes in the zone of rib fractures were revealed, consisting in the fact that necrotic changes in tissues, hemolysis of erythrocytes, leukocyte and macrophage reaction, fibroblast proliferation and formation of granulation tissue unfold faster, and the reaction of vessels later than with damage to other localization and kind. Practical significance The results of the dissertation can be used for forensic diagnostics of the prescription of rib fractures. Based on the data obtained, a complex method for forensic determination of the prescription of rib fractures was developed, which includes regression equations based on histological and fractological features, as well as a table of qualitative features. The proposed method is easy to perform, does not require special training and the proposed use of expensive forensic medical expendable materials. allows to increase the accuracy and objectivity of forensic medical diagnostics of prescription of mechanical chest injury. Implementation into practice The results of the study were introduced into the practice of the Federal State Institution "Russian Center for Forensic Medical Examination of Roszdrav", into the practice of the Main State Center for Forensic and Forensic Examinations of the Ministry of Defense of the Russian Federation; into the work of the thanatological department No. 6 of the Bureau of Forensic Medical Examination of the DZ of Moscow. 6 Approbation of the work The materials of the dissertation were presented and discussed at scientific conferences of the Federal State Institution “RC SME of Roszdrav”. Approbation of the work took place on November 15, 2007 at the extended scientific-practical conference of the Federal State Institution "RC SME of Roszdrav". Publications 3 scientific articles were published on the topic of the dissertation, 1 of them - in the journal "Forensic Medical Expertise". The dissertation structure The dissertation consists of an introduction, literature review, description of the materials and methods used, 2 chapters of the results of own research, their discussion, conclusion, conclusions and bibliography (258 sources, of which 236 are domestic and 22 foreign). The text is set out on 199 pages of a computer set, illustrated with 33 microphotographs, 9 tables. The main provisions submitted for defense: 1. The degree of severity of changes in the contact zone of rib fragments detected by the fractographic method (trass, rubbing, grinding) can be used for forensic diagnostics of fracture age. 2. Necrotic, inflammatory and regenerative processes in the rib fracture zone have features that necrotic tissue changes, erythrocyte hemolysis, leukocyte and macrophage reaction, granulation tissue formation and fibroblast proliferation unfold faster, and vascular reaction - later than with damage other localization and type. 3. A comprehensive method has been developed for determining the age of rib fractures, based on a semi-quantitative fractographic, quantitative and qualitative histological assessment of signs of injury age, which makes it possible to increase the accuracy and objectivity of establishing the age of damage. MATERIALS AND METHODS OF THE STUDY Material of the study As the material of the study, 203 (213 fractures) ribs and soft tissues from the area of the fracture were used, from which 213 bone preparations and 179 histological sections were prepared. The material was obtained as a result of a sectional forensic examination of 84 corpses (59 men and 25 women aged 25-89 years) with a chest injury from 30 minutes to 27 days (according to the SMP accompanying sheet (time of the call) and from decisions on the appointment of a forensic examination of 7 corpses). The cause of death in 8 cases was cardiovascular and neurological diseases, in the rest - mechanical trauma. There were 25 people in a state of 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 the state of intoxication with the conclusion - alcohol intoxication, without the results of blood tests for alcohol. Sectional research method Forensic examination of corpses was carried out on the basis of traditional sectional methods (A.I. Abrikosov 1939, G.G. Avtandilov, 1994). Fractographic method of research To study the morphology of fractures of the ribs, the method of I.B. Kolyado and V.E. Yankovsky 1990, then a detailed study of the fracture surface was carried out to identify expert diagnostic criteria for intravital rib fractures (Klevno V.A., 1991, Kolyado I.B., 1991), using a LEICA EZ4D stereomicroscope (with x 8-fold magnification) , the data obtained were recorded in the columns: 1. TRACES (they are traces of the dynamic mutual impact of rib fragments with continued breathing) (in points): 3); Fig.1. Inconspicuous tracks (1 point), with an injury prescription of 55 minutes; x8 Fig.2. Pronounced traces (2 points) inconspicuous shiny rubbing (1 point) with an injury prescription of 5 hours 40 minutes; x 8 2. NATIRS (or a shiny area - a piece 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 surface of the fracture and in the region of the marginal areas of the fragments, depending on their conditions of initial sliding .) the presence and severity of shiny areas were noted (in points): 3 - most pronounced (Fig. 4), 2 - pronounced (Fig. 3), 1 - hardly noticeable (Fig. 2), 0 - none; 8 Fig.3. Pronounced rubbing (2 points) with an injury prescription of 3 days; x8 Fig.4. The most pronounced rubbing (3 points) with an injury prescription of 7 days; x8 3. GRINDING (Grinding of the fracture edge 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 actual touch area. ): 3 - the most pronounced (Fig. 7), 2 - pronounced (Fig. 6), 1 - inconspicuous (Fig. 5), 0 - none. Fig.5. Mild grinding (1 point) of the fracture surface with an injury prescription of 19 hours 20 minutes; x8 Fig.6. Pronounced grinding (2 points) of the fracture surface with an injury prescription of 5 days; x8 Fig.7. The most pronounced grinding (3 points) of the fracture surface with an injury prescription of 6 days; x8 9 Microscopic examination method Soft tissues from the area of the fracture were taken with a zone of adjacent undamaged tissues. The samples were fixed in 10% neutral formalin solution and subjected to standard paraffin wiring (D.S. Sarkisov, Yu.L. Perov, 1996). Paraffin sections 5–10 µm thick were stained with hematoxylin and eosin and by 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 wiring, 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 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 trait, wall, perivascular location, perivascular accumulations (mufts, lanes, accumulations at the border of the 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 thickness periosteum, 8. analysis of all observations that do not fit into the general law accuracy, in order to establish their number and the reasons for the increase or decrease in the studied reaction. 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 the hemorrhage, these signs were observed in 1 field of view. Signs - the area of the histological section; the number of arteries, veins, capillaries; the 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 clutches, fibrin, hemolysis, necrosis, leukocyte breakdown, vascular proliferation, lacunae, periosteum were described and measured at a magnification of 100 times, other signs - at a magnification of 400 times. 10 Based on the primary data, the calculated signs were obtained: 1. RATIO OF THE NUMBER OF NEUTROPHILS PER LUMINAL OF ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of neutrophils in the lumen of arteries, veins, capillaries / to the total number of arteries, veins, capillaries) 2. RATIO OF THE NUMBER MACROPHAGES PER LIGHT OF ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of macrophages in the lumen of arteries, veins, capillaries / total number of arteries, veins, capillaries) lymphocytes in the lumen of arteries, veins, capillaries / total number of arteries, veins, capillaries) 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, in ene, 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 NEAR THE ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of neutrophils near the walls of arteries, veins, capillaries / to the total number of arteries, veins, capillaries) 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 / per total number of arteries, veins, capillaries) 10. RATIO OF THE NUMBER OF FIBROBLASTS NEAR ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of fibroblasts near arteries, veins, capillaries / per total number of arteries, veins, capillaries) 11. SHARE OF FULL-BLOODED, EMPTY, SPASMED ARTERIES (number of full-blooded, empty, spasmodic arteries / total number of arteries) 11 / per total number of veins) 13. SHARE OF FULL-BLOODED, DESERTED, CAPILLARIES (number of full-blooded, desolate, 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 rank nature, since they were scores of features. Others had a distribution that differed from normal. Therefore, the multivariate correlation analysis of the obtained data was carried out according to Spearman. In the study of the correlation of fractographic signs with the duration of the injury, it was carried out for the entire range of the duration of the post-traumatic period, and the 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 choosing the parameters most strongly correlated with injury age, a multivariate regression analysis was also performed, resulting in regression equations that can be used to determine injury age. During the statistical study, the following were used: - operating shell Microsoft Windows XP Professional 2002; - software tool for statistical analysis SPSS for Windows v.7.5 (SPSS Inc.). Results of the study Results of fractographic study Trases are the earliest sign of dynamic sliding of bone fragments, which, according to our data, can be clearly seen as early as 30 minutes after 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 the prescription of the post-traumatic period up to 5 hours. From 5:00 to 1:00, trails are found only in combination with shiny grounds. This combination may appear earlier, starting from 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 more than this value. Starting from 70 minutes to 24 hours, a combination of traces can also be observed with a polished fracture edge. The first mild rubbing (shiny areas, 1 point) appears when the injury is 30 minutes old. Their weak severity can be observed up to 8 days, 12 significantly pronounced shiny areas (2 points) were detected with an injury prescription from 3 to 27 days. 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. Grinding (weakly expressed - 1 point) was observed along with traces and rubbing, in the period from 1 hour 20 minutes to 7 days, mild rubbing (1 point) was combined with mild grinding (1 point). Pronounced grinding (2 points) was noted by us in the range of injury prescription from 19.3 hours to 11 days, always with equally pronounced shiny areas, both on the surface and on the edge of the fracture. 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 the complete absence of traces (0 points). Less pronounced signs of dynamic sliding: - with incomplete fractures; - on the side of the chest where more ribs are broken; - on the upper (from 1 to 2 ribs) and lower ribs (starting from 7); - with fractures passing at the border of bone and cartilage tissue. The use of multivariate correlation and regression analysis of signs (fractographic and histological) of injury prescription, taking into account the factors affecting the healing dynamics and, accordingly, the severity of the symptom, made it possible to develop criteria for the prescription of rib fractures. It was found that the following fractographic features have the highest correlation coefficients with the duration of the injury in the entire studied range of the duration of the post-traumatic period: traces, rubbing, grinding, rolling. On their basis, an expert model for determining the prescription of rib fractures was developed in the form of a regression equation (No. 1), which has the form: Т=k0+k1 R1+k2R2+k3 R3, where Т is the predicted duration of damage in minutes; k0, k1, k2, k3 - regression coefficients calculated in the study of the fracture surface of a rib with known damage age, where k0=-1359, 690; k1=3.694; k2=1538.317; k3=3198.178; R1, R2, R3, - the severity of the trait in points, where R1 - traces, R2 - rubbing, R3 - grinding. Thus, Т= -1359.690+3.694R1+1538.317 R2+3198.178 R3< 0,001). 13 Результаты гистологического исследования. По нашим данным, реакция организма на перелом ребер в динамике развертывается следующим образом. Повышение кровенаполнения артерий, вен и капилляров развивается в течение 1 часа после травмы груди, но в артериях полнокровие сохраняется до 7 часов, в капиллярах – до 6 часов, а в венах лишь до 1,5-2 часов. В посттравматическом периоде от 1 до 27 суток полнокровие сосудов нарастает повторно: вен - в сроки от 7 до 11 суток после травмы, артерий - с начала вторых суток до 8 суток после травмы, капилляров - от 7 до 16 суток после травмы. Гемолиз эритроцитов может начаться уже через полчаса после травмы и нарастает по мере увеличения посттравматического периода. При давности травмы свыше 10 суток наступает гемолиз практически 100% эритроцитов, находящихся в зоне кровоизлияния. Некроз мышечной, жировой, соединительной и костной ткани развивается примерно через 1 час после травмы. Лейкоцитарную реакцию на перелом ребра можно охарактеризовать следующим образом. Повышение количества нейтрофилов в сосудах и их краевое стояние заметно уже через 30 минут после травмы (в капиллярах – через 1 час), но в артериях оно достигает максимальной выраженности в период от 1 до 3 часов, в капиллярах - к 3-4 часам, в венах около 5-7 часов после травмы. Диапедез нейтрофилов в ткани начинается уже при давности травмы 35 минут и наиболее выражен в артериях, где через час после травмы формируются лейкоцитарные муфты и дорожки. Он завершается в артериях после 12 часов, в стенках вен уже после 4,5 часов, а в стенках капилляров после 2 часов. Периваскулярно нейтрофилы обнаруживаются около вен до 6 часов после травмы, около капилляров до 11 часов, а около артерий единичные нейтрофилы и периваскулярные муфты можно определить даже через 24 часа после травмы. На границе кровоизлияния лейкоциты появляются не ранее чем через 1 час после травмы. Их количество достигает максимума в сроки от 6 до 24 часов, и с 16 часов уже прослеживается лейкоцитарный вал. В эти же сроки можно видеть множественные лейкоцитарные дорожки, идущие от сосудов к кровоизлиянию. При давности травмы более 1 суток реакция лейкоцитов становится очень вариабельной и зависит от сохранности реактивности организма и от наличия лейкоцитоза как реакции на гнойно-воспалительный процесс (пневмония, менингит и т.д.). Тем не менее, некоторые закономерности удается проследить. Небольшие лейкостазы в сосудах различного типа могут обнаруживаться до 11 (капилляры), 16 (вены) и 27 суток (артерии). Лейкодиапедез, однако, со 2 суток отсутствует или незначителен – в виде единичных клеток и только через артерии. Единичные нейтрофилы около сосудов могут определяться до 27 суток после травмы, но лейкоцитарные муфты в препаратах с давностью травмы свыше 1 14 суток не определяются. Лейкоцитарные дорожки перестают наблюдаться при давности травмы свыше 2 суток. Лейкоцитарный вал может определяться до 5-10 суток. Позже можно обнаружить лишь единичные нейтрофилы в толще грануляционной ткани, образующейся на месте кровоизлияния, но не на границе. Распад лейкоцитов начинается уже при давности травмы более часа и продолжается до 14 суток, после чего перестает определяться в связи с затуханием лейкоцитарной реакции. В первые сутки в просветах сосудов могут наблюдаться лишь единичные моноциты. Реакция моноцитов становится отчетливой (в виде повышения их количества в просветах вен) не раньше чем через 4-6 часов после травмы и не во всех случаях. Диапедез моноцитов в ткани может начаться уже через 1 час после повреждения в артериях и только через 4 часа – в других сосудах. Основная масса моноцитов выходит из крови в ткани через артерии. Появление единичных макрофагов на границе кровоизлияния и в его толще также отмечается уже через 1 час после травмы, но количество их нарастает медленно, и его небольшое увеличение становится заметным лишь к концу 1 суток. Моноциты скапливаются в сосудах (главным образом артериях) в основном в период времени от 5 до 10 суток. Для вен этот интервал дольше – от 2 до 14 суток, - но реакция моноцитов в них менее постоянна. Диапедез моноцитов наблюдается в основном в период 2-6 суток. Позже около сосудов могут обнаруживаться лишь единичные макрофаги либо они вообще отсутствуют. Соответственно с 5 по 10 сутки после травмы обнаруживается наибольшее количество макрофагов в толще кровоизлияния, а со 2 до 7 суток – на его границе. В течение первых суток реакция лимфоцитов на травму незначительна и обнаруживается не всегда. Однако первые лимфоциты, выходящие из сосудов в ткани, могут быть обнаружены уже через 1 час после травмы. К концу 1 суток отдельные лимфоциты отчетливо заметны на границе кровоизлияния и в его толще. Диапедез лимфоцитов менее интенсивен, чем других клеток крови, происходит в основном через артерии и в меньшей степени – через вены в период от 1 до 10-11 суток после травмы, достигая максимума примерно на 5 сутки. На границе кровоизлияния и в его толще лимфоциты также появляются через 1 сутки после травмы, достигают максимума к 5 суткам, и при давности травмы свыше 10 суток они перестают определяться на границе и становятся немногочисленными или исчезают совсем в толще кровоизлияния. Возможны повторные волны усиления диапедеза лимфоцитов в наблюдениях с давностью травмы 14 и 27 суток, но из-за редкости таких случаев дать их объяснение невозможно. Достоверных признаков пролиферации фибробластов или иных проявлений регенерации в случаях с давностью травмы до 24 часов не обнаруживается. 15 Пролиферация фибробластов происходит главным образом вокруг артерий (через 5-10 суток после травмы) и в соединительной ткани в толще кровоизлияния (начиная с 3 суток после травмы). На границе кровоизлияния единичные фибробласты появляются не раньше чем через 3 суток после травмы, а после 7 суток после травмы уже не определяются. В противоположность этому, количество фибробластов в толще кровоизлияния нарастает по мере развития грануляционной ткани. Толщина надкостницы может возрастать до 3х клеток уже после 35 минут после травмы и продолжает увеличиваться до 27 суток, однако прямая зависимость между давностью травмы и количеством слоев камбиальных клеток в надкостнице отсутствует. Грануляционная ткань в виде скопления тонкостенных сосудов, между которыми имеются макрофаги, лимфоциты и фибробласты, обнаружена при давности травмы от 5 суток до 27 суток. Таким образом, формирование грануляционной ткани начинается уже с 5 суток после травмы. Рис. 8. Формирование хряща, давность травмы 8 суток х200 Рис. 9. Формирование травмы 16 суток х200 хряща, давность При давности травмы от 9 суток в области перелома отмечаются пролифераты хондроцитов, а развитая хрящевая ткань обнаруживается при давности травмы при длительности посттравматического периода 27 суток (рис.8-9). Исследования показали, что наибольшие коэффициенты корреляции с давностью травмы на всем изученном диапазоне длительности посттравматического периода имеют признаки: доля полнокровных артерий, доля спавшихся вен, количество макрофагов, лимфоцитов и фибробластов около артерий и около вен, количество макрофагов около капилляров, количество макрофагов, лимфоцитов и фибробластов в толще кровоизлияния, количество макрофагов на границе кровоизлияния, наличие и выраженность отложений фибрина, пролиферация сосудов. 16 На их основе была разработана экспертная модель определения давности переломов ребер в промежуток времени от 30 минут до 27 суток в виде уравнения регрессии (№2): Т=k1+k2Q1+k3Q2+k4Q3+k5Q4+k6Q5+k7Q6+k8Q7; где Т – прогнозируемая давность повреждения в минутах; k1,k2,k3,…. k8 – коэффициенты регрессии, вычисленные при гистологическом исследовании лиц с известной давностью травмы груди; Q1 – количество макрофагов около артерий; Q2 – количество фибробластов около артерий; Q3 - количество фибробластов около вен; Q4 – количество макрофагов в толще кровоизлияния; Q5 – количество лимфоцитов в толще кровоизлияния; Q6 – степень выпадения фибрина; Q7 – степень выраженности сосудов пролиферации; Таким образом, давность травмы в минутах можно определять по следующей формуле: Т=711,241+158,345Q1+277,643Q2+331,339Q3-7,899Q483,285Q5+681,551Q6+4159,212Q7, (.коэффициент корреляции для данной модели r = 0,877, стандартная ошибка 2783,82, значимость р < 0,001). С учетом того, что лейкоцитарная реакция нарастает в основном в первые сутки с момента причинения травмы, для дифференциальной диагностики, мы постарались более подробно изучить данный временной интервал. На основании данных корреляционного анализа была выявлена сильная корреляционная зависимость между давностью механической травмы ребер (до 1 суток) и степенью выраженности скоплений и распада лейкоцитов, а также процентом гемолиза эритроцитов, долей полнокровных капилляров, количеством макрофагов в толще кровоизлияния, и корреляционная зависимость средней степени между давностью механической травмы груди и отношением количества нейтрофилов и макрофагов около артерий к числу этих сосудов в препарате, отношением количества нейтрофилов и макрофагов около капилляров к числу этих сосудов в препарате, количеством лимфоцитов в толще кровоизлияния, количеством макрофагов на границе кровоизлияния. На их основе была разработана экспертная модель определения давности переломов ребер в промежуток времени от 30 минут до 24 часов в виде уравнения регрессии (№3): Т=k1+k2G1+k3G2+k4G3+k5G4+k6G5+k7G6+k8G7+k9G8+k10G9+k11G10+k12G11; где Т – прогнозируемая давность повреждения в минутах; k1,k2,k3,…. k12 – коэффициенты регрессии, вычисленные при гистологическом исследовании лиц с известной давностью травмы груди; 17 G1 – отношение количества нейтрофилов около артерий к числу артерий; G2 – отношение количества макрофагов около артерий к числу артерий; G3 – доля полнокровных капилляров; G4 – отношения количества нейтрофилов около капилляров к числу капилляров; G5 – отношение количества макрофагов около капилляров к числу капилляров; G6 – степень выраженности лейкоцитарного вала; G7 – количество макрофагов в толще кровоизлияния; G8 – количество лимфоцитов в толще кровоизлияния; G9 – количество макрофагов на границе кровоизлияния; G10 – процент гемолизированных эритроцитов; G11 – степень распада лейкоцитов; Таким образом, Т=-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+х,488G10+61,029G11, (коэффициент корреляции для данной модели r = 0,819, стандартная ошибка 174,05, значимость р < 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 средней степени между давностью травмы и степенью выраженности трас. 3. Менее выражены фрактологические признаки давности при неполных переломах, на той стороне грудной клетки, где сломано большее количество ребер, на верхних (с 1 по 2) и нижних ребрах (начиная с 7), при некоторых оскольчатых и косопоперечных переломах, при переломах, проходящих по окологрудинной линии и на границе костной и хрящевой ткани. 4. Особенности некротических, воспалительных и регенераторных процессов в зоне переломов ребер заключаются в том, что гемолиз эритроцитов, лейкоцитарная и макрофагальная реакция, некротические изменения тканей, пролиферация фибробластов и формирование грануляционной ткани развертываются быстрее, а реакция сосудов - позднее, чем при повреждениях других локализаций и видов. 5. В первые сутки обнаруживается сильная корреляция с давностью травмы следующих гистологических параметров: процентом гемолиза эритроцитов, долей полнокровных капилляров, среднего количества нейтрофилов около артерий и капилляров, количества нейтрофилов на границе кровоизлияния в поле зрения х400, степенью выраженности распада лейкоцитов, среднего количества макрофагов около артерий и около капилляров, количества макрофагов на границе кровоизлияния в поле зрения х400, количества макрофагов и лимфоцитов в толще кровоизлияния в поле зрения х400. 6. Во всем диапазоне давности травмы обнаруживается сильная корреляция с давностью травмы ребра следующих гистологических параметров: доля полнокровных 19 артерий, доля спавшихся вен, среднее количество макрофагов, лимфоцитов и фибробластов около артерий и около вен, среднее количество макрофагов около капилляров, количество макрофагов, лимфоцитов и фибробластов в толще кровоизлияния в поле зрения х400, количество макрофагов на границе кровоизлияния в поле зрения х400, наличие и характер отложений фибрина, выраженность пролиферации сосудов. 7. Предложен комплексный метод судебно-медицинского определения давности переломов ребер, включающий в себя уравнения регрессии на основании гистологических и фрактологических признаков, а также таблицу качественных гистологических признаков. Практические рекомендации 1. Для судебно-медицинской диагностики давности переломов ребер рекомендуется использовать комплексное фрактологическое исследование области излома и гистологическое исследование кости и мягких тканей из зоны перелома. 2. Поскольку в основе формирования признаков прижизненного происхождения переломов ребер лежат процессы трения, то необходимо исключить грубые манипуляции в области переломов при приготовлении препаратов: - сломанные ребра изымаются целиком путем рассечения межреберных промежутков и вычленения их головок, маркируются; - изъятые переломы ребер вместе с мягкими тканями предварительно помещаются минимум на трое суток в 10% раствор нейтрального формалина; - зафиксированные отломки ребер промываются от формалина в течение одних суток в проточной воде и скальпелем, не задевая краев перелома, очищаются от мягких тканей; - ребра вновь помещаются в проточную воду на 1-2 часа и осторожно очищаются от остатков надкостницы, а губчатое вещество промывают от крови; - очищенные переломы обезжириваются в спирт эфирном растворе (1:1), высушиваются при комнатной температуре, маркируются. 3. Для более точного определения давности указывается: - подвид перелома и его особенности: полный или нет, расположение плоскости перелома относительно длинной оси ребра; - порядковый номер ребра и сторона; - локализация переломов ребер относительно анатомических линий. Для непосредственной микроскопии используется стереомикроскоп (с х 8 кратным увеличением), вращая ребро под объективом микроскопа, выявляют по краям признаки давности (трасы, натиры, зашлифованность). Обнаружив их, необходимо при помощи 20 пластилина закрепить ребро на предметном столике и продолжать осмотр, обращая внимание на следующие моменты: - степень выраженности трас: 2 –выраженные, 1-малозаметные, 0-нет; - степень выраженности натиров: 3 – максимально выраженные, 2 –выраженные, 1малозаметные, 0-нет; - степень выраженности зашлифованности: 3 – максимально выраженная, 2 – выраженная, 1-малозаметная, 0-нет. 4. Полученные результаты подставить в разработанную экспертную модель определения давности переломов ребер в виде уравнения регрессии (№1). 5. Для гистологического исследования признаков давности травмы груди: - мягкие ткани из области перелома берутся с зоной прилежащих неповрежденных тканей. Образцы фиксируются в 10% растворе нейтрального формалина и подвергаются стандартной парафиновой проводке (Д.С. Саркисов, Ю.Л. Перов, 1996); - парафиновые срезы толщиной 5-10 мкм окрашиваются гематоксилин и эозином; - кость декальцинируется в 7% растворе азотной кислоты в течение двух недель, далее промывается в проточной воде и также подвергается стандартной парафиновой проводке, с последующим окрашиванием срезов гематоксилин эозином. 6. Площадь гистологического среза; количество артерий, вен, капилляров; количество полнокровных артерий, вен, капилляров, количество пустых артерий, количество артерий со спазмом, количество спавшихся вен, капилляров, муфты, дорожки, фибрин (выраженность признака в баллах: 0-нет, 1-нити фибрина, 2-зернистый фибрин), гемолиз, некроз, распад лейкоцитов (0-нет. 1-мало, 2-много), пролиферация сосудов (0нет, 1-мало, 2-много), лакуны, надкостница, описываются при увеличении в 10 раз, остальные признаки: количество нейтрофилов, макрофагов, лимфоцитов в просвете / в стенке / около артерий, вен, капилляров, количество фибробластов около артерий, вен, капилляров, количество нейтрофилов, лимфоцитов, макрофагов, фибробластов в толще / на границе кровоизлияния - при увеличении в 40 раз. 7. На основе первичных данных получить расчетные признаки (см. главу «Материал и методы исследования»). 8. Полученные результаты подставить в разработанные экспертные модели определения давности переломов ребер (в промежуток времени от 30 минут до 27 суток №2, №4 или промежуток времени от 30 минут до 24 часов -№3). 9. Для более точной судебно - медицинской диагностики давности переломов ребер следует воспользоваться таблицей № 1 качественных гистологических признаков, характеризующих давность травмы. 21 Таблица №1. Качественные гистологические признаки давности образования переломов ребер. Название признака Полнокровие артерий Полнокровие вен Полнокровие капилляров Нейтрофилы в просвете артерий Нейтрофилы в просвете вен Нейтрофилы в просвете капилляров Нейтрофилы в стенках артерий Нейтрофилы в стенках вен Нейтрофилы в стенках капилляров Нейтрофилы около артерий Нейтрофилы около вен Нейтрофилы около капилляров Лейкоцитарные муфты Лейкоцитарные дорожки Лейкоцитарный вал Нейтрофилы на границе кровоизлияния Нейтрофилы в толще кровоизлияния Моноциты в просвете артерий Моноциты в просвете вен Моноциты в просвете капилляров Моноциты в стенке артерий Моноциты в стенке вен Моноциты в стенке капилляров Макрофаги около артерий Макрофаги около вен Макрофаги около капилляров Макрофаги на границе кровоизлияния Макрофаги в толще кровоизлияния Лимфоциты в просвете артерий Лимфоциты в просвете капилляров Лимфоциты в стенке артерий Лимфоциты в стенке вен Лимфоциты в стенке капилляров Лимфоциты около артерий Лимфоциты около вен Лимфоциты около капилляров Лимфоциты на границе кровоизлияния Лимфоциты в толще кровоизлияния Некроз жировой, мышечной и соединительной ткани Гемолиз эритроцитов Фибрин Время появления признака 30 минут 30 часов 30 минут 30 часов 30 минут 30 часов 30 минут 30 минут 1 – 6 часов 2 суток 35 минут 1 час 1 час 10 минут 35 минут 80 минут 1 час 55 минут 30 минут 16 часов 1 час 30 минут 30 минут 30 минут 1 -24 часа 1 час 10 минут 16 часов -24 часа а 1 час 25 минут 1 час 3 часа 4 часа 1 час 1 час 30 минут 1 час – 24 часа 1 час -24 часа 24 часа и 5 суток 1 час - 24 часа 35 минут - 24 часов 5 часов 25 минут - 24 часа 1 час 1 сутки 1 сутки 55 минут Время исчезновения признака 7-24 часа 8-27 суток 6-24 часа 7-27 суток 1-6 часов 16-27 суток 27 суток <= 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 center of forensic medical examination. –M. -2006. - P.70-74. (co-author Suvorova Yu.S.). 2. Possibilities of forensic medical determination of the prescription of rib fractures (preliminary study) // Current issues of forensic medicine and expert practice at the present stage. –M. -2006. –S.39-41. (co-author Bogomolova I.N.). 3. Forensic medical determination of the prescription of fractures of the ribs // Sud.-med. expert. - 2008. - No. 1. - S. 44-47. (co-author Klevno V.A., Bogomolova I.N.).
When describing how a fracture looks on an X-ray, it is impossible to offer readers a standard scheme. Each radiologist has his own algorithms for establishing a conclusion based on x-rays. Radiology has the ability to detect bone pathology in traumatic, destructive, 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 the radiograph does not always allow the correct conclusion to be established.
With minor damage, which is popularly called "cracks", specific signs may not be visualized. If there is a history of trauma, clinical symptoms of pathology, computed tomography is prescribed. Magnetic resonance imaging is performed to determine soft tissue changes.
What does a fracture look like on an x-ray: types, description
On x-ray, the fracture looks specific. Classical signs are a linear area of enlightenment, displacement of fragments, and 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, an enlightenment line is observed with no displacement or small discrepancies (convergences) of the fragments.
A complex variety is characterized by the presence of wedge-shaped areas of destruction with separate fragments, various types of displacements.
To determine the tactics of treatment, it is important for a 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 damage to the bones with localization inside the joint. With such a nosology, mobility is limited in most cases. If healing occurs with excessive callus formation, severe immobility is possible.
In relation to the skin, there are 2 types of fractures:
1. Closed;
2. Open.
In the latter form, damage to the skin occurs, the bones protrude outward through the defect. Fractures are accompanied by profuse bleeding. Injury with an open skin defect increases the risk of bacterial infection due to contamination of the wound from the external environment.
In children, a fracture of the left wrist joint in the area of metaepiphyseolysis through the growth zones overgrows for a long time. After healing, shortening of the upper limb is often traced due to improper fusion of the radius or ulna.
On the 20th day, the healing area does not look like a bright band of enlightenment, but the appearance of foci of darkening in the fracture area due to the deposition of calcium salts. On x-rays, the compaction of the fracture area due to an increase in the number of bone beams indicates the healing of the defect.
When analyzing the radiograph, the specialist should pay attention to the stratification of muscle fibers, the appearance of gas bubbles indicating the presence of air between the muscles. Magnetic resonance imaging in this pathology shows the destruction of the muscular-ligamentous structures.
Callus growth radiographs are taken to dynamically monitor bone health. Corn 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 for 1-2 weeks intensifies. The process is due to the resorption of bone beams. Connective tissue grows between fragments. It is not visible on the picture, so it is almost impossible to assess healing until the 20th day.
Osteoid tissue can be traced in the picture, starting from the second decade. It does not contain bone beams, so it is not clearly visualized on the radiograph. If we compare the images in the first and second decades, a more “muddy” spot will be visualized in the area of enlightenment. At the same time, osteoporosis is formed in the articular ends of the bones - a restructuring of the structure.
Dense corn is formed in the 3rd decade. Complete calcification is formed for 2-5 months. Long-term restructuring causes hardening of the damage site. This is how large tubular bones grow together.
The traumatologist or surgeon who treats the patient will be able to determine the timing of repeat radiographs for dynamic tracking. Sometimes it is required to check the fixation of metal pins, plates. Pictures are also assigned to control complications.
With a weak formation of callus, you do not need to think about a violation of bone fusion. Connective, osteoid tissue grows between the fragments, which firmly fuses the fragments together. With such a pathology, radiologists suggest a false joint, but its presence, with a long preservation of the line of enlightenment on an x-ray image, is not necessarily fixed. The fusion of fragments is provided by osteoid tissue. Closing bone plates in the absence of foreign bodies are able to provide the healing process.
Is the fracture visible on x-ray?
Patients who ask the doctor if a fracture is visible on x-rays most often face the problem of visualizing a fracture on an x-ray when they first seek medical help. Either a re-shot after a while or computed tomography helped establish the correct diagnosis.
Let us give an example of a specific case history.
A 14-year-old child had an x-ray of a hand after an injury. The X-ray showed no clearing, no displacement of the fragments, no separation of the fragments. After examining the traumatologist and analyzing the x-ray, the diagnosis of "soft tissue injury" was made.
Treatment for a week did not bring relief. A bandage was applied, gypsum was not performed. After repeated radiography, a fracture of the 1st metacarpal bone of the right hand was revealed.
Patients in such a situation often write complaints about doctors, as they worry that the diagnosis was not established on time. During the week, the child was not provided with qualified assistance. Is there a mistake by specialists, and what harm is caused by the “wrong” treatment of a bruise, and not 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 path of the beam or incomplete damage to the bone. In children, bone tissue contains a large amount of cartilage.
On the second image, the line of enlightenment appeared due to the greater divergence of the bone fragments. If we assume such a situation, then the fracture is not visible on x-ray. In the people, such damage is simply called a “crack”.
Even with a computed tomogram for such injuries, it is impossible to accurately establish the diagnosis. Confirmation of the assumption is the lack of alertness of the traumatologist when examining the patient.
A visible gap is not always a fracture, since the lines of enlightenment create blood vessels, hemorrhages. The absence of a defect is not a guarantee of the exclusion of damage to the bone structure.
When performing a CT scan, the child would receive a dose of radiation exposure. To avoid it, traumatologists did not prescribe an additional examination. For a week, in the absence of displacement of fragments, the defect could not increase.
In such a situation, the most correct decision of the doctor is the restriction of mobility even in the absence of visible signs of damage on the x-ray. When analyzing the medical history of the above-described child, it should be clarified how the mobility of the arm was limited, since in the second week a line of enlightenment appeared during the second radiography.
If the x-ray does not show a fracture, a dynamic examination should be performed. A series of follow-up radiographs will carefully assess the nature of the traumatic injury.
X-ray signs of a fracture in a birth injury
X-ray signs of a fracture in a birth injury are not studied at the institutes for advanced training of doctors. Pathology remains poorly understood, but according to statistics, it often occurs in newborns who are subsequently diagnosed with perinatal encephalopathy.
The cause of 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 been published in which biomechanical damage to the nervous system occurs.
According to typical concepts, bone damage in the fetus in the region of the parietal and occipital bones occurs in the following sequence:
The head of the child is pressed against the birth canal under the influence of exorcising forces. In this case, a hemorrhage is formed in the periosteum, aponeurosis, scalp;
The deflection of the bones of the skull occurs at the "wire point", where the hyperextension of the brain is formed, the likelihood of intradural bleeding increases;
The tension of the spine in the cervical region increases due to synchondrosis of the occipital bone, the displacement of the bones leads to compression of the 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 with increasing pressure and can lead to displacement of the skull bones;
With a further increase in pressure, “shear” fractures occur, deformation and syndesmoses are traced, and hemorrhages appear in the meninges;
Rotation of the bones occurs during the period of expulsion of the fetus;
Simultaneously with the bones of the skull, damage to the spinal cord and cervical spine is possible.
With a traumatic injury to the nervous system in the fetus, it is impossible to detect a fracture in the picture, since radiography is not prescribed.
In case of a birth injury, it is rational to prescribe an X-ray image of a fracture if the patient has the following morphological markers of pathology:
1. Cephalhematoma in the area of contact between the bones of the skull and the pelvic organs;
2. Bleeding under the aponeurosis of the scalp;
3. Changing the configuration of the head;
4. Damage to the meninges;
5. Bleeding under the area of the ligaments of the atlantoaxial and atlantooccipital joints;
6. Local epidural hemorrhage in the spinal canal;
7. Spinal deformity;
8. Bleeding into the interarticular ligaments of the cervical region;
9. Damage to the vertebral arteries;
10. Cracks, fractures of synchondroses of the base of the skull;
11. Spinal cord injury;
12. Hypoxic conditions;
13. Tearing of the septal part;
14. Intradural bleeding.
In an x-ray examination, it must be taken into account that in the picture in newborns there will be no fracture of the bones of the skull without damage to the periosteum. X-ray 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 bones of the skull during the expulsion of the fetus is accompanied by cracks, stepped deformation. The expansion of the gap appears due to excess pressure during rotation of the cervical vertebrae. Ruptures, tears of the ligamentous apparatus of the cervical-occipital joint are markers of the primary lesion.
If a cephalohematoma is detected on a radiograph in a fetus, an x-ray of the skull is not required. It is more rational to carry out computed tomography or magnetic resonance imaging. Clinical statistics show that a birth injury with cephalohematoma is often accompanied by a spongy bone fracture.
The mechanism of traumatic injury is accompanied by a rupture of the bone beams that feed the periosteum. Up to complete bone fractures, periosteal displacement and detachment should be analyzed. When moving the head along the birth canal, tangential pressure exacerbates 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 the deformation of occipital synchondrosis, lateral-basilar structures. The appointment of a snapshot is recommended 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 pictures with a birth injury of a newborn, certain signs are tracked:
1. Deformation of squama-lateral synchondrosis;
2. Fracture of the occipital bone;
3. Visualization of cephalohematoma;
4. Deformity of the cervical spine;
5. X-ray markers of birth trauma in children;
6. Other biomechanical injuries.
Thus, in the classical course, the fracture in the picture looks quite typical. Determination of the line of enlightenment, displacement of fragments, divergence of bones determines specific symptoms.
With a small crack, deformations, it is not always possible to detect a fracture during primary radiography. Only by re-examination is it possible to establish the nature of the traumatic injury. Computed tomography may be ordered if needed.
When answering whether a fracture is visible on an X-ray, it is necessary to take into account the features of the pathology. Not always a crack can be traced in the picture.
The weakest point of modern X-ray radiodiagnosis is the visualization of changes in birth trauma in children. Due to the low predisposition of doctors to diagnose damage 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. Signs are clearly defined - a decrease in the height of the vertebral body, fragments, free bone fragments.
X-ray of the spine with a compression fracture. Signs are clearly defined - a decrease in the height of the vertebral body, fragments, free bone fragments
X-ray of a fracture of the proximal epiphysis of the humerus in a child with an angular displacement of the fragments
X-ray of a large-focal intra-articular fracture of the right tibia
The main radiological signs of fractures
X-ray examination is the main in the diagnosis of fractures. 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 also used. The diagnosis of a fracture in all cases must be confirmed by objective radiographic findings. Radiographic signs of a fracture include:
1. the presence of a fracture line (the line of enlightenment in the shadow display of the bone),
2. break the cortical layer,
3. displacement of fragments,
4. changes in the bone structure, including both compaction in impacted and compression fractures, and areas of enlightenment due to the displacement of bone fragments in fractures of flat bones,
5. bone deformities, such as compression fractures.
In children, in addition to those listed, the signs of a fracture are also deformation of the cortical layer in case of green twig fractures and deformation of the cartilaginous plate of the growth zone, for example, during epiphyseolysis.
Indirect symptoms of fractures - changes in the 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 enlightenments in the joints, darkening of the air cavities in fractures of pneumatized bones. An indirect sign of a fracture, which has been at least 2-3 weeks old, is local osteoporosis due to intensive restructuring of bone tissue.
The diagnosis of a fracture in all cases must be confirmed by objective radiographic findings. Its direct signs include the presence of a fracture line (the line of enlightenment in the shadow display of the bone), a break in the cortical layer, displacement of fragments, changes in the bone structure, including both compaction with impacted and compression P., and areas of enlightenment due to the displacement of bone fragments in flat fractures. bones, bone deformities, such as compression fractures. In children, in addition to those listed, P.'s signs are also deformation of the cortical layer in fractures like a green twig and deformation of the cartilaginous plate of the growth zone, for example, during epiphyseolysis. Indirect symptoms of fractures - changes in the 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 enlightenments in the joints, darkening of the air cavities in P. pneumatized bones. An indirect sign of a fracture, which has been at least 2-3 weeks old, is local osteoporosis due to intensive restructuring of bone tissue.
The fracture line reflects the gap between the fragments and is absent if it is not present (with superposition of fragments, impacted and compression P.). To identify this symptom, it is necessary that the plane of the fracture coincide with the direction of the beam of rays for a sufficient length. Often this condition is not fulfilled throughout the fracture plane, which creates a false impression of an incomplete fracture (crack). The fracture line becomes better visible due to the resorption of the edges of the fragments in the first weeks after the fracture. It can be imitated by linear enlightenments caused by the tangential effect in the superposition of bones, congenital defects in bone tissue, artifacts, channels of the supply arteries, and in the bones of the cranial vault - also by vascular grooves and sutures. Marginal avulsions of bone fragments should be differentiated from non-fused ossification nuclei, supernumerary bones, paraosseous calcifications, and ossificates.
By the number and direction of the fracture lines, its character is judged - transverse, oblique, spiral, comminuted, T- or U-shaped, etc. The transition of the fracture line to the articular surface is a defining sign of an intra-articular fracture. A break in the cortical layer, displaying a fracture line in a compact substance, is referred to as its reliable symptoms.
Displacement of fragments is also a pathognomonic sign of a fracture. Distinguish the following types of displacement: lateral (along the width of the bone), along the length (intrusion or divergence), angular and rotational (along the axis of the bone). In thoracic cases for diagnosis, attention should be paid to the minimum lateral displacement with the formation of a step along the contour of the bone.
Each type and localization of P. correspond to certain displacements of fragments due to the traction of the muscles attached to them. Avulsion P. in the area of attachment of tendons and ligaments to the 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.
With impacted and compression P., the main radiological symptom is bone reformation. Deformations in such P. differ from deformities caused by impaired bone formation in that there is a break in the cortical layer and a strip of compaction of the bone structure, which corresponds to the compression of bone trabeculae in the area of fragments wedging. Thus, the wedge-shaped deformity of the vertebral body in a compression fracture is accompanied by a break in the compact plate along the anterior or lateral contour with a step-like or angular deformity of the latter, a break or punching of the end plate, and a more or less pronounced compaction of the bone structure.
X-ray picture allows you to judge the mechanism of bone damage. A number of features have fractures "from overload", which are regarded by many authors as a pathological restructuring of the bone. It is difficult to overestimate the importance of X-ray examination in the recognition of pathological fractures that occur with inadequate trauma due to a decrease in the mechanical strength of bones due to a local pathological process or systemic skeletal damage. 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 damage to the bone itself. Osteoporosis is the most common cause of P. with an inadequate nature of the injury in old age.
X-ray examination is the main method for monitoring the reposition of fragments and the correctness of their position throughout the treatment and with its various methods. It makes it possible to evaluate the results of osteosynthesis and other surgical interventions; allows you to judge the healing of fractures, which occurs due to periosteal, endosteal and intermediary callus. At diaphyseal P. the periosteal corn is found first of all. Well-aligned and securely fixed fragments grow together without periosteal callus (the so-called primary healing). Fractures of those parts of the skeleton, which are built mainly of spongy substance, grow together 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, due to the fragments wedging or compression, disappears. Consolidation of fragments is characterized by the restoration of a continuous bone structure, incl. compact plates.
Kireeva E.A. Forensic medical determination of prescription of rib fractures: author. dis. cand. honey. Sciences: 14.00.24 / RC SME. - M., 2008. - 22 p.
scientific adviser:
Official opponents:
Honored Worker of Science of the RSFSR,
doctor of medical sciences, professor
Candidate of Medical Sciences
O.V. Lysenko
Lead institution: Military Medical Academy. CM. Kirov
The defense of the dissertation will take place on April 10, 2008 at 13-00 hours at a meeting of the Dissertation Council D 208.070.01 at the Federal State Institution "Russian Center for Forensic Medical Examination of Roszdrav" (125284, Moscow, Polikarpova St., house .12/13).
The dissertation can be found in the library of the Federal State Institution "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 topical issues in forensic medicine is the establishment of lifetime and prescription of 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). Assessment of lifetime and prescription of bone fractures using X-ray (S.B. Maltsev, E.Kh. Barinov, M.O. Solovieva, 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 microscopy (L. Harsanyi, 1976, 1981, V.A. Klevno, 1994), and biophysical methods (A.M. Kashulin, V.G. Baskakov, 1978, VF Kovbasin, 1984), single works are devoted to it. Most of the listed works are descriptions of the results of preliminary studies and are unsuitable for practical use (L. Harsanyi, 1976, 1981, A.M. Kashulin, V.G. Baskakov, 1978, S.B. Maltsev, E.Kh. Barinov, M O. Solovieva, 1995, A. V. Saenko et al., 1996, 1998). The remaining works are not detailed enough, and their practical application 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 survival, a fractographic method was used to study the traces of dynamic sliding on the fracture surface of rib fragments, and morphological changes in the surface of fractures during active breathing were also evaluated (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 prescription of fractures has not been studied enough and its solution is possible through a comprehensive analysis of changes occurring in the biotribological system, which is a rib fracture, with continued breathing, as well as to develop criteria for diagnosing the prescription of rib fractures.
Purpose of the study- to develop criteria for forensic diagnostics of the prescription of rib fractures.
To achieve this goal, the following tasks:
1. Conduct a qualitative analysis of pathomorphological changes in the area of the ends of the fragments and the surrounding soft tissues of rib fractures of various age.
2. Carry out a quantitative histomorphological analysis of signs in the area of the ends of fragments and soft tissues of rib fractures of various age.
3. Conduct a semi-quantitative fractographic study of rib fractures to establish morphological features that reflect their age.
4. Based on the results of pathomorphological, histological and fractographic studies, develop criteria for forensic diagnostics of the prescription of rib fractures.
Scientific novelty
The fractographic method was used for the first time to identify and semi-quantify fractographic features that can serve as criteria for forensic medical diagnosis of the prescription of rib fractures; the dynamics of these signs is described for the first time.
A set of fundamentally new histomorphometric parameters reflecting the dynamics of fracture healing was used.
For the first time, the features of necrotic, inflammatory and regenerative processes in the zone of rib fractures were revealed, consisting in the fact that necrotic changes in tissues, hemolysis of erythrocytes, leukocyte and macrophage reaction, fibroblast proliferation and formation of granulation tissue unfold faster, and the reaction of vessels later than with damage to other localization and kind.
Practical significance
The results of the dissertation can be used for forensic diagnostics of the prescription of rib fractures. Based on the data obtained, a complex method for forensic determination of the prescription of rib fractures was developed, which includes regression equations based on histological and fractological features, as well as a table of qualitative features. The proposed method is easy to perform, does not require special training and the use of expensive consumables. The use of the proposed forensic criteria makes it possible to increase the accuracy and objectivity of forensic medical diagnosis of the prescription of a mechanical chest injury.
Implementation into practice
The results of the study are implemented in the practice of the Federal State Institution "Russian Center for Forensic Medical Examination of Roszdrav", in the practice of the Main State Center for Forensic and Forensic Examinations of the Ministry of Defense of the Russian Federation; into the work of the thanatological department No. 6 of the Bureau of Forensic Medical Examination of the DZ of Moscow.
Approbation of work
The dissertation materials were presented and discussed at scientific conferences of the Federal State Institution "RC SME of Roszdrav".
Approbation of the work took place on November 15, 2007 at the extended scientific and practical conference of the Federal State Institution "RC SME of Roszdrav".
Publications
Thesis structure
The dissertation consists of an introduction, a review of the literature, a description of the materials and methods used, 2 chapters of the results of our own research, their discussion, conclusion, conclusions and bibliography (258 sources, of which 236 are domestic and 22 foreign). The text is set out on 199 pages of a computer set, illustrated with 33 microphotographs, 9 tables.
The main provisions for defense:
1. The severity of changes in the contact zone of rib fragments detected by the fractographic method (trass, rubbing, grinding) can be used for forensic diagnostics of fracture age.
2. Necrotic, inflammatory and regenerative processes in the rib fracture zone have features that necrotic tissue changes, erythrocyte hemolysis, leukocyte and macrophage reaction, granulation tissue formation and fibroblast proliferation unfold faster, and vascular reaction - later than with damage other localization and type.
3. A comprehensive method has been developed for determining the age of rib fractures, based on a semi-quantitative fractographic, quantitative and qualitative histological assessment of signs of injury age, which makes it possible to increase the accuracy and objectivity of establishing the age of damage.
Materials and methods of research
Research material
203 (213 fractures) ribs and soft tissues from the area of the fracture 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 examination of 84 corpses (59 men and 25 women aged 25-89 years) with a history of chest injury from 30 minutes to 27 days (according to the accompanying sheet of the SMP (time of accepting a 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 trauma. There were 25 people in a state of 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 the state of intoxication with the conclusion - alcohol intoxication, without the results of blood tests for alcohol.
Sectional research method
Forensic 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, the method of I.B. Kolyado and V.E. Yankovsky 1990, then a detailed study of the fracture surface was carried out to identify expert diagnostic criteria for intravital rib fractures (Klevno V.A., 1991, Kolyado I.B., 1991), using a LEICA EZ4D stereomicroscope (with x 8-fold magnification) , the data obtained were recorded in the columns:
1. TRACES (they are traces of the dynamic mutual impact of rib fragments with continued breathing) (in points): 1-subtle (Fig. 1) 2-pronounced (Fig. 2), 0-no (Fig. 3);
Fig.1. Inconspicuous tracks (1 point), with an injury prescription of 55 minutes; x8
Fig.2. Pronounced traces (2 points) inconspicuous shiny rubbing (1 point) with an injury prescription of 5 hours 40 minutes; x 8
2. NATIRS (or a shiny area - a piece of bone tissue polished to a shine. Shiny areas are formed in the zones of actual contact and are located in isolation from each other, both on the surface of the fracture and in the region of the marginal areas of the fragments, depending on their conditions of initial sliding.) it was noted (in points) the presence and severity of shiny areas: 3 - most pronounced (Fig. 4), 2 - pronounced (Fig. 3), 1 - hardly noticeable (Fig. 2), 0 - none;
Fig.3. Pronounced rubbing (2 points) with an injury prescription of 3 days; x8
Fig.4. The most pronounced rubbing (3 points) with an injury prescription of 7 days; x8
3. GRINDING (Grinding of the fracture edge 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 actual touch area.): 3 - most pronounced (Fig. 7), 2 - pronounced (Fig. 6), 1 - inconspicuous (Fig. 5), 0 - no.
Fig.5. Mild grinding (1 point) of the fracture surface with an injury prescription of 19 hours 20 minutes; x8
Fig.6. Pronounced grinding (2 points) of the fracture surface with an injury prescription of 5 days; x8
Fig.7. The most pronounced grinding (3 points) of the fracture surface with an injury prescription of 6 days; x8
Microscopic research method
Soft tissues from the area of the fracture were taken with the area of adjacent undamaged tissues. The samples were fixed in 10% neutral formalin solution and subjected to standard paraffin wiring (D.S. Sarkisov, Yu.L. Perov, 1996). Paraffin sections 5–10 µm thick were stained with hematoxylin and eosin and by 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 wiring, followed by hematoxylin-eosin and Weigert staining of the sections.
We have applied a number of new methodological principles:
1. study of all reactions associated with 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. an assessment not only of the timing of the appearance, but also the timing of the 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-couplings, paths, 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 periosteal thickness,
8. analysis of all observations that do not fit into the 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 the hemorrhage, these signs were observed in 1 field of view. Signs - the area of the histological section; the number of arteries, veins, capillaries; the 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 clutches, fibrin, hemolysis, necrosis, leukocyte breakdown, vascular proliferation, lacunae, periosteum were described and measured at a magnification of 100 times, other signs - at a magnification of 400 times.
Based on the primary data, the calculated signs were obtained:
1. RATIO OF THE NUMBER OF NEUTROPHILS PER LIGHT OF ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of neutrophils in the lumen of arteries, veins, capillaries / to the total number of arteries, veins, capillaries)
2. RATIO OF THE NUMBER OF MACROPHAGES PER LIGHT OF ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of macrophages in the lumen of arteries, veins, capillaries / to the total number of arteries, veins, capillaries)
3. RATIO OF THE NUMBER OF LYMPHOCYTES PER LUMINAL OF ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of lymphocytes in the lumen 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 / to the 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 / to the 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 THE ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of neutrophils near the walls of arteries, veins, capillaries / to the total number of arteries, veins, capillaries)
8. RATIO OF THE NUMBER OF MACROPHAGES NEAR THE ARTERIES, VEINS, CAPILLARIES TO THE NUMBER OF VESSELS (total number of macrophages near the walls of arteries, veins, capillaries / to the total number of arteries, veins, capillaries)
9. RATIO OF THE NUMBER OF LYMPHOCYTES NEAR THE 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, CAPILLARIES TO THE NUMBER OF VESSELS (total number of fibroblasts near arteries, veins, capillaries / to the total number of arteries, veins, capillaries)
11. PROPORTION OF THROODED, EMPTY, SPASMED ARTERIES (number of full-blooded, empty, spasmodic arteries / total number of arteries)
12. SHARE OF FULL-BLOODED, DESERTED, COLLAPSE VEINS (number of full-blooded, desolate, collapsed veins / per total number of veins)
13. PERCENTAGE OF FULL-BLOODED, DESERTED, COLLAPSE CAPILLARIES (number of full-blooded, deserted, collapsed capillaries / 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 rank nature, since they were scores of features. Others had a distribution that differed from normal. Therefore, the multivariate correlation analysis of the obtained data was carried out according to Spearman. In the study of the correlation of fractographic signs with the duration of the injury, it was carried out for the entire range of the duration of the post-traumatic period, and the 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 choosing the parameters most strongly correlated with injury age, a multivariate regression analysis was also performed, resulting in regression equations that can be used to determine injury age.
The statistical study used:
Operating shell Microsoft Windows XP Professional 2002;
Statistical analysis tool SPSS for Windows v.7.5 (SPSS Inc.).
Research results
Results of the fractographic study
Trace is the earliest sign of dynamic sliding of bone fragments, which, according to our data, can be clearly seen as early as 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 the prescription of the post-traumatic period up to 5 hours. From 5:00 to 1:00 p.m., trails are found only in combination with shiny grounds. This combination may appear earlier, starting from 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 more than this value. Starting from 70 minutes to 24 hours, you can observe a combination of traces also with a polished fracture edge.
The first mild rubbing (shiny areas, 1 point) appears when the injury is 30 minutes old. Their weak severity can be observed up to 8 days, significantly pronounced shiny areas (2 points) were detected with an injury prescription from 3 to 27 days. 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.
Grinding (weakly expressed - 1 point) was observed along with traces and rubbing, in the period from 1 hour 20 minutes to 7 days, mild rubbing (1 point) was combined with mild grinding (1 point). Pronounced grinding (2 points) was noted by us in the range of injury prescription from 19.3 hours to 11 days, always with equally pronounced shiny areas, both on the surface and on the edge of the fracture. 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 the complete absence of traces (0 points).
Less pronounced signs of dynamic sliding:
With incomplete fractures;
On the side of the chest where more ribs are broken;
On the upper (from 1 to 2 ribs) and lower ribs (starting from 7);
With fractures passing at the border of bone and cartilage tissue.
The use of multivariate correlation and regression analysis of signs (fractographic and histological) of injury prescription, taking into account the factors affecting the healing dynamics and, accordingly, the severity of the symptom, made it possible to develop criteria for the prescription of rib fractures.
It was found that the following fractographic features have the highest correlation coefficients with the duration of the injury in the entire studied range of the duration of the post-traumatic period: traces, rubbing, grinding, rolling.
On their basis, an expert model for determining the prescription of rib fractures was developed in the form of a regression equation (No. 1), which has the form:
T \u003d 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 in the study of the fracture surface of the rib with a known damage prescription, where k 0 =-1359, 690; k 1 =3.694; k 2 =1538.317; k 3 =3198.178;
R 1 , R 2 , R 3 , - the severity of the feature in points, where R 1 - tracks, R 2 - rubbing, R 3 - polished.
In this way,
Т= -1359.690+3.694R 1 +1538.317 R 2 +3198.178 R 3
The results of histological examination.
According to our data, the reaction of the body to a fracture of the ribs develops in dynamics as follows.
An increase in blood filling of arteries, veins and capillaries develops within 1 hour after a chest injury, but in the arteries the plethora persists up to 7 hours, in the capillaries - up to 6 hours, and in the veins only 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 erythrocytes can begin as early as half an hour after injury and increases as the post-traumatic period increases. With a prescription injury of more than 10 days, hemolysis occurs in almost 100% of erythrocytes located in the area of hemorrhage. Necrosis of muscle, fat, connective and bone tissue develops approximately 1 hour after injury.
The leukocyte response 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 the injury (in the capillaries - after 1 hour), but in the arteries it reaches its maximum severity in the period from 1 to 3 hours, in the capillaries - by 3-4 hours, in veins - about 5-7 hours after the injury. Diapedesis of neutrophils in the tissue begins already at a time of injury of 35 minutes and is most pronounced in the arteries, where leukocyte muffs and paths are formed 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 clutches can be detected even 24 hours after injury. At the border of the hemorrhage, leukocytes appear no earlier than 1 hour after the injury. Their number reaches a maximum in the period from 6 to 24 hours, and from 16 hours a leukocyte shaft is already traced. At the same time, you can see multiple leukocyte paths going 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 reactivity of the body and on the presence of leukocytosis as a reaction to a purulent-inflammatory process (pneumonia, meningitis, etc.). However, some regularities can be traced. Small leukostases in vessels of various types can be detected up to 11 (capillaries), 16 (veins) and 27 days (arteries). Leukodiapedesis, however, from day 2 is absent or insignificant - in the form of single cells and only through the arteries. Single neutrophils near the vessels can be determined up to 27 days after injury, but leukocyte muffs are not detected in preparations with an injury duration of more than 1 day. Leukocyte tracks cease to be observed when the prescription of the injury is more than 2 days.
Leukocyte shaft can be determined up to 5-10 days. Later, only single neutrophils can be found in the thickness of the granulation tissue that forms at the site of the hemorrhage, but not at the border.
The disintegration of leukocytes begins already when the injury is more than an hour old and lasts up to 14 days, after which it ceases to be determined due to the attenuation of the leukocyte reaction.
On the first day, only single monocytes can be observed in the lumen of the vessels. The reaction of monocytes becomes distinct (in the form of an increase in their number in the lumen of the veins) not earlier than 4-6 hours after the injury and not in all cases. Diapedesis of monocytes in the 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 the arteries. The appearance of single macrophages at the border of the hemorrhage and in its thickness is also noted already 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 vessels (mainly arteries) mainly in the period from 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 of 2-6 days. Later, only single macrophages can be found near the vessels, or they are absent altogether. 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 tissues can be detected as early as 1 hour after the 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, occurs mainly through the arteries and to a lesser extent through the veins in the period from 1 to 10-11 days after injury, reaching a maximum at about 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 if the injury is more than 10 days old, they cease to be detected at the border and become few or disappear completely in the thickness of the hemorrhage. Repeated waves of increased diapedesis of lymphocytes are possible in cases with an injury duration of 14 and 27 days, but due to the rarity of such cases, it is impossible to give an explanation for them.
There are no reliable signs of fibroblast proliferation or other manifestations of regeneration in cases with an injury older than 24 hours.
Fibroblast proliferation 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 the hemorrhage, single fibroblasts appear no earlier than 3 days after the injury, and after 7 days after the injury, they are no longer detected. In contrast, the number of fibroblasts within the hemorrhage increases as the granulation tissue develops.
The thickness of the periosteum can increase up to 3 cells already after 35 minutes after the 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 an accumulation of thin-walled vessels, between which there are macrophages, lymphocytes and fibroblasts, was found with an injury prescription from 5 days to 27 days. Thus, the formation of granulation tissue begins as early as 5 days after injury.
Rice. 8. Cartilage formation, injury prescription 8 days x200
Rice. 9. Cartilage formation, injury duration 16 days x200
With an injury prescription of 9 days or more, chondrocyte proliferates are noted in the fracture area, and developed cartilage tissue is detected with an injury prescription with a post-traumatic period of 27 days (Fig. 8-9).
Studies have shown that the highest correlation coefficients with the duration of injury over the entire range of the duration of the post-traumatic period studied 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 near the veins, the number of macrophages near the 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.
On their basis, an expert model was developed for determining the prescription of rib fractures in a time interval 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 in the course of histological examination of persons with a known chest injury age;
Q1 is the number of macrophages near the arteries;
Q2 is the number of fibroblasts near the arteries;
Q3 - the number of fibroblasts near the veins;
Q4 - the number of macrophages in the thickness of the hemorrhage;
Q5 - the number of lymphocytes in the thickness of the hemorrhage;
Q6 is the degree of fibrin deposition;
Q7 - the degree of severity of proliferation vessels;
Т=711.241+158.345Q1+277.643Q2+331.339Q3-7.899Q4-83.285Q5+681.551Q6+4159.212Q7
Taking into account the fact that the leukocyte reaction increases mainly on the first day after the injury, for differential diagnosis, we tried to study this time interval in more detail. Based on the data of correlation analysis, a strong correlation was revealed between the duration of mechanical injury to the ribs (up to 1 day) and the severity of accumulations and decay 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 the correlation of an average degree between the prescription 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.
On their basis, an expert model was developed for determining the prescription of rib fractures in a time interval 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;
k1,k2,k3,…. k12 - regression coefficients calculated in the course of histological examination of individuals with a known chest injury age;
G1 is the ratio of the number of neutrophils near the arteries to the number of arteries;
G2 is the ratio of the number of macrophages near the arteries to the number of arteries;
G3 is the proportion of full-blooded capillaries;
G4 - the ratio of the number of neutrophils near the capillaries to the number of capillaries;
G5 is the ratio of the number of macrophages near the capillaries to the number of capillaries;
G6 - the degree of severity of the leukocyte shaft;
G7 - the number of macrophages in the thickness of the hemorrhage;
G8 - the number of lymphocytes in the thickness of the hemorrhage;
G9 - the number of macrophages at the border of the hemorrhage;
G10 is the percentage of hemolyzed erythrocytes;
G11 is the degree of leukocyte decay;
In this way,
Т=-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, (standard correlation coefficient for this model 0.8 r = 9 error 174.05, significance p
The results of our study show the fundamental possibility of establishing the age of rib injury by 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 prescription 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 in the course of histological examination of persons with a known chest injury age;
G1, G2, G8, G9 - severity of the trait in points, where G1 - traces, G2 - polished, G8 - fibrin, G9 - severity of proliferation vessels,
G3 - the total number of macrophages near the arteries to the number of arteries,
G4 - the total number of fibroblasts near the arteries to the number of arteries,
G5 - the total number of fibroblasts near the veins to the number of veins,
G6 - the number of macrophages in the thickness of the hemorrhage,
G7 - the number of lymphocytes in the thickness of the hemorrhage;
Thus, the duration of the injury in minutes can be determined by the following formula:
Т=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 prescription 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 detected by the fractographic method (traces, rubbing, grinding) can be used for forensic medical diagnosis of fracture age.
2. There is a strong correlation between the age of rib fractures and the severity of rubbing and grinding, and a moderate correlation between the age of the injury and the severity of the traces.
3. Less pronounced fractological signs of prescription for incomplete fractures, on the side of the chest where more ribs are broken, on the upper (from 1 to 2) and lower ribs (starting from 7), with some comminuted and oblique fractures, with fractures, passing along the peristernal line and on the border of bone and cartilage tissue.
4. Features of necrotic, inflammatory and regenerative processes in the zone of rib fractures are that hemolysis of erythrocytes, leukocyte and macrophage reaction, necrotic tissue changes, fibroblast proliferation and formation of granulation tissue unfold faster, and the reaction of blood vessels - later than with damage to other localizations and types.
5. On the first day, there is a strong correlation with the duration of injury of the following histological parameters: the percentage of hemolysis of erythrocytes, the proportion of full-blooded capillaries, the average number of neutrophils near arteries and capillaries, the number of neutrophils at the border of hemorrhage in the x400 field of view, the degree of severity of leukocyte decay, the average number of macrophages about arteries and near capillaries, the number of macrophages at the border of the hemorrhage in the field of view x400, the number of macrophages and lymphocytes in the thickness of the hemorrhage in the field of view x400.
6. In the entire range of injury prescription, a strong correlation with the prescription of injury of the rib of the following histological parameters is found: the proportion of full-blooded arteries, the proportion of collapsed veins, the average number of macrophages, lymphocytes and fibroblasts near the arteries and near the veins, the average number of macrophages near the capillaries, the number of macrophages, lymphocytes and fibroblasts in the thickness of the hemorrhage in the field of view x400, the number of macrophages at the border of the hemorrhage in the field of view x400, the presence and nature of fibrin deposits, the severity of vascular proliferation.
7. A comprehensive method for the forensic medical determination of the prescription of rib fractures is proposed, which includes regression equations based on histological and fractological features, as well as a table of qualitative histological features.
1. For forensic medical diagnosis of the age of rib fractures, it is recommended to use a complex fractological examination of the fracture area and a histological examination of the bone and soft tissues 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 gross manipulations in the area of fractures when preparing preparations:
Broken ribs are removed entirely by dissecting the intercostal spaces and isolating their heads, marked;
Removed fractures of the ribs, together with soft tissues, are pre-placed for at least three days in a 10% solution of neutral formalin;
The fixed fragments of the ribs are washed from formalin for one day in running water and with a scalpel, without touching the edges of the fracture, are cleaned of soft tissues;
The ribs are again placed in running water for 1-2 hours and carefully cleaned of the 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 marked.
3. For a more accurate determination of prescription, the following is indicated:
Subspecies of the fracture and its features: complete or not, the location of the fracture plane relative to the long axis of the rib;
Serial number of the rib and side;
Localization of rib fractures relative to anatomical lines.
For direct microscopy, a stereo microscope (with x 8 magnification) is used, rotating the edge under the microscope lens, signs of prescription are revealed along the edges (traces, rubbing, grinding). Having found them, it is necessary to fix the rib on the stage with plasticine and continue the examination, paying attention to the following points:
The degree of severity of traces: 2 - pronounced, 1 - barely noticeable, 0 - no;
The degree of severity of rubbing: 3 - the most pronounced, 2 - pronounced, 1 - hardly noticeable, 0 - no;
The degree of severity of grinding: 3 - the most pronounced, 2 - pronounced, 1 - hardly noticeable, 0 - none.
4. Substitute the results obtained into the developed expert model for determining the prescription of rib fractures in the form of a regression equation (No. 1).
5. For histological examination of signs of prescription of chest injury:
Soft tissues from the area of the fracture are taken with the area of adjacent undamaged tissues. Samples are fixed in 10% neutral formalin solution and subjected to standard paraffin wiring (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 wiring, followed by hematoxylin-eosin staining of the sections.
6. Area of the histological section; the number of arteries, veins, capillaries; the number of full-blooded arteries, veins, capillaries, the number of empty arteries, the number of arteries with spasm, the number of collapsed veins, capillaries, clutches, lanes, fibrin (severity of the sign in points: 0-none, 1-strand fibrin, 2-granular fibrin), hemolysis , necrosis, leukocyte breakdown (0-none, 1-few, 2-many), vascular proliferation (0-none, 1-few, 2-many), lacunae, periosteum, described at 10x magnification, other signs: number 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 an increase of 40 times.
7. Based on the primary data, obtain design features (see the chapter "Material and research methods").
8. Substitute the obtained results into the developed expert models for determining the prescription of rib fractures (in the time interval from 30 minutes to 27 days - No. 2, No. 4 or the time interval from 30 minutes to 24 hours - No. 3).
9. For a more accurate forensic medical diagnosis of the prescription of rib fractures, you should use Table No. 1 of qualitative histological signs that characterize the prescription of the injury.
Table number 1. Qualitative histological signs of the age of formation of rib fractures.
|
Feature name |
Appearance time sign |
Disappearing time sign |
|
Congestion of the arteries |
30 minutes 30 hours |
|
|
Plethora of veins |
||
|
Plethora of capillaries |
16-27 days |
|
|
Neutrophils in the arterial lumen |
||
|
Neutrophils in the lumen of the veins |
||
|
Neutrophils in the lumen of capillaries |
16 hours |
|
|
Neutrophils in arterial walls |
||
|
Neutrophils in the walls of the veins |
4 hours 40 minutes |
|
|
Neutrophils in capillary walls |
1 hour 10 minutes |
|
|
Neutrophils near arteries |
||
|
Neutrophils near the veins |
over 6 hours |
|
|
Neutrophils near capillaries |
||
|
Leukocyte couplers |
||
|
Leukocyte tracks |
||
|
Leukocyte shaft |
||
|
Neutrophils at the border of hemorrhage |
||
|
Neutrophils in the hemorrhage |
||
|
Monocytes in arterial lumen |
up to 27 days |
|
|
Monocytes in the lumen of the veins |
10-27 days |
|
|
Monocytes in the lumen of capillaries |
||
|
Monocytes in the wall of arteries |
1 hour 10 minutes |
|
|
Monocytes in the vein wall |
16 hours -24 hours a |
|
|
Monocytes in the capillary wall |
1 hour 25 minutes |
|
|
Macrophages around arteries |
||
|
Macrophages near veins |
||
|
Macrophages near capillaries |
||
|
Macrophages at the border of hemorrhage |
||
|
Macrophages in the hemorrhage |
||
|
Lymphocytes in arterial lumen |
||
|
Lymphocytes in the lumen of capillaries |
1 hour - 24 hours |
|
|
Lymphocytes in the wall of arteries |
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 around the veins |
5 hours 25 minutes - 24 hours |
2 – 10 days |
|
Lymphocytes around capillaries |
24 hours, 14 and 27 days |
|
|
Lymphocytes at the border of hemorrhage |
||
|
Lymphocytes within the hemorrhage |
||
|
Necrosis of fat, muscle and connective tissue |
||
|
RBC hemolysis |
||
|
Proliferation of fibroblasts around arteries |
||
|
Fibroblasts within the hemorrhage |
||
|
Fibroblasts at the border of the hemorrhage |
||
Granulation tissue |
||
Proliferation of chondrocytes |
1. The state of the problem of forensic determination of lifetime and prescription of bone fractures (according to the literature) // Proceedings of the final scientific conference of the Russian Center for Forensic Medical Examination. –M. -2006. - P.70-74. (co-author Suvorova Yu.S.).
2. Possibilities of forensic medical determination of the prescription of rib fractures (preliminary study) // Current issues of forensic medicine and expert practice at the present stage. –M. -2006. –S.39-41. (co-author Bogomolova I.N.).
3. Forensic medical determination of the prescription of fractures of the ribs // Sud.-med. expert. - 2008. - No. 1. - S. 44-47. (co-author Klevno V.A., Bogomolova I.N.).
