FORENSIC MEDICAL DETERMINATION THE AGE OF FRACTURES BASED ON DATA OF X-RAY RESEARCH METHODS. LITERATURE REVIEW

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Introduction.

The specificity of the work of a forensic expert when conducting an examination of victims, accused and other persons is that the main objects for research are living people and medical documents, which in some cases makes it problematic to specify the duration of the injury, given the objective difficulties of determining its exact time limits in living persons, in contrast to the examination of corpses, where it is possible to use additional methods for studying biological material. In such conditions, it is difficult to overestimate the radiographic method of examination for skeletal trauma, which allows, together with clinical data, to establish the age of fractures.

The process of bone tissue regeneration. Stages of callus formation.

The process of consolidation itself depends on a number of factors, which include the type and extent of injury, the nature and type of fracture, the degree of comparison of bone fragments, early dosed loading, defects in the provision of specialized medical care (the use of large loads during traction, incorrectly performed osteosynthesis, unreasonable removal of viable areas of bones, excessive resection of bone fragments leading to the formation of a bone defect),

incorrectly chosen tactics of surgical treatment, which respectively determines the local conditions of regeneration, which include the state of blood supply to a given area of ​​interest, the presence or absence of inflammation, and others [1-4].



Currently, the types of fracture healing, the morphological stages of callus development, and the conditions affecting the rate of the reparative process of bone tissue have been well studied. There are periosteal, intermediary, endosteal and excess (paraosseous) callus (Fig. 1) [5-8].

When studying literary sources, one can identify a general tendency of authors to identify several successive stages of the reparative process in the injured bone. Basically, three to five morphological stages of callus development are distinguished [9, 10].



In general, cellular and tissue changes in the fracture area occur in this way: reparative bone regeneration after injury begins immediately after the fracture.

Blood poured out from damaged intraosseous and muscle blood vessels and edematous fluid form an extravasate around bone fragments, which coagulates; from the second day, multiplying mesenchymal cells grow into it along with vascular formations, activation and proliferation of osteoblasts occurs in the area of ​​damage, primarily in periosteum and endosteum, the emergence of mesenchymal tissue is stimulated by tissue decay products formed in the fracture area. The organization and simultaneous resorption of extravasation around the fragments is completed by 5-7 days; liquid blood and tissue detritus still remain in the gap between the fragments.

The presence of an extensive hematoma slows down the organization processes and leads to a delay in consolidation. Slightly calcified bone beams appear in the osteogenic fibroreticular tissue, the number of which increases. By 5-12 days after the injury, as a result of the organization of extravasation, loose connective tissue is formed that connects the fragments (primary soft callus), which is subsequently replaced by primitive spongy and then mature bone.

The first bone callus beams appear 4-5 days after the injury. Mesenchymal tissue in the fracture zone tends under normal conditions to transform into osteogenic or osteoblastic tissue [7, 11]. Ossification of the callus occurs due to calcium in the blood, where it comes from the entire skeletal system; in addition, calcium enters the callus directly from the areas of the bone adjacent to the fracture.

Thus, post-traumatic osteopenia is the result of high activity of bone metabolism; fracture healing is accompanied by an increase in the levels of biochemical markers of bone metabolism, especially markers of bone resorption [9, 12, 13]. The final callus in its structure differs from bone tissue only in the random arrangement of bone crossbars. The final phase is the restructuring of the callus with the replacement of immature bone structures with more mature ones, with adaptation to static-dynamic conditions.

In the restructuring of callus, osteoclasts and osteoblasts play an important role, which change the fracture area in such a way that bone marrow appears, vascularization and innervation are restored [4, 9, 14, 15, 16].



Factors and conditions affecting the speed of the reparative process of bone tissue. Timing of fracture consolidation.

According to clinical data, the average time for fracture healing varies widely and depends on a number of factors, including the type of damaged bone, the location and nature of the fracture, the impact of surgical treatment, including the correctness of the chosen treatment tactics and the quality of specialized medical care, the presence concomitant pathology and other factors and conditions [3, 5, 16, 17, 18, 19]. It is known that the rate of fracture healing correlates with the age of the patient (injured person), which is confirmed by the results of studies by many authors [1, 4, 5, 12, 20, 21, 22]

Fracture healing slows down in case of various disorders of the homeostasis of the human body associated with a disorder of the endocrine system, common serious diseases, including those accompanied by the development of cachexia, osteoporosis, associated with taking certain drugs (cortisone, hydrocortisone, prednisolone and other hormonal drugs), with vitamin deficiencies, radiation illness, various variants of the physiological state of the body (pregnancy, lactation), against the background of a general severe combined injury [4, 17, 18, 21, 22]. This also includes estrogen deficiency in women with declining ovarian function [12, 20].

In recent years, the positive role of the mechanical factor (mechanotransduction) in the process of reparative regeneration of bone tissue has been actively discussed in the scientific literature. The idea of ​​mechanotransduction is not new and has roots back in the 19th century (Wolf’s law); its essence lies in the fact that bone restructuring occurs in accordance with the load on it and is carried out by converting mechanical signals into cellular signals. Mechanotransduction includes the steps of mechanical coupling, biochemical coupling, signal transduction, and cellular response.

The specific effects of cellular reorganization depend on the duration, amplitude and strength of the load. It has been established that only repeated (regular) or cyclic loading can stimulate bone formation [23-32].



X-ray timing of fracture healing. Current state of the problem.

The first and, perhaps, basic information about the radiographic timing of fracture consolidation can be found in monographs, textbooks and manuals on classical radiology and radiation diagnostics. The radiographic timing of fracture healing is reflected in the works of such famous radiologists as S.A. Reinberg (1964), L.D. Lindenbraten, L.B. Naumov (1984), Zedgenidze G.A. (1984).

Manuals and monographs on radiology diagnostics give average time frames for fracture consolidation. The terms of reparative regeneration of bone tissue presented in these literary sources are presented in the form of the healing process of a fracture in an x-ray image: on x-rays taken on the first day after injury, the edges of the fragments have sharp-angled teeth (on high-quality x-rays), later, due to osteoclastic resorption of the bone ends these denticles begin to smooth out and disappear completely (according to various authors, this occurs in the period from 7 days to 20 days), usually in the first 7-10 days after the injury [9, 33, 34, 35, 37].

In connection with this, the X-ray picture of the broken ends of the bone changes, becoming dull and smoothed out, but at the same time, the resorption of the broken bone beams makes the fracture line clearer due to the diastasis that occurs between the fragments, compared to X-rays taken immediately after bone damage, in parallel the formation of connective tissue callus, which in the next 7-10 days is replaced by osteoid callus, which does not contain lime and is therefore invisible on radiographs.

Starting from about the third week, calcification of the osteoid callus occurs, but the lime content is still too small to cause darkening on X-ray images [15, 33, 34]. Based on the results of research by other authors - Burova S.A., Reznikova B.D. cloud-shaped callus is visible already on the 16-20th day after the fracture. Radiologically visible bone callus in the form of areas of its calcification appears on images approximately at the end of the 4th and beginning of the 5th week after the fracture in the form of a cloud-like gentle darkening [33], according to Reinberg S.A. – approximately already in the third or fourth week after injury (Fig. 2).

Gradually, the shadow of the callus becomes denser, the so-called bone consolidation occurs 3-8 months after the fracture (depending on the location and nature of the fracture), the fracture line remains visible on radiographs for a long time and disappears after approximately 4-8 months [34, 35] (Fig. 3). In the manual of R.P. Matveeva and S.V. Bragina (2018) describes types of reparative regeneration of bone tissue, but without specific timing for the formation of callus.

According to manuals on traumatology and orthopedics, as well as literary sources devoted to the topic of reparative regeneration against the background of various methods of surgical treatment, radiologically dense callus is determined approximately by the end of the third to fifth month after injury. The restructuring of callus, caused by the functional load of the damaged bone, continues for several months [21, 22, 33-37].

In the works of Sharmazanova E.P. and Moseliani H. (2016, 2017) determine the main terms of consolidation depending on treatment methods (external fixation, external osteosynthesis, plaster immobilization), selectively indicate the radiological periods of callus formation, and it is noted that in some patients for about 6 months there are no signs of callus on radiography, the clinical timing of fusion of diaphyseal fractures is indicated, without emphasis on the dynamics of callus development, it is described with what frequency and in what cases different types of callus are determined: periosteal, intermediary, paraosseous callus.

Complications during fracture healing are indicated, as well as the frequency of nonunion of diaphyseal fractures, the causes and frequency of formation of false joints. In the article by Pankratov A.S., Rubtsov A.A. et al. (2022) conducted a review of literature sources exploring the use of external osteosynthesis of human long tubular bones, and considered the features of modern osteosynthesis with plates based on the results of clinical studies and biomechanical experiments. The advantages and disadvantages of minimally invasive osteosynthesis for different segments were identified, and a comparative analysis of callus density was carried out according to data

MSCT studies for different types of surgical treatment in the period from 2 to 6 months after surgery. The approximate total duration of fracture healing is given (15.6 ± 6.2 weeks), but it is noted that, in general, the results of different authors differ and sometimes are completely contradictory. A special niche is occupied by works devoted to the fusion of flat bones, which, as mentioned above, has its own characteristics and proceeds according to the type of primary fusion - enchondral osteogenesis with the formation of gradually calcifying reticulofibrous tissue, which is why the consolidation of this type of bones is not indicative of the dynamics of development callus. In the articles of Grebenkov A.B. (2015),

Rasulova M.R., Indiaminova S.I. (2020), Romanova P.G. et al. (2022) indicate radiological signs of the age of fractures of the nasal bones, describe in detail the morphological features of the fracture according to radiography, depending on the stage of fracture healing, indicating time intervals; It is noted that approximately 2-3 months after the injury, the edges of the fracture are heterogeneous in structure, sclerotic, the fracture line can be traced in fragments.

However, as mentioned above, the timing of fusion of the bones of the facial skeleton is uninformative from the point of view of the dynamics of consolidation due to the healing of the bones of the facial skeleton in general according to the type of primary fusion, without the formation of a classic periosteal callus. The same applies to the work of M.G. Panin, V.B. Bogdashevskaya, A.V. Alekseev. (1990), which determines the approximate radiographic timing of mandibular fusion after osteotomy, without describing the morphological radiographic features of consolidation. In the works of Osipenkova-Vichtomova T.K. (2000),

Pigolkina Yu.I., Nagornova M.N. et al. (2005) reflect in detail the dynamics of fusion of the bones of the cranial vault and describe the features of healing of post-trepanation defects. The authors indicated that the nature of healing of fractures of the calvarial bones depends on the type of fracture (linear, depressed, fracture with a defect in the bone area); it was noted that 1-2 years after the injury there is an absence of primary callus and small areas of secondary callus. The bone defect is replaced by a scar made of dense connective tissue, which gives the impression of imperfect fusion of the bones of the cranial vault.

At the same time, the authors argue that the constant slow development of secondary callus results in a tendency towards complete healing, which occurs over years and decades, regardless of the nature and extent of the damage. In the work of Gabunia G.V. (2000) discusses the features of the process of consolidation of long tubular bones in combined traumatic brain injury and only states the fact of the formation of a dense callus at a certain period after the injury; as such, the dynamics of bone regeneration are not described.

In the leadership of Ilyasova E.B. (2021) describe the radiological stages of fusion of the damaged bone, but without indicating time periods, there is a simple statement that complete calcification occurs after 2-5 months, and further reconstruction of bone tissue takes even longer. In the article by Matsukatov F.A. and Gerasimova D.V. (2016) reflected the factors influencing the timing of fracture consolidation, and analyzed the dependence of the timing of consolidation of helical fractures of the tibia during treatment with transosseous osteosynthesis on the initial value of the transverse displacement of fragments, the age of the patients, the duration of the injury, the accuracy of reposition and the stability of fixation.

The authors examined the relationship between the timing of consolidation and five factors: the magnitude of the transverse displacement, the age of the patients, the accuracy of the reposition of fragments, while emphasizing that accurate reposition and the associated stable fixation make it possible to minimize or completely eliminate the influence of negative factors on the timing of consolidation of long bone fractures during treatment them using the method of transosseous osteosynthesis. There is no X-ray dynamics of reparative osteogenesis.

There are articles devoted to the influence of osteotropic therapy, as well as various biomaterials on the timing of reparative regeneration of bone tissue (Klimovitsky V.G., Chernysh V.Yu., 2011; Kokorevoy I., 2020; V.I. Strukov et al., 2016, Prokhorov M. et al., 2016, Lubenets A, 2017). In the article by Kokoreva I. on the effect of taking an osteoprotector on the timing of consolidation of bone fractures in children and adolescents (2020), radiographs of two patients from the control group who did not take this drug are presented, in whom the authors did not find signs of callus, and radiographs of three patients are also presented 18. 10 and 3 years, with comments on the consolidation that has occurred.

These images do not visually identify signs of callus; in the text of the article, the authors also do not indicate the timing of callus formation. Based on the studies conducted, it was concluded that in children who received this osteoprotector, fracture consolidation occurred 1–1.5 weeks earlier than in children in the control group (who did not receive the drug). In general, the authors of the articles note an acceleration in the time of consolidation and a decrease in the frequency of complications during fracture healing while taking osteotropic drugs.

The effect of hydroxyapatite-containing material on the healing time of comminuted fractures of the femur during osteosynthesis is described in the article by Protsenko A.I., Gazhev A.Kh., Gordeeva G.G., Zheltikova D.I. (2012). The authors note that in 19 of 25 patients after 3 months. after the operation there were no radiological signs of callus, after repeated stimulation of osteogenesis - the introduction of a gel under the control of an electron-optical converter into the fracture zone on control radiographs after 4 months. after surgery, 17 out of 19 patients showed signs of callus.

A 28-year-old patient with a comminuted fracture of the femoral diaphysis after surgery - splinting osteosynthesis on radiographs with collapanoplasty with plates and granules after 3 months. There were no signs of consolidation after surgery. After repeated stimulation of osteogenesis with puncture gel after 6 months.

the authors point to the achievement of consolidation of the fracture, however, in these cases there is no staging of the development of callus and its description as such. In the article by Sadykov R.I., Akhtyamova I.F. (2022) reflects the relevance of drug and local therapy for the treatment of patients with delayed consolidation of fractures, and describes conservative and surgical methods for correcting delayed reparative osteogenesis. It is indicated that one of the promising directions in the treatment of delayed consolidation of fractures is currently the local use of bisphosphonates,

however, there are no specific time frames for the consolidation of fractures; there is only a statement that the use of osteotropic treatment accelerates the healing of fractures. In the original article by V.D. Zavadovskaya, V.P. Popova, O.E. Akbasheva, E.G. Grigorieva, T.V. Druzhinina (2014) describes ultrasound monitoring of the processes of consolidation of fractures of long tubular bones during osteosynthesis using bioactive implants, while mentioning the limitations of radiography in assessing the early stages of consolidation, associated with the inability to display non-ossified structures.

In this case, ultrasound examination acts as an alternative to radiography, but with greater capabilities in terms of monitoring the healing process of fractures at stages before the formation of a full-fledged callus. The pathomorphology of bone tissue and its significance for forensic medicine was studied by Osipenkova-Vichtomova T.K. (2000), Nagornov M.N. (2012). The works of these authors reflect the dynamics of healing of fractures of tubular, spongy bones, and calvarial bones based on sectional, histological, histochemical, and angiographic research methods.

Step by step, the dynamics of histo-chemical and patho-morphological changes in the area of ​​fracture of the integumentary bones of the cranial vault are reflected in detail, depending on the duration of the damage and the stage of the reparative process. Foreign literature also describes the reasons for the delayed consolidation of fractures, studies the influence of the stability of metal osteosynthesis on the healing time of fractures, and the dependence of the speed of reparative processes on the volume and type of injury - Stefan Recknagel (2012).

In Verhoff, Marcel A., Kreutz, Kerstin; Ramsthaler, Frank (2006) reflects the problems of forensic anthropology and osteology. There are works on the pathomorphology of fractures: Stoss H, Pontz B., Brenner R., Vetter U., Freisinger P., Karbowski A. (1992), Albrecht K., Breitmeier D., Huefner T. (2005), which describes the features formation of callus in congenital pathology of osteogenesis and in fractures of a certain localization. “Stress fractures” and the dynamics of their healing are described in the works of Engelhardt M. (2009), Aderhold L., Weigelt S (2012), T. Schneider (2020). Inga Keil (2009) studies the issues of fractures in two-year-old children. Doctors from the Clinic for Emergency Surgery and Orthopedics (Lüdenschein) Christian Konrads, Gerfried Giebel (2012)

in their work they outlined in detail the basics of surgical treatment of fractures and the problems of osteogenesis. The issues of bone tissue regeneration after osteosynthesis were dealt with by Markus Muhm, Hartmut Winkler (2008), Dr. L. Claes (2018), X-ray signs of fracture healing are shown in the work of Christian Fischer (2020). The article by Asadi K., Mardani-Kivi M., Aris A. (2022) presents the results of a study on the effect of substance abuse and smoking on the healing time of closed transverse femoral shaft fractures treated with an intramedullary nail and open reduction.

Discussion.

When studying literary sources of forensic medicine, it was established that there are no exact criteria and stages of fracture consolidation as such, indicating clear time intervals for healing. Moreover, many authors, both from the field of forensic medicine and radiology, indicate fairly wide time corridors for the stages of fracture consolidation they established. The currently available more accurate data on the timing of fracture healing are in no way related to the radiographic method, but relate mainly to the study of “native” material in situ,

or associated with the use of histological, histochemical, fractographic, ultrasound and other research methods and their combinations. As for the extensive literature information from general clinical (traumatological) practice, taking into account the initially completely different goals of research, in contrast to forensic medicine, in these works the authors, in principle, do not focus on clear temporal and X-ray morphological criteria for reparative post-traumatic bone regeneration.

In most of these works, carried out mainly from a clinical and pathomorphological point of view, in order to study the influence of various factors, as well as different methods of treating fractures on the timing of their healing, fairly wide time corridors for consolidation of fractures are indicated, specific timing of fracture healing, and thus more radiological signs and features of callus at different stages of its formation were left without attention due to initially completely different tasks and problems posed by the authors.

Conclusion

As can be seen from the above analysis of scientific sources of X-ray, forensic and general clinical (traumatology) profiles, since the initial basic studies of the founders of domestic radiology and foreign authors - radiologists, the issue of determining the age of fractures based on the X-ray method of research has remained at almost the same level - those However, there are quite wide time corridors and the absence of specific X-ray morphological signs of consolidation characteristic of each time period.

This issue has not been resolved by forensic experts either: the timing and radiological signs of consolidation of fractures in most studies were either not studied specifically, or are a copy of the descriptions of radiologists. Moreover, the indicated timing and radiological dynamics of fracture consolidation do not always correspond to what a forensic expert sees in practice. The issue of sensitivity and specificity of the x-ray method in diagnosing not just age, but also fractures as such, as well as in the differential diagnosis of “fresh” and “old” fractures, remains particularly acute.

As a rule, the accuracy of x-ray diagnostics is directly related to the qualifications and experience of the doctor. With proper X-ray placement (installation) and good quality of the X-ray image, a fracture can, as a rule, be missed only for reasons not related to the X-ray method itself. When studying a fairly extensive literature devoted to issues of traumatology and orthopedics, it was found that assessing the duration of fractures was not the main priority of research, since the main focus

The timing of fracture healing is set depending on different treatment methods, both conservative and surgical, and their combinations, taking into account the age and anamnestic specifics of the patients. All of the above confirms the relevance of this work to establish clear criteria and time periods for reparative post-traumatic bone tissue regeneration in an x-ray manner.

Fig. 1 Diagram of callus.1 – periosteal; 2 – endosteal; 3 – intermediate; 4 – paraosseous. Fig. 2. X-ray picture of the development of a fracture of the diaphysis of the ulna: 2a – 1 day, 2c – 1 month, 2c – 1.5 months. Fig. 3. Fracture of the diaphysis of the radius - 5 months.

About the authors

Yulia Li

GBUZ MO "MONIKI im. M.F. Vladimirsky", Moscow, Russian Federation

Primorsky Regional Bureau of Forensic Medicine, Vladivostok, Russian Federation.

Author for correspondence.
Email: reineerdeluft@gmail.com
ORCID iD: 0000-0001-7870-5746
SPIN-code: 2397-7425

Postgraduate student of the Department of Pathological Anatomy and Forensic Medicine 
GBUZ MO "MONIKI im. M.F. Vladimirsky"

Russian Federation, 1 bld 61/2 Shchepkina street 129110 Moscow, Russian Federation

Marina V Vishniakova

GBUZ MO "MONIKI im. M.F. Vladimirsky", Moscow, Russian Federation

Email: cherridra@mail.ru
ORCID iD: 0000-0003-3838-636X
SPIN-code: 1137-2991

Doctor of Medical Sciences, Head of the Department of Radiation Diagnostics, GBUZ MO "MONIKI im. M.F. Vladimirsky"

Russian Federation, 1 bld 61/2 Shchepkina street 129110 Moscow, Russian Federation;

Aleksandr V Maksimov

GBUZ MO "MONIKI im. M.F. Vladimirsky";
State University of Education

Email: mcsim2002@mail.ru
ORCID iD: 0000-0003-1936-4448
SPIN-code: 3134-8457

Dr. Sci. (Med.), Associate Professor, State University of Education;

Dr. Sci. (Med.), Associate Professor Department of Pathological Anatomy and Forensic Medicine, MBUZ MO "MONIKI im. M.F. Vladimirsky";

Russian Federation, 1 bld 61/2 Shchepkina street 129110 Moscow, Russian Federation

References

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