DETERMINING THE DISTANCE OF DIAPHYSAL FRACTURES OF LONG TUBULAR BONES BASED ON THE RADIOGRAPHY METHOD

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JUSTIFICATION

Due to the particularly significant share of skeletal trauma in the daily practice of a forensic expert, determining the age of fractures makes a significant contribution to establishing the circumstances of the incident. Until now, the main sources for determining the timing of fracture healing are works on traumatology and orthopedics, as well as radiology [1-7]. However, in these studies, more attention is paid to the dependence of the timing of consolidation on the chosen tactics and methods of treatment, the use of osteotropic and other drugs, and determining the duration of fractures as such is not a priority [8-9].

Modern research in this area in forensic medicine is mainly associated with the use of methods not related to radiology, but based on the results of autopsy, histological, factual, ultrasound and other methods [10-12]. In this regard, the problem of establishing the timing of consolidation of fractures from the perspective of the x-ray method remains unresolved, while during the examination of living persons in the absence of complete medical documentation, the results of x-ray examination of the area of ​​interest sometimes represent the only significant source of information for the expert.

TARGET  

	Identification of radiological features of diaphyseal fractures of long tubular bones, characteristic of a certain stage of consolidation. 

MATERIALS AND METHODS

Archival materials of 56 expert subjects (men and women) with diaphyseal fractures of long tubular bones for the period from 2019 to 2024 were studied.

	Study design

	The study is observational (observational), single-center, retrospective, selective, uncontrolled.

Stages of the study: selection of groups of patients by gender, age, location and nature of diaphyseal fractures, the presence or absence of a history of surgical intervention for the fractures being studied. When examining radiographs, the following periods were identified: fractures up to 7 days, fractures from 7 to 20 days, from 21 to 30 days, 31-60 days (1-2 months), 61-90 days (2-3 months), 91-120 days (3-4 months), 121-180 days (4-6 months), 181-270 days (6-9 months), 271-365 days (9-12 months), more than a year . The main morphological signs of fracture healing have been identified and studied: changes in the main fracture line (FL),

the nature of the fracture edges (CF) and the ends of fragments (CF), the presence or absence of callus (CM), changes in the X-ray contrast of the callus, comparative characteristics in relation to the density of spongy (CS) and compact substance (CS) bone, uniformity of callus , clarity or blurring of its boundaries, the presence or absence of signs of callus restructuring; generalization and cumulative analysis of the obtained data.

Eligibility Criteria

	Inclusion criteria: subject men and women aged 20-80 years, fractures of long tubular bones in the diaphyseal zone. 

	Non-inclusion criteria: refractory and pathological fractures; low-quality radiographs taken with improper placement.

	Conditions

The study was conducted on the basis of the Primorsky Regional Bureau of Forensic Medicine. We studied archival materials, examinations of victims, accused and other persons living in the Primorsky Territory who were injured in domestic and work conditions, as a result of illegal and other actions.

	Duration of the study

	The duration of the observation period is 6 years.

Period of the retrospective study: 2019-2024. We consistently studied data from criminal cases and preliminary checks, medical documents, primary and control X-rays from analogue and digital X-ray machines, on X-ray films and digital media in JPEG format and DICOM file format.

	Methods for recording outcomes

During the study, systemic and comparative analysis, synthesis, axiomatic method, analysis of the conceptual and terminological system, method of analogies, observation, and x-ray method were used. X-ray images from analog X-ray machines were studied on a single-frame X-ray viewer "Armed" and in transmitted daylight natural light with the naked eye and at ninefold magnification; Digital radiographic images were studied on a personal computer with the Windows 10 operating system, processor: Intel(R) Core(TM) i3-3220 CPU @ 3.30GHz 3.30 GHz; in addition, the RadiAnt program was used for DICOM files.

Ethical review

	The study protocol was reviewed by an independent ethics committee at the State Budgetary Institution of Healthcare of the Moscow Region MONIKI named after. M.F. Vladimirsky. It was decided to approve the conduct of this study (extract from the minutes of meeting No. 15 dated 10/07/2021).

	Statistical analysis

	The sample size was not previously calculated. The frequency of repetition of values ​​with the same value of the diagnostic sign was recorded. The obtained values ​​were expressed as a percentage of the total number of the statistical population

RESULTS

In case of diaphyseal fractures, the following dynamics of the X-ray picture were revealed:

1) up to 7 days, a clear fracture line, clearly visible along the entire length, clearly defined edges of the fractures, the ends of the fragments are acute-angled, in 31% of men and 33% of women small teeth are identified along the edges of the fracture; 

2) in the period from 7 to 20 days, the picture is almost identical, however, the previously existing denticles along the edges of the fracture are leveled out, there are no signs of callus (Table 1);

3) 21-30 days: the main crack is clearly visible along its entire length, the edges of the fracture are gradually smoothed out, the ends of the fragments are rounded, the bone callus is not identified, only in isolated cases (17% in men) - a weak, tender cloud-shaped bone callus, with a density lower than the density of spongy callus bone parts;

4) 31-60 days (1-2 months): the main crack is clearly visible along its entire length, in isolated cases only 2/3 is clearly visible, on the rest of the length it is unclear (in 22% of women), the edges of the fracture are gradually smoothed out, the ends of the fragments are rounded, callus is absent in 43% of men and 67% of women;

weakly expressed, tender, cloud-shaped callus, without clear boundaries, below the density of the spongy layer of bone was recorded in 29% of men and 11% of women, subsequently the callus gradually becomes denser, corresponding in intensity to the spongy part of the bone (14% of men, 22% of women); in 14% of men, callus of uneven density: higher than the density of the spongy layer of bone, but lower than the density of the compacta, the boundaries of the callus are still unclear and uneven (Table 2);

5) 61-90 days (2-3 months): the fracture line is clearly visible along its entire length in 92% (m.) and 80% (f.), in some cases - only 1/2 (8% of men) and 2/3 of its length (20% of women),

the edges of the fracture are smoothed, the ends of the fragments are rounded, the callus is not visualized in 75% of men and 60% of women; tender, cloud-shaped callus is detected in 4% of women; bone callus is equal in intensity to spongy bone with uneven, unclear boundaries in 17% of men, with clear, even boundaries in 20% of women; callus of uneven density, more than the spongy layer of bone, but less of its cortical layer was observed in 8% of men, while the boundaries of the callus were clear and even;

6) 91-120 days (3-4 months): the fracture line gradually loses its clarity and definition; in 67% of men and 33% of women it is visible throughout, in 17% of men it is visible on 2/3, in 17% of men – 1/2 of the entire length, the edges of the fracture remain smoothed, the ends of the fragments are rounded, the callus becomes denser, in 33% of men it is equal to the density of the spongy substance, has clear, even boundaries, in 67% of men the intensity of the callus corresponds to the density of the cortical layer, Moreover, in 17% it does not have clear boundaries, and in 50% of men and 33% of women it has clear, even boundaries (Fig. 1);

7) 121-180 days (4-6 months): the X-ray picture of the fracture continues to change, the fracture line is not clearly visible, along its entire length in 23% of men, gradually closing: in 11% only 2/3 is visible, in 43% - by 1/2, in 23% - less than half of its entire length, the bone callus also evolves: in 23% of men its density corresponds to the density of the spongy part of the bone, in 23% - the intensity of the callus is higher than the spongy layer of bone, but less cortical layer, in 54% it corresponds to the density of the cortical layer, with clear, relatively smooth boundaries. The callus still remains of uneven density (Tables 3 and 4);

8) 181-270 days (6-9 months) the main crack gradually closes, in 60% of men it is visible at 1/2, in 40% - less than 1/2 of its length; in women, 40% and 50%, respectively; the callus undergoes changes, becomes more dense, of uniform intensity, with clear, even boundaries, in 20% of men it is equal to the density of the cancellous part of the bone, in the vast majority (80%) it is equal to the density of the cortical layer; respectively for women: in 24%, the callus is equal to the density of the compact layer, with uneven, unclear boundaries, uneven intensity, in 76% - with clear, even boundaries, uniform density, equal to the compact layer of bone, the edges of fractures and the ends of fragments are not clearly visible;

9) 271-365 days (9-12 months) further gradual closure of the fracture line occurs: in 17% of men it is visible at 1/2, in 83% - less than 1/2 of its length; in women, respectively - 14% and 86%, the callus is dense, the intensity corresponds to the cortical layer of bone, of uniform intensity, with clear boundaries, in 23% of men and 19% of women with signs of bone tissue restructuring, which are more pronounced after 11 months, edges fractures and the ends of the fragments are not visible (Fig. 2, 3).

10) fractures more than a year old, in all observations have the same type of characteristics: the fracture line is completely closed, not visible, the callus is dense, well-defined, of uniform intensity, with signs of bone tissue restructuring (Fig. 4).

In the studied groups, 43% of women and 34% of men underwent metal osteosynthesis (MOS) for diaphyseal fractures; there was both extraosseous osteosynthesis with a plate and screws, and intramedullary locked one.

In periods of up to 3 months, the presence or absence of MOS surgery for these fractures did not play a significant role in the timing of the onset of callus formation, and in the future there was also no significant difference in the dynamics of fracture healing compared to the expert subjects without MOS. The exceptions were isolated cases of unstable MOS with migrating screws, performed for comminuted-fragmented fractures, including those with a bone tissue defect, with significant displacement of fragments. In such rare cases, callus was not radiologically detected for a long period of time - up to 6-8 months.

DISCUSSION

	Summary of the main finding of the study

	In accordance with the dynamics of the X-ray picture of diaphyseal fractures, 10 main periods are identified, which are characterized by a certain impregnation with corresponding characteristic X-ray signs. The main morphological features of fractures identified using the x-ray method allow the expert to determine their age.

Discussion of the main result of the study

	Determining the age of fractures under the conditions of certain limitations of the forensic expert in terms of the usefulness of the objects provided often causes difficulties. This may be due to some lack of information in the specialized forensic literature on this issue [13-14]. According to literary sources on forensic medicine and radiology, the main radiological picture of consolidation comes down to three main periods: the beginning

precipitation of calcium salts in the area of ​​the “primary” callus, its gradual compaction until the formation of a full-fledged callus. At the same time, these works leave out the detailed dynamics of the X-ray picture of the fracture, the time periods of healing of which range from 2 to 6-8 months or more from the moment of injury [15-17]. 

	In this regard, our study revealed fairly clear time periods of consolidation, which together represent a continuous and consistent chain of dynamically changing radiographic patterns of the fracture. The main “reference markers” have been established,

allowing to track the dynamics of healing: the fracture line or main crack, the nature of the edges of the fracture and the ends of the fragments and, directly, the callus itself, the gradual metamorphosis of which allows the expert to more accurately guide the expert on the issue of how long ago the injury was. We have established that there is a consistent change in the morphology of the fracture during healing: there is a gradual closure of the fracture line, smoothing and blurring of the edges and ends of fragments, the callus is gradually compacted, its X-ray contrast changes, the uniformity of darkening, the clarity of the edges, up to the final completeness of the consolidation picture .

The study found that the dynamics of callus formation and changes in the x-ray picture of the fracture (type and nature of the main crack, fracture edges, ends of fragments) depend on the gender of the expert, while the difference in the dynamics of fracture healing by gender is most pronounced in the period from 31 -60 days to 271-365 days and ranges from 12 to 34%, healing of fractures in men occurs faster than in women. Fractures that are more than a year old do not differ by gender; their x-ray picture is almost the same type.

Of greater importance is the nature of the fracture, as well as the usefulness and stability of the performed MOS: comminuted, comminuted-fragmented fractures, with bone tissue defects, with initially significant displacement of fragments, and with unstable MOS are consolidated much more slowly. However, with the opposite pattern of fracture, the presence or absence of MOS did not play a significant role in the rate of consolidation. The average scores in the groups were approximately the same.

Limitations of the study

	The difficulties of the study and the interpretation of its results include the quality of radiographs: “soft” or, conversely, “hard” X-ray images, X-ray images taken with a violation of the patient’s positioning or installation, the presence of foreign shadows that complicate the study: shadows of staircases (transport) splints, elements of the skeletal traction system, MOS elements (plates, screws, intramedullary rods, etc.), dynamic blur, artifacts in the form of scratches, spots, film defects, etc.

Moreover, the visualization of the callus itself is sometimes limited in images in certain projections. These difficulties can be overcome by repeated radiography of the area of ​​interest.

CONCLUSION

	The healing of a diaphyseal fracture of a long tubular bone goes through certain stages, with the X-ray picture of the fracture area consistently changing.

	 The key points are changes in the main fracture line (main crack) - from sharp and clear to its complete closure, fracture edges, ends of fragments,

dynamics of callus up to a complete x-ray picture of fracture consolidation. It is important to establish these signs, record their changes and give them a correct assessment. The conducted research allows the expert to more accurately determine the issue of how long ago the fracture occurred and, accordingly, make a certain contribution to clarifying the mostly vague and contradictory circumstances of the injury.

Table 1. Diaphyseal fractures, up to 20 days old

Table 2. Diaphyseal fractures, 21 to 60 days old

Table 3. Diaphyseal fractures, aged from 61 to 180 days (2 - 6 months) and from 181 to 365 days (6-12 months) and more than a year

Table 4. Dynamics of callus development in diaphyseal fractures, 61 to 180 days old (2 - 6 months)

Table 5. Dynamics of callus development in diaphyseal fractures aged from 181 to 365 days (6-12 months) and more than a year

Fig. 1. Fracture of the diaphysis of the ulna, 4 months old. The fracture line is not clearly visible, the callus is of uneven density, with clear, relatively smooth boundaries

Fig. 2. Fracture of the femoral diaphysis, 9 months old, in the conditions of MOS. The fracture line is not clearly visible at 1/2-1/3, the callus is of uniform intensity, with clear, even boundaries.

     Fig. 3. Fracture of the diaphysis of the ulna, 11,5 months old. The fracture line is practically not visible, the edges of fractures and the ends of fragments are not visualized, the bone callus shows initial signs of restructuring.

Fig. 4. Fracture of the upper third of the diaphysis of the fibula, 1 year 4 months old. The   fracture line has completely closed, the callus is dense, with clear signs of bone tissue restructuring.

About the authors

Yulia B Li

GBUZ MO "MONIKI im. M.F. Vladimirsky"; Primorsky Regional Bureau of Forensic Medicine,

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

State forensic medical expert of the Primorsky Regional Bureau of Forensic Medicine

Россия, Russian Federation, 129110, Moscow, st. Shchepkina, 61/2; Russian Federation,690105,Vladivostok, st. Russian, 61v

Marina V Vishniakova

GBUZ MO "MONIKI im. M.F. Vladimirsky";
FGBU “National Medical Research Center for Surgery named after A.V. Vishnevsky"

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

MD, Dr. Sci. Head of the Department of Radiation Diagnostics GBUZ MO "MONIKI im. M.F. Vladimirsky"

Россия, Russian Federation, 129110, Moscow, st. Shchepkina, 61/2; Russian Federation, Moscow, st.Bolshaya Serpukhovskaya,27

Aleksandr V Maksimov

GBUZ MO "MONIKI im. M.F. Vladimirsky", Moscow, Russian Federation
State University of Education

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

Doctor of Medical Sciences, Associate Professor, Professor of the Department of Pathological Anatomy and Forensic Medicine of the State Budgetary Institution of Healthcare of the Moscow Region "MONIKI named after M.F. Vladimirsky";



Doctor of Medical Sciences, Associate Professor, Professor of the Department of Fundamental Medical Disciplines of the Faculty of Medicine of the Federal State Autonomous Educational Institution of Higher Education "State University of Education".

Россия, Russian Federation, 129110, Moscow, st. Shchepkina, 61/2; Moscow, ext. ter. Basmanny municipal district, st. Radio, 10A, building 2

References

Supplementary files