A RARE CASE OF DIAPHYSISAL FRACTURES OF THE SHIN BONES IN A CHILD WHEN JUMPING ON A TRAMPOLINE. WAYS TO PREVENT EXPERT ERRORS USING COMPLEX ANALYSIS OF RADIOGRAPHY DATA AND CASE MATERIALS: A CASE FROM PRACTICE

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RATIONALE
Relevance.
Child injury remains one of the main problems in medicine and occupies a significant share in the structure of general health problems in children. The main risk group is children from 10 to 14 years old, who account for approximately 1/3 of all childhood injuries [1-5]. Injuries to children remain a serious social problem, especially considering the consequences of significant injuries in the form of fractures. Against this background, special attention is drawn to injuries sustained by children in children's entertainment centers, for the most part associated with a gross violation of the rules for the operation of sports and entertainment devices and equipment, when the immediate juvenile "culprits" become victims of their own carelessness. Injuries on the trampoline are not uncommon, which are not always limited to superficial injuries in the form of bruises, abrasions, etc. The fractures obtained during the operation of the trampoline are mainly localized in the epimetaphyseal zones of the long tubular bones of the upper and lower extremities, in the area of the ankle bones of the leg bones [6, 7]. However, there are fractures of atypical localization and morphology, which are a source of expert errors in terms of determining the mechanism of injury, especially in cases where the expert and his legal representative describe the circumstances of the injury that do not correspond to the data of the case file, as well as the nature of the injury. Of great importance in this case are the age-related features of the bone tissue of a child, which contains more organic substances than inorganic ones, which provides the characteristic features of diaphyseal fractures in children [8-11].

Purpose of the study
Demonstration of an example of a comprehensive expert evaluation of X-ray data and case materials to accurately determine the mechanism of diaphyseal fractures of the leg bones in a child.

An example from practice.
A forensic medical examination was carried out by order of the investigator of the investigative committee, two months after the incident.
Facts of the case: a statement from the legal representative, the mother of underage K., with a request to “bring responsibility for the perpetrators for providing services that do not meet safety requirements, as a result of which her underage daughter was injured as a result of falling from a trampoline in a trampoline center” was suppressed (exact quote from the ruling).
The following were submitted for examination: a medical record of an inpatient, radiographs and a juvenile K., 11 years old. When questioned by a forensic expert, juvenile K. and her mother stated that the victim received fractures of the bones of the right shin when she jumped from the trampoline onto the mat and hit her right shin on the edge of a solid rectangular “pedestal” installed next to the trampoline. During the forensic medical examination of the subject, as expected, no bodily injuries and traces of their healing related to the events described above were found.
In the submitted medical card of an inpatient in the name of the victim, no external bodily injuries were indicated in her. In the study of primary radiographs of the right lower leg in direct, non-standard oblique and lateral projections (from the date of injury), the following fractures were identified: a helical-comminuted fracture of the middle third of the diaphysis of the right tibia with displacement of the distal fragment inwards by the width of the compact and at an obtuse angle, open outwards, with the formation of a bone fragment in the form of an elongated parallelogram along the posterior-outer surface of the tibia, with a screw part of the fracture clearly visible in the lateral projection image; oblique fracture of the middle third of the diaphysis of the right fibula with displacement of the distal fragment medially to the width of the bone and with a slight overlap of the fragments, with the zone of the fracture predominantly along the posterior-outer, the gap - along the inner surface of the bone; subperiosteal (green branch type) fracture of the upper third of the diaphysis of the right fibula (subcapital fracture) without displacement of fragments, with a roller-like swelling of the compact more along the posterior-inner surface of the bone. A more detailed description of the fractures is difficult due to the partial overlap of the shadows of the tibia on each other in the images in the lateral and oblique projections.
The investigator additionally provided a video recording from a surveillance camera installed to the left and above the location of the part of the trampoline where this event occurred, and the part of the above “pedestal” opposite to the camera was outside the camera’s viewing perimeter. When viewing this video recording in slow motion and frame by frame, the following was established: a juvenile K. bounces on a trampoline, at that moment another girl jumps off the “pedestal”, with a height and physique approximately corresponding to the subject. The moment of K.’s “landing” on the surface of the trampoline (with the supporting right leg) coincides with the “landing” on the trampoline of the second girl, after which K. jumps onto the mat outside the trampoline with her right foot slightly tucked in towards the “pedestal” falling out of the camera’s field of view , the fact of a blow on which it is impossible to establish on the basis of the video recording, and then the child falls on the mat on the buttocks.

Discussion.
When examining radiographs of the right tibia, the forensic expert found that the juvenile K. had the following injuries at the time of seeking medical help: a closed helical-comminuted fracture of the middle third of the tibial shaft with displacement of fragments, a closed oblique fracture of the middle third of the fibula shaft with displacement, closed subperiosteal (green line) fracture of the upper third of the diaphysis of the fibula (subcapital fracture) without displacement. Analysis of the video recording made it possible to establish that at the time of K.'s "landing" on the trampoline on the supporting right leg, the surface of the trampoline was tightly stretched due to the simultaneous "landing" the second girl jumped on him from the height of the "pedestal" at the edge of the trampoline, which allows us to evaluate the trampoline at the time of "landing" of the young K. as a hard, flat, even surface. Taking into account the above, taking into account the age specificity of the child's bone tissue (higher water content and organic matter , less - mineral substances, which provides greater compliance, elasticity, less fragility compared to the bones of an adult), as well as morphological features of fractures, indicating their constructive nature (indirect injury mechanism): a combination of rotation and bending with simultaneous forced longitudinal loading, it can be said that these fractures occurred at the same time, as a result of K.’s “landing” on a hard, tightly stretched surface of the trampoline on the supporting right leg. Thus, despite the incomplete informational content of the presented video recording due to the limited perimeter of the camera’s view, it is possible with full confidence to exclude the possibility of the formation of these fractures as a result of a blow to a “hard pedestal”, as originally indicated by the victim and her mother.

CONCLUSION
The above case from expert practice demonstrates the importance of a thorough study of radiographs not only to establish the fact of fractures as such, but also their morphological features, which allows the expert at this stage of the examination to determine the nature of fractures (local or structural). However, a full restoration of the circumstances of the incident is possible only with a comprehensive analysis of both these medical documents and the case materials, while it is important to take into account the age, constitutional features of the subject.

Rice. 1. Helical-comminuted fracture of the middle third of the tibial shaft, oblique fracture of the middle third of the fibula shaft, subperiosteal fracture of the upper third of the fibula shaft (subcapital fracture) with displacement of fragments on radiographs in the straight line (a), lateral (b) and non-standard oblique ( c) projections.

Rice. 1а

Rice. 1b

Rice. 1c

About the authors

Yulia Li

GBUZ MO MONIKI them. M. F. Vladimirsky

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

Государственный судебно-медицинский эксперт ГБУЗ "Приморское краевое Бюро судмедэкспертизы", Уссурийский межрайонная отдел

 

Russian Federation, 1 bld 61/2, Shchepkina str., Moscow, Russia;

Vladimir А Klevno

GBUZ MO MONIKI them. M. F. Vladimirsky

Email: vladimir.klevno@yandex.ru
ORCID iD: 0000-0001-5693-4054
SPIN-code: 2015-6548

Doctor of Medical Sciences, Professor; Head of the Department of "Forensic Medicine" GBUZ MO MONIKI them. M. F. Vladimirsky

Russian Federation, 1 bld 61/2, Shchepkina str., Moscow, Russia;

Marina V Vishniakova

GBUZ MO MONIKI them. M. F. Vladimirsky

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

Doctor of Medical Sciences

Russian Federation, 1 bld 61/2, Shchepkina str., Moscow, Russia;

References

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