CC BY
11
УДК 340.6:611.781
DOI 10.53065/kaznmu.2022.98.70.041
S.A. Mussabekova1, A.O. Stoyan 2
1NJSC «Medical University of Karaganda», Karaganda city, Republic of Kazakhstan 2lnstitute of Forensic Expertise in Almaty RSUC "Forensic Examinations Center of the Ministry of Justice of the Republic of
Kazakhstan" Almaty city, Republic of Kazakhstan
THE IMPORTANCE OF FORENSIC ASSESSMENT OF EPACTAL BONES
Resume: The observation reveals the diagnostic capabilities of forensic medical examination to resolve controversial issues arising in the establishment of the cause of death. A case of a forensic medical examination of a four-year-old child is presented to resolve the issue of the possibility of a head injury during his stay in a hospital and the degree of involvement of medical workers in his death. The detection of an intercalary bone formed as a result of the appearance of additional ossification points in the large fontanel in the embryonic period and which is a congenital malformation during a forensic study indicates the absence of traumatic brain injury. The interdisciplinary approach made it possible to completely exclude the possibility of a child getting a head injury in a hospital.
Key words: infant mortality, forensic medical examination, skull bones, trauma, developmental anomalies.
С.А.Мусабекова 1 А.О.Стоян 2
Щараганды медицина университету Караганды к., К,азацстан 2Алматы каласы бойынша сот сараптамалары институты "К,Р ЭМ Сот сараптамасы орталыгы"РМ^К, Алматы к.,
Цазакстан
ЕНД1РМЕ СТЙЕКГЕРШ СОТ-МЕДИЦИНАЛЬЩ БАFАЛАУДЫH1 МАН,ЫЗДЫЛЬ№Ы
Тушн: Байкауда елшнщ себебш аныктау кезтде туындайтын даулы мэселелердi шешу ушш медициналык-криминалистикалык сараптаманыц диагностикалык мyмкiндiктерi ашылады. Стационарда болу барысында оныц басынан жаракат алу мумкшдт жэне медицина кызметкерлертщ оныц елiмiне катыстылык дэрежеа туралы мэселеш шешу ушт терт жасар балага сот-медициналык сараптама жyргiзу жагдайы усынылды. Медициналык-криминалистикалык зерттеу жyргiзу кезтде улкен ецбекте эмбриональды кезецде суйектенудщ косымша нуктелертц пайда болуы нэтижестде пайда болган жэне дамудыц туа бткен аномалиясы болып табылатын кондырма суйегт аныктау ми жаракатыныц жоктыгын керсетедь Пэнаралык тэал баланыц бас жаракатын емдеу мекеместде алу мумюнд^ш толыгымен жоща шыгарды.
Туйт свздер: балалар елШ, сот-медициналык сараптама, бас суйек суйектеру жаракат, даму аномалиялары.
С.А.Мусабекова 1, А.О.Стоян 2
1НАО «Медицинскийуниверситет Караганды», город Караганда, Республика Казахстан 2Институт судебных экспертиз по г.Алматы РГКП «Центр судебной экспертизы МЮ РК», город Алматы, Республика Казахстан
ВАЖНОСТЬ СУДЕБНО-МЕДИЦИНСКОЙ ОЦЕНКИ ВСТАВОЧНЫХ КОСТЕЙ
Резюме: В наблюдении раскрываются диагностические возможности медико-криминалистической экспертизы для решения спорных вопросов, возникающих при установлении причины смерти. Представлен случай проведения судебно-медицинской экспертизы четырехлетнего ребёнка для решения вопроса о возможности получения им травмы головы в ходе пребывания в стационаре и степени причастности медицинских работников к его гибели. Обнаружение при проведении медико-криминалистического исследования вставочной кости, образованной в результате возникновения в большом родничке дополнительных точек окостенения в эмбриональном периоде и являющейся врожденной аномалией развития, свидетельствует об отсутствии черепно-мозговой травмы. Междисциплинарный подход позволил полностью исключить возможность получения ребенком травмы головы в лечебном учреждении. Ключевые слова: детская смертность, судебно-медицинская экспертиза, кости черепа, травма, аномалии развития.
Introduction
The World Health Organization (WHO) and the international organization United Nations Children's Fund (UNICEF) have repeatedly noted that infant and child mortality (in the first five years of life), along with life expectancy, are an integral indicator of the quality of life in a particular region [12]. One of the leading indicators of the state of health of the child population, mortality in childhood, is an important component in the process of characterizing the demographic situation in the country and is considered as the main criterion not only for protecting the health of mothers and children, but also for
the state of the national health system as a whole [3,4,12]. All death cases of children under 5 years of age are subject to careful analysis and clinical discussion [3,10]. According to UNICEF data over the past year, the main causes of infant mortality in Kazakhstan are non-compliance by medical workers with existing standards and algorithms, a shortage of neonatologists, insufficient knowledge and skills, and the lack of a unified approach to the use of antimicrobial drugs [12]. Both in frequency and in the structure of causes, a mortality in infancy differs in its various periods [3,4,10]. However, the death of children of this age group in inpatient institutions is not always
associated with incorrect actions of doctors in their treatment [2,8]. External influences, certain conditions arising in the perinatal period, and congenital anomalies remain the absolute leading causes of mortality in the child population in many countries [4,10]. Analyzing the main causes of death of children in Kazakhstan, special emphasis should be paid to the high mortality rate of children under 5 years of age from congenital malformations, various injuries and other causes [4]. One of the urgent problems of the health care system in Kazakhstan is improving the quality of medical care to the population [3,4,7]. At the same time, a significant role in assessing the quality of medical care is assigned to forensic medical examination [7]. To date, there has been a steady increase in the number of lawsuits filed by patients in connection with the inadequate quality of medical care, leading to an increase in the number of forensic medical examinations in civil cases.
Irregular bones of the skull (Wormian, sutural, epactal, Andernach's ossicles) are additional bones that form along the sutures in the fontanelles due to the appearance of additional ossification points in the bones of the skull. Such features are small developmental anomalies, and are most often an accidental finding during X-ray examination of the skull of children under the age of 5 years [6,10]. Irregular bones of the skull are often found in defects of the skull, in osteogenesis imperfecta, as well as in combination with congenital malformations of the brain [9]. Until the middle of the last century, it was believed that epactal bones had no medical significance. However, a number of authors have noted that unilateral suture bones are a convincing sign of brain damage [5]. Literary data testify to numerous finds of epactal bones of the skull during archaeological excavations [6,10]. At the same time, specialists do not provide a detailed description and microscopy of the additional bones, and in such cases such sources have no forensic value. Meanwhile, the main significance of irregular bones of the skull in forensic practice, under certain circumstances of the case, is that they can be mistakenly regarded as fragments [1,9]. This fact can negatively affect the subsequent delivery of a court decision. Taking into account all possible options for the development of anomalies, correct medical and forensic assessment of the skull bones plays an important role in ascertaining the true cause of death. The message under consideration clearly demonstrates the role of forensic research in the diagnosis of trauma in all controversial cases and reveals the importance of its timely and comprehensive implementation for solving specific forensic medical problems. Case presentation
In this case, a commissioned forensic medical examination was carried out in connection with the initiation of a criminal case on the possible infliction of serious harm to
the health of a child in a hospital. For a forensic study on the death of a four-year-old child, a skin flap and skull bones were provided to the forensic department. According to the circumstances of the case: "The reasons for the death of the minor have not been fully established". However, according to the statement, the mother of the child «... asks to adopt legal measures against the medical staff of the children's hospital.... where her child died due to their improper performance of professional duties». For the permission of the forensic medical examination, the question of determining the mechanism of the formation of injuries on the child's body, discovered during the commission of the forensic medical examination was raised. According to the conclusion of the forensic examiner, an internal examination of the corpse revealed: that hemorrhage on the skin of the parietal region of a dark brown color, irregular in shape with indistinct contours, measuring about 5.0x2.0 cm (Figure 1) and a quadrangular bone plate measuring about 1.9 x 3.0 x 2.0x3.1 cm (presumably the area of the large fontanelle), which was connected with the frontal and parietal bones through the sutures of the skull (Fig.2). A skin flap from the corpse of a child presented for examination is dry, dark in color, dense to the touch. To restore the original properties, the skin flap was placed for three days in an alcohol-vinegar solution (Ratnevsky's solution). After that, for clarification, the above-mentioned flap was placed for two hours in a solution of alcohol-vinegar solution with the addition of hydrogen peroxide (Ratnevsky's solution №2). After the reconstruction of the skin flap, a medical and forensic research was carried out: no damage was found during visual and stereomicroscopic examination of the skin preparation (Figure 3) (Figure 4). During the medical and forensic examination of a fragment of the frontal bone, two fragments of the parietal bones and the epactal bone of the child's skull, it was found: the bones of the skull are yellow-brown, hard, solid, light, smooth to the touch, with an oily sheen. The above-mentioned fragments of bones for three days were placed in an alcohol-vinegar solution with the addition of hydrogen peroxide to restore (Ratnevsky's solution №2). The research established: the epactal bone is connected to a fragment of the frontal bone by a sagittal suture, and its connection with fragments of the parietal bones is carried out using abnormal sutures of the skull. In this case, all of the above-mentioned fragments of bones are completely comparable (Figure 5)(Figure 6). Stereomicroscopic examination of the provided fragments showed that the teeth of the sutures are quite marked, not crushed or displaced. No damage was found on the bones of the skull. The intercalation bone could have formed as a result of the appearance in the large fontanelle of additional ossification points in the embryonic period, which is a congenital malformation.
Figure 1 - Hemorrhage into the skin of the occipital Figure 2 - View of the bones of the cranial vault during region, detected during a forensic examination of a corpse exhumation
Figure 3 - Skin flap after recovery Figure 4 - Stereomicroscopic picture of a skin flap
Figure 5 - Skull bones, outside view__Figure 6 - Skull bones, inside view
Discussion:
The literature on forensic fractology describes in detail the morphological characteristics of fractures of the skull bones, which are formed as a result of impact when falling or when the head is compressed [11,13]. At the same time, the type of fractures is mediated by the peculiarities of the trauma mechanism, that is, in each specific case, according
to the morphological features of injuries to the bones of the skull or their fragments, one can judge the possible conditions corresponding to certain biomechanical patterns of the formation of trauma to the bones of the skull [11]. The morphological features of fragments of the child's skull revealed during the medical and forensic examination made it possible to exclude the possibility of
their formation as a result of the shock mechanism of a skull injury in a single fall from a height of about 1 meter or hitting the head on the floor. Meanwhile, it was found that the identified epactal bone (insular, suture, Wormian) could have formed as a result of the appearance of additional ossification points in the bones of the cranial vault in the embryonic period, which is a congenital developmental anomaly. According to A.A. Zajchenko et al. the insular bones of the skull are included in the form of islets in typical bones adjacent to the sutures and are formed from centers of ossification enclosed in the membranous tissue of the fontanelles [5]. By their characteristic location - along the seam, serrated contours, thin linear enlightenment separating them from the main bone and the zone of «physiological sclerosis», they are distinguished from bone fragments and sequesters [11]. For practical medicine, knowledge of possible options for the location of inconsistent bones of the skull is determined mainly by the fact that in case of head injuries or on X-ray images they can be mistaken for cracks or bone fragments, as described in the literature [13]. Forensic medical examination is able to provide adequate explanations for the formation of certain injuries, especially if there are doubts about the origin of some nonspecific elements found during autopsy [1,7]. However, in some cases, a more detailed analysis of the mentioned material is needed, with a justification of the mechanism of damage formation or existing anomalies. Forensic medical examination is an important step in ascertaining the true cause of a person's death. However, it is the medical and forensic examination that makes it possible to establish a detailed description of a congenital small anomaly of development and to judge the mechanism of its formation, taking into account knowledge about the morphological patterns of the
formation of skull fractures from classical forensic fracture science, thus solving a complex forensic medical problem that has an important legal meaning.
Authors' Contributions. All authors participated equally
in the writing of this article.
No conflicts of interest have been declared.
This material has not been previously submitted for
publication in other publications and is not under
consideration by other publishers.
There was no third-party funding or medical representation in the conduct of this work. Funding - no funding was provided.
Авторлардьщ улеа. Барлык; авторлар осы ма;аланы
жазуга тен, дэрежеде катысты.
Мудделер цацтьгеысы - мэлiмделген жок;.
Бул материал бас;а басылымдарда жариялау ушш
бурын мэлiмделмеген жэне баска басылымдардын,
карауына усынылмаган.
Осы жумысты журпзу кезшде сырт;ы уйымдар мен медициналык; екшджтердщ каржыландыруы жасалган жок;.
Царжыландыру журпзшмедь
Вклад авторов. Все авторы принимали равносильное участие при написании данной статьи. Конфликт интересов - не заявлен. Данный материал не был заявлен ранее, для публикации в других изданиях и не находится на рассмотрении другими издательствами. При проведении данной работы не было финансирования сторонними организациями и медицинскими представительствами. Финансирование - не проводилось.
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The address of the author responsible for correspondence with the editors:
Saule Amangeldiyevna Mussabekova
Candidate of Medical Sciences,
Professor of the Department of Pathology of the Nonstock Corporation "Medical University of Karaganda", master level forensic medical expert
ORCID: 0000-0001-9622-8218 https://orcid.ora/0000-0001 -96228218
100009, Republic of Kazakhstan Karaganda city, MusabekovaS@qm u.kz
