Forensic assessment of lung injuries and correlations between pattern of thoracic trauma and lung injuries

1 INTRODUCTION Thoracic trauma (TT) is all injuries of thoracic wall and organs within the thorax Thoracic trauma is broadly categorized by mechanism into blunt (BTT) or penetrating trauma (PTT) [1] Thoracic trauma is one of the most commonly found injuries among traffic accidents and often results in severe stage and high mortality rate Prior to the 20th century-, the majority of thoracic trauma victims were soldiers while the number of work accidents was minor let alone a tiny number of traffic accidents From the mid20th century, thanks to the advance of technology and the proliferation of cars as vehicles and highway systems, the quantity of thoracic accidents broke out and the number of injuries and deaths caused by traffic accidents increased exponentially [2] In the world scale TT is a leading cause of hospitalization as well as death, accounting for 10% of traumatic hospitalizations and 25-50% of traumatic deaths [3] The main reason of TT is road ttaffic accidents (RTA) making up for 80% of all TT cases, the percentage is even higher in countries with low to mid incomes [4] In Vietnam while there is lacking of detail statistics on TT of all causes, roadtraffic-accidents-related TT was the reason behind 50% of8248 traffic-related deaths found in 2018 [5] In the period of 1989-1998 the number of traffic accidents climbed rapidly with head injury was the most prominent cause Nowadays, due to the improvement of traffic infrastructure and the growth in number of high speed personal vehicle owners, the pattern of injuries has become greatly different compared to the past Newly enacted policies on road transport policy and safety, especially legalization of helmet laws for motorbike, also play an important role to the shift of 2ĩ tlte pattern, from head injuries to thoracic and other traumas [6] In TT scenarios, lung is the most vulnerable organ BTT tends to cause more severe lung injuries with higher mortality rate than PTT Conduction of a research to assess lung injury pattern in more detail maimer and the correlations between pattern of thoracic trauma and lung injuries is an uigent need as it would provide a aid to the clinical doctors in diagnosing and treating wounded victims Thereby, elucidating the injuries and it relevant to other thoracic injuries would help to improve the diagnosis and treating procedures, minimize the secondary injuries and lower the mortality rate and overall, improve the outcome of traumatic victims Those amelioration would eventually contribute to ease the social burden of diseases While there are several studies on TT and lung injuiy in Vietnam, most of them are focus on the TT in clinical situations For the forensic approach, there are not many research on the field conducted recently Luu Sy Hung et al (2008) have reported on similar assessment, however the research only cover cases from 2004- 2007 which is outdate by 2021 Base on these aforementioned scenarios, to provide more up-to-date data and statistics, this study was performed with two purposes as follows: Firstly, assess the common pattern of lung injuries in recorded victims Secondly, evaluate the correlations between pattern of thoracic trauma and lung injuries CHAPTER 1: LITERATURE REVIEW 1.1 Global injuries burden and Vietnam's statistics There are 4.4 million deaths annually from injuries in general making trauma the 3rd leading cause of death and the most prominent cause of death for people from 15-44)0 (WHO report in 2020) [7] In 15- 29yo age group out of top cause of death are injury-related namely, road ttaffic injuries, homicide and suicide [S] In 2020 the road accidents, the most prominent cause among traumatic events, rose to 2rd leading cause of deaths, taking away 1.5 million lives per year globally [7] Among traumatic deaths RTA accounts for the largest proportion with 35% of total cases reported, followed by falling, violence, gun abuse Traumatic deaths are far more common in underdeveloped countries with low to mid incomes (9) Gender is also a factor as males to female are about 2:1 when it comes to overall traumatic events and 3:1 in ttaffic-related traumas [10] Among preventable death causes, traumatic injuries and deaths are society the most as those outstanding events lead burden toas on a significant individuals, workforce families and decrease compensation, and tremendous funeral payments cost for medical well asdeaths treatments, other related conflict costs The steps, prevention starting of from traumatic surveillance injuries to and gather the has data several to understand identify the the risk extent factors and nature of each of type injury of injury problems, It then followed shortly address by the intervention root causes development and evaluate to these develop measures strategies After to all prevention three steps, programs the researched [10] methods could be implemented into 8.996 and 24.417 injuries [11] The figures for 2018 were For 2020 18.763 the accidents figures further 8.248 deaths decreased and 16.802 to 14.510 accidents [5] 6.700 figures, deaths while 10.804 all three injuries numbers [12] decreased, As illustrated theinjuries differences by those be are apply insignificant in order to Aforementioned alle\iate the reason, problems proper method should 1.2 Anatomy review GENERAL DESCRIPTIONS The thorax is an irregularly shaped cylinder with a narrow opening (superior thoracic aperture) superiorly and a relatively large opening (inferior thoracic aperture) inferiorly The superior thoracic aperture is open, allowing continuity with the neck; the inferior thoracic aperture is closed by the diaphragm The musculoskeletal wall of the thorax is flexible and consists of segmentally arranged vertebrae, ribs, and muscles and the sternum The thoracic canty enclosed by the thoracic wall and the diaphragm is subdivided into three major compartments: + a left and a right pleural cavity, each surrounding a lung, and - the mediastinum The mediastinum is a thick, flexible soft tissue partition oriented longitudinally in a median sagittal position It contains the heart esophagus, trachea, major nen es, and major systemic blood vessels The pleural canties are completely separated from each other by tlie mediastinum Therefore, abnormal events in one pleural cavity not necessarily affect the other canty This also means that the mediastinum can be entered surgically without opening the pleural cavities Another important feature of the pleural canties is that they extend above the level of rib I The apex of each lung actually extends into the root of the neck As a consequence, abnormal events in the root of the neck can involve tile adjacent pleura and Iring and events in the adjacent pleura and lung can involve the root of the neck FUNCTIONS i) Breathing One of the most important functions of the thorax is breathing The thorax not only contains the lungs but also provides the machineiy necessary-the diaphragm, thoracic wall, and ribs-for effectively moving air into and out of the lungs Up and down movements of the diaphragm and changes in the lateral and anterior dimensions of the thoradc wall, caused by movements of the ribs, alter the volume of the thoracic cavity and are key elements in breathing ii) Protection of vital organs The thorax houses and protects tile heart, lungs, and great vessels Because of the domed shape of the diaphragm, the thoracic wall also offers protection to some important abdominal viscera Much of die liver lies under the right dome of the diaphragm, and the stomach and spleen lie under the left The posterior aspects of the superior poles of the kidneys lie on the diaphragm and are anterior to rib Nil on the right, and to ribs XI and XII on the left iii) Conduit The mediastinum acts as a conduit for structures tliat pass completely through the tliorax from one body region to another and for structures that connect organs in the thorax to other body regions The esophagus, vagus nerves, and thoracic duct pass through the mediastinum as they course between die abdomen and neck The phrenic nerves, which originate in the neck, also pass through the mediastinum to penetrate and supply the diaphragm Other structures such as the trachea, thoracic aorta, and superior vena cava course within the mediastinum en route to and from major visceral organs in the thorax COMPONENT PARTS i) Thoracic wall The thoracic wall consists of skeletal elements and muscles: + Posteriori)', it is made up of twelve thoradc vertebrae and their intervening intervertebral discs: - Laterally, the wall is formed by ribs (twelve on each side) and three layers of flat muscles, which span the intercostal spaces between adjacent ribs, move the ribs, and provide support for the intercostal spaces: + Anteriorly, the wall is made up of the sternum, which consists of the manubrium of sternum, body of sternum, and xiphoid process The manubrium or stur urn angled posteriorly on the body of sternum at the manubriosternal joint forms the sternal ar^le which is a major surface landmark used by clinicians in performing physical examinations of thorax The anterior (distal) end of each rib is composed of costal cartilage, which contributes to the mobility and elasticity of the wall All ribs articulate with thoracic vertebrae posteriorly Most ribs (from rib II to IX) have three articulations with the vertebral column The head of each rib articulates with the body of its own vertebra and with the body of the vertebra above As these ribs cure posteriorly, each also articulates with the transverse process of its vertebra Anteriorly, the costal cartilages of ribs I to articulate with the sternum The costal cartilages of ribs Mil to X articulate with the inferior margins of the costal cartilages above them Ribs XI and XII are called floating ribs because they not articulate with other ribs, costal cartilages, or the sternum Their costal cartilages are small, only covering their tips The skeletal framework of the thoracic wall provides extensive attachment sites for muscles of the neck, abdomen, back, and upper limbs A number of these muscles attach to ribs and function as accessory respiratory muscles; some of them also stabilize the position of the first and last ribs ii) Superior thoracic aperture Completely surrounded by skeletal elements, the superior thoracic aperture consists of the body of vertebra TI posteriorly, the medial margin of rib I on each side, and the manubrium anteriorly The superior margin of the manubrium is in approximately the same horizontal plane as the intervertebral disc between vertebrae TH and Tm The first ribs slope inferiorly from their posterior articulation with vertebra TI to their anterior attachment to the manubrium Consequently, the plane of the superior thoracic aperture is at an oblique angle, facing somewhat anteriorly At the superior thoracic aperture, the superior aspects of the pleural cavities, which surround the lungs, lie on either side of the entrance to the mediastinum Structures that pass between the upper limb and thorax pass over rib I and the superior part of the pleural cavity as they enter and leave the mediastinum Structures that pass between the neck and head and the thorax pass more vertically through the superior thoracic aperture iii) Inferior thoracic aperture The inferior thoracic aperture is large and expandable Bone, cartilage, and ligaments form its margin The inferior thoracic aperture is closed by the diagram and structures passing between the abdomen and pierce or pass posteriorly to the diaphragm Skeletal elements of the inferior thoracic aperture are - the body of vertebra TXII posteriorly - rib XII and the distal end of rib XI posteriolaterally - the distal cartilaginous ends of ribs to X which unite to form the costal margin anterolaterally, and - the xiphoid process anteriorly The joint between the costal margin and sternum lies roughly in the same horizontal plane as the intervertebral disc between vertebrae Tix and TX In other words, the posterior margin of die inferior thoracic aperture is inferior to the anterior margin When viewed anteriorly the inferior thoracic aperture is tilted superiorly iv) Diaphragm The musculotendinous diaphragm seals the inferior thoracic aperture Generally, muscle fibers of the diaphragm arise radially, from the margins of the inferior thoracic aperture, and converge into a large central tendon Because of the oblique angle of aperture, the posterior attachment inferior to the anterior attachment The diaphragm is not Hat; rather, it "balloons" superiorly, on both the right and left sides, to form domes The right dome is higher than the left, reaching as far as rib V As the diaphragm conưacts the height of the domes decreases and the volume of the thorax increases The esophagus and inferior vena cava penetrate the diaphragm: the aorta passes posterior to the diaphragm V) Mediastinum The mediastinum is a thick midline partition that extends from the sternum anteriorly to the thoracic vertebrae posteriorly, and from the superior thoracic aperture to the inferior thoracic aperture A horizontal plane passing through the sternal angle and the intervertebral disc between vert ebrae ĨTV and TV separates the mediastinum into superior and inferior parts The inferior part is further subdivided by the pericardium, which encloses the pericardial cavity surrounding the heart The pericardium and heart constitute the middle mediastinum The anterior mediastinum lies between the sternum and the pericardium: tire posterior mediastinum Mies between the pericardium and thoracic vertebrae vi) Pleural cavities The two pleural cavities are situated on either side of the mediastinum Each pleural cavity is completely lined by a mesothelial membrane called the pleura During development the lungs grow out of the mediastinum, becoming surrounded by the pleural cavities As a result, the outer surface of each organ is covered by pleura Each lung remains attached to the mediastinum by a root formed by the airway pulmonary blood vessels, lymphatic tissues, and nen es The pleura lining the walls of the cavity is the parietal pleura, whereas that reflected from the mediastinum at the roots and onto the surfaces of the lungs is the visceral pleura Only a potential space normally exists between the visceral pleura covering lung and the parietal pleura lining the wall of the thoracic cavity Thethe lung does not completely fill the potential space ofwhich the pleural lung and cavity, are important resulting for in accommodating recesses, which changes recess, not in[13] contain lung volume is during largest breathing and clinically The costodiaphragmatic most important recess, lies inferiorly between the thoracic wall and diaphragm 50 APPENDI X APPENDIX 1: Forensic Photos Photo 1: skin abrasion TC •$ V*: -u 51 Photo 2: rib fracture Photo 3: spine fracture Photo 4: tracheobronchial rupture Photo 5:pulmonary contusions Photo 6: pulmonary laceration APPENDIX 2: Data collecting form ID medical record ID victim's name gender age 1.8-14 VO 2.15-29VO 3.30 - 44 yo 45 - 59 yo >= 60 \D time scenario motorbike - car motorbike - motorbike car - car pedestrian - motoibike pedestrian - car self-harm others cause thorax thorax and abdomen thorax and cranium polytrauma skin skin abrasion skin laceration tire mark body deformation none thoracic wall thoracic contusion sternum fracture rib fracture collarbone fracture Clavicle fracture spine fracture none flail chest anterior flail chest lateral flail chest posterior flail chest thorax deformation none lung injuries pulmonary contusions pulmonary7 laceration tracheobronchial rupture bronchial rupture airway bleeding Hemothorax Hemothorax pneumothorax pulmonary edema atelectasis 10 none heart and blood vessels Myocardial contusion tamponade hemorrhagic pericardial effusion pericardial rupture aortic rupture vascular injuries none diaphragm and esophagus esophageal injury diaphragm injury none APPENDIX 3: List of victims I D name gende r MR ID Tran VanN M 10/15 Nguyen Van p M 16/15 Dang Van H M 18/15 Nguyen VanN F 6 159/1 Lo Hong L M Pham Van D M Nguyen Van B M Duong Thi N F Nghiêm Ngoe H F Do Van H M Nguyen Thi Hong T F 1 165/1 164/1 6 152/1 153/1 151/1 137/1 144/1 1 Ỉ S 2 2 150/1 Kieu Tien T M Tran Van N M Tran Thi KieuN F Phung Thi M F Kieu Tien K M Vu Trong A M Nguyen Tlú L F Lo Van D M Nguyen Ngoe H M 44/15 Nguyen Thi T F 45/15 Lo Thuv H * F 49/15 Nguyen Quoc D M 24/15 Nguyen Bo T M 85/15 133/1 134/1 101/1 103/1 104/1 7 110/1 116/1 81 8 8 3 3 3 Nguyen Duy T M 87/15 Tran Van T M 92/15 Nguyen Qujilh H F 83/15 Nguyen Thanh T M 75/15 Nguyen Xuon D M 76/15 Ta Van T M 79/15 Ngu ven Tlú B F 29/15 Phan Duong N M 2/16 Nguyen VanN M 11/16 Khong Van L M 13/16 Tran Hoảng Q M 20/16 Nguyen Duy B M 21/16 Nguyen Bonli N M 19/16 8 8 8 9 1 4 4 4 Ha Thi Thu H F 24/15 Dang Van H M 25/16 Nguyen Van M M 32/16 Luong Thi Huym V F 47/16 Vu Thi L F 52/16 Lo Van H M 55/16 Nguyen Van T M 60/16 Nguyen Van T M 61/16 Bui Thi Minh Á F 64/16 Nguyen Thien D M 65/16 Nguyen Huy T M 74/16 Nguyen Phuong A M 76'16 Kieu Quoc c M 91/16 21 2 5 5 5 6 6 Nguyen Van T M 95/16 Duong Due Tuan H M Lo Tlii u F To Quang H M Lo Huu T M Tong Thanh T M Nguyen Danh N M Ho Thanh T M 95/17 Nguyen Van c M 81/17 Do Due M M 73/17 Dang Trong H M 72/17 Nguyen Hieu K M 64/17 Nguyen Tlũ T F 102/1 114/1 3 112/1 130/1 169/1 6 177/1 S 41 158/1 6 6 7 7 7 151/1 Pham Van V M Lo Manh L M Nguyen Van D M Nguyên Quy B M 62/17 Lo Minh T M 56/17 Lo Viet H M 44/17 Nguyen Due T M 40/17 Trinh Xuon B M 39/17 Do Thi Kim L F 31/17 Nguyen Vu D M 30/17 Nguyen Tung L M 26'17 Kieu Tuan D M 13/17 Bui Thi T F 11/17 4 124/1 116/1 7 5 5 5 5 7 8 8 8 8 8 Hả Minh T M 5/17 Tran Thi T F 3/17 Duong Hung s M 2/17 Chu Thi p F Bui Van T M Nguyen Cung H M Lo Ngoe K M 97/18 Nguyen Thi M F 94/1S Lo Thi H F Quàng Van D M 52/18 Ngan Van T M 99/18 Nguyen Tien M M 81/18 Pham Thi s F 58/18 9 109/1 136'1 136/1 114/1 9 9 Tran Thi L F 43/18 Duong Xuon T M 20/18 Nguyen Danh Q M 47/19 Lo Van H M 60/19 10 1 93 ... pattern of lung injuries in recorded victims Secondly, evaluate the correlations between pattern of thoracic trauma and lung injuries CHAPTER 1: LITERATURE REVIEW 1.1 Global injuries burden and. .. mortality rate than PTT Conduction of a research to assess lung injury pattern in more detail maimer and the correlations between pattern of thoracic trauma and lung injuries is an uigent need as... Correlations between thoracic trauma and lung injuries In order to evaluate the relationship between outer injuries and injuries of organs and other components of thoracic wall and cavity, we analyzed the