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Medical Legal Illustration and Animation - Cross Sections

  
  
  
  
  

By: Robert Shepherd MS, Certified Medical Illustrator, Vice President and Director of Eastern Region Operations,MediVisuals Incorporated

Long before science had advanced to allow imaging of the body in sectional views by computed tomography (CT) and magnetic resonance imaging (MRI), medical illustrators were illustrating the body in sectional views because these views are the best way to appreciate some anatomical relationships. 

Medical illustrators, physicians, and others who have studied anatomy are familiar with sectional views of the body and appreciate the value of these views in explaining the relationship of anatomical structures. However, accomplished and well respected jury consultants and non-medical illustrator legal graphics experts have expressed concerns that sectional views may be difficult for some jury members to understand. These individuals' opinions are valuable to those of us in the legal graphics business, and I agree with their opinions that, when other views can communicate a particular relationship message equally as well or better, sectional views should be avoided. I also believe most of these experts will agree that there are times and places in which sectional views of anatomy are the best way to appreciate some anatomical relationships. Granted, there have been times when we have been working on specific cases and experts have insisted that sectional views be absolutely and unconditionally avoided. Unfortunately, in these situations the experts were unable to suggest a more effective view to communicate the relevant anatomical relationships (at least in a way that was practical in terms of time and expense). That being the case, sometimes the sectional views were used despite the input of the experts, and at other times, the relationships of the structures had to be explained without the benefits of graphics.

A way to perhaps explain how sectional views help decision makers appreciate relevant anatomical and pathological relationships is to compare them to aerial views or photographs of the scene of a collision.  Space is defined in three planes. Only two of these planes can effectively be demonstrated in a two-dimensional rendering. For example, aerial views have long been used to help explain the positions of vehicles and structures that simply can't be appreciate from "street views". When viewing the scene of a collision from a "street view", one can appreciate vertical and horizontal distances, but not depth; distances close to and far from the viewer's perspective are very difficult to appreciate (see the below figures). By comparison, when viewing an operative site through a "surgeon's view", vertical and horizontal distances can be appreciated, but the depth of the incision and the relationships of the various structures within and around the incision are very difficult or impossible to appreciate.

 

Cross Section Blog image1 REVISED

 

The "aerial view" of the collision scene allows the viewer to appreciate distances in two geographical planes as well (distances right and left, and toward and away from the "street view," but the ability to appreciate up and down is lost). Also, the locations of relevant structures or vehicles that may have been obstructed by nearby structures (such as buildings trees, signs, or other vehicles) can now be appreciated. Similarly, a sectional view of anatomy can help decision makers appreciate depth relationships of structures. Or, a sectional view of a step in a surgical illustration can allow the viewer to appreciate the depth of the surgery as well as the additional structures that may have been injured (or at risk of injury) during the invasive procedure.  These specific depth  relationships could not be appreciated from the "surgeon's view" of the same surgery shown in the above illustration.

 

Cross Section Blog image2 REVISED

 

Exhibits developed to help explain the invasive nature of a surgery and the disruption of the soft tissues during operative procedures are critical. For that reason, sectional views are critical in aiding a testifying physician to explain these issues. For example, the exhibit panel that demonstrates an anterior cervical discectomy and fusion (ACDF) that does not include a cross-section through the neck fails to emphasize the depth of the incision and disruption of tissues (essentially all the way to the center of the neck). This depth simply cannot be appreciated in a "surgeon's view".

In order to appreciate cross-sections, orientation views that show the level and direction of the section are helpful (see below), or when time, budget, and presentation format (digital as opposed to a physical panel) allow, a short animation showing the sectional view actually coming out of the orientation view such as MediVisuals' "Scan SelectorTM" can be used.

 

cross-section plane of brain hematoma

© MediVisuals, Inc. - Permission to use any image (or parts thereof) posted on this blog in depositions, demand packages, settlement hearings, mediation, trial, and/or any other litigation or non-litigation use can be obtained by contacting MediVisuals at www.medivisuals.com – otherwise copyright laws prohibit their use for those or other purposes.

Disc-Osteophyte Complex Explained

  
  
  
  
  

By: Robert Shepherd MS, Certified Medical Illustrator, Vice President and Director of Eastern Region Operations, MediVisuals Incorporated

Individuals who develop new or suddenly worsening symptoms consistent with nerve root or spinal cord impingement following a traumatic event are sometimes diagnosed with “disc-osteophyte complexes”. The term “disc-osteophyte complex” generally refers to abnormal extension of intervertebral disc material that accompanies immediately adjacent osteophyte formation at the vertebral body margin (see the below figure). It is important to note (as shown in the illustrations) that the disc almost always extends further than the osteophytes into the neural foramen or spinal canal to irritate or impinge upon nerve roots or the spinal cord.

 

DiscOstCompBlogASTAMP

 

Occasionally, individuals who are evaluated shortly after a traumatic event are found to have disc-osteophyte complexes. Because a minimum of several weeks is required for osteophytes to form as a result of a traumatic event, defendant insurance companies may argue that the presence of osteophytes so soon after the traumatic event in question may prove that the plaintiff’s injuries preexisted the traumatic event. Since it is the disc pathology extending beyond the osteophytes that is the actual cause of the nerve root or spinal cord irritation and inflammation, the defense’s arguments are not valid. As shown in the illustrations below, the sequence of events that typically takes place in these cases is that the plaintiff had minimally symptomatic or asymptomatic disc osteophytes prior to the traumatic event in question. During the traumatic event, the disc sustains trauma that results in worsening of the disc pathology while the osteophyte portion of the osteophyte/disc complex remains essentially unchanged. This worsening of the disc pathology in turn results in new or increased irritation or impingement of the neural elements.

 

DiscOstCompBlogBSTAMP

© MediVisuals, Inc. - Permission to use any image (or parts thereof) posted on this blog in depositions, demand packages, settlement hearings, mediation, trial, and/or any other litigation or non-litigation use can be obtained by contacting MediVisuals at www.medivisuals.com – otherwise copyright laws prohibit their use for those or other purposes.

Intra-articular Fractures Explained

  
  
  
  
  

By: Robert Shepherd MS, Certified Medical Illustrator, Vice President and Director of Eastern Region Operations, MediVisuals Incorporated

Intra-articular fractures are simply fractures that involve a joint space (see below figure). While intra-articular fractures appear very similar to those that do not involve a joint space (extra-articular fractures), intra-articular fractures are significantly more serious because they are associated with a much greater incidence of long-term complications.

 

Image1 TwoFracsSTAMPED


In order to appreciate why intra-articular fractures can be so problematic, a fundamental understanding of a typical joint is helpful. The following images show a knee joint. With the exception of a meniscus, almost all moveable joints are similar to the knee joint in that the joints are lined with a thick, shock-absorbing articular cartilage adherent to smooth, bony surfaces that allow pain-free movement.


Image2 NormJointSTAMPED

When a fracture involves the articular surface of one or more bones of a joint, the articular cartilage and smooth articular surface of the bone are disrupted. In order for joints to have the best chance of proper joint function after healing, physicians go to greater effort to make sure the bony surfaces are properly aligned and that the joint is properly immobilized than they would with a similar fracture that is extra-articular. Even with the best fracture alignment and joint immobilization, subtle disturbances in the joint surface and the natural bone reformation that take place during healing can result in uneven joint surfaces and injury to the overlying articular cartilage (see the below illustration). Because of the abnormalities of the injured and healed joint surface, natural movement of the joint can also damage the articular cartilage of the opposing joint surface. Over the course of time, these injuries self-perpetuate and may necessitate arthroscopic debridementchondroplasty or even joint replacement.



Image3 Frac AfterHealSTAMP

It is also important to realize that a fracture needs not enter a joint to result in injury to the articular surfaces and begin the self-perpetuating post-traumatic breakdown of the joint surfaces (post-traumatic arthritis). As shown in the below illustrations, joint trauma without a diagnosable fracture of any type can injure the smooth, shock-absorbing articular cartilage, with or without microfractures of the underlying bone. This can result in partial or total loss of the articular cartilage and in uneven "bone-on-bone" articulation that severely decrease range of motion and result in debilitating joint pain.


Image4 ArthritisSTAMPED2

© MediVisuals, Inc. - Permission to use any image (or parts thereof) posted on this blog in depositions, demand packages, settlement hearings, mediation, trial, and/or any other litigation or non-litigation use can be obtained by contacting MediVisuals at www.medivisuals.com – otherwise copyright laws prohibit their use for those or other purposes.

Association of Medical Illustrators Recognizes the Best in Medical-Legal Illustration

  
  
  
  
  

By: Delia Dykes, MS

Each year, the Association of Medical Illustrators has a juried Salon at its national conference (this year in Baltimore, at the end of July). Unlike most "art" competitions, the judging criteria are not just based upon the aesthetics of the illustration -- instead, the illustrations are most heavily judged by how well the illustrations communicate a message and upon the illustrations' anatomical and medical accuracy.  MediVisuals was honored once again this year to receive the Award of Excellence and the Award of Merit in Medical Legal illustration.

The below illustration, created primarily by Paul Gross, MS, received the Award of Excellence for effectively demonstrating a surgical procedure to repair severe facial lacerations resulting from a dog bite.  The illustrations were created for Susan M. Bourque of Parker & Scheer, LLC in Boston. The exhibit assisted Parker & Scheer in obtaining a substantial recovery on behalf of the client.

blog awards paul

The Association's Award of Merit was bestowed to Cynthia Yoon, MS.BMC, the primary illustrator for a series of three exhibits demonstrating severe facial injuries and surgical repairs resulting from an awning pole from a passing camper flying through the windshield of a vehicle.  The exhibits were developed for William Cunningham of the Burns, Cunningham & Mackey firm in Mobile, Alabama.  The first exhibit shows the initial fractures and external injuries.

McSween for blog1

The second exhibit demonstrates the chronic left jaw dislocation that ensued after the initial ORIF of the jaw had healed.

McSween for blog2

The third exhibit highlights the surgical procedure the plaintiff underwent to correct the malunion of the mandible and the left jaw dislocation.

describe the image

Bob Shepherd, MS, developed the concepts for the illustrations and worked with the illustrators and counsel to help ensure the illustrations met the desired objectives.

© MediVisuals, Inc. - Permission to use any image (or parts thereof) posted on this blog in depositions, demand packages, settlement hearings, mediation, trial, and/or any other litigation or non-litigation use can be obtained by contacting MediVisuals at www.medivisuals.com – otherwise copyright laws prohibit their use for those or other purposes.

Understanding the Brachial Plexus Injury: Part 1

  
  
  
  
  

By: Robert Shepherd MS, Certified Medical Illustrator, Vice President and Director of Eastern Region Operations, MediVisuals Incorporated

Injuries to the brachial plexus can often take place from trauma similar to that which causes cervical spine injuries and can also manifest similar symptoms. As shown in the illustration below, the brachial plexus is formed by several of the cervical nerve roots and the T1 nerve root.

Brachial Plexus 205299 02XA

Sometimes injury to the brachial plexus can be the direct result of excessive stretch during a traumatic event. For example, in a motor vehicle collision with a violent side impact the nerves on the contralateral side of the impact (and resulting flexion) may be stretched and/or torn. [see illustration below]

Brachial Plexus R14893 05X

Injury to the surrounding muscles can indirectly cause injury to the brachial plexus, as well. The brachial plexus runs between the anterior and middle scalene muscles, which connect the cervical spine and first rib. In a motor vehicle collision, hyperextension of the neck may excessively stretch these muscles, as demonstrated in the illustration below.

Brachial Plexus 306036 01XB

When these muscles are stretched, the resulting swelling or spasm can result in symptoms consistent with cervical nerve root injury even though the cervical nerve roots or brachial plexus themselves may not be directly injured. [see illustration below]

Brachial Plexus 205299 02XB

Thoracic outlet syndrome is another mechanism by which the brachial plexus can be injured. The illustration below shows that the axillary sheath, which contains the nerves from the brachial plexus and the axillary vein and artery, passes through the opening created between the clavicle and first rib.

Brachial Plexus 399048 04Apart2

Thoracic outlet syndrome can occur either by (1) the elevation of the first rib due to spasm of the scalenes or (2) the loss of innervation to the trapezius and/or other muscles that insert on the clavicle or scapula, causing the shoulder to droop [see illustration below]. By either mechanism, the opening between the clavicle and first rib is closed and the nerves and blood vessels that travel through the thoracic outlet become compressed.

Brachial Plexus 399048 04Apart1

As one can see in the illustration below, an injury to the brachial plexus affects the motor and sensory function of the arm. The earlier the injury is identified and treated, the better chances are for recovery and preventing permanent damage. However, this is also dependent on the severity of the initial injury. Sometimes surgical intervention is needed to address torn/ruptured nerves and excessive scarring.

Brachial Plexus R16249 01XB

This is the first of a two part article. Please check back to read Part 2, which discusses brachial plexus injury in infants during delivery (Shoulder dystocia). You can also sign up for email alerts, which announce when another article has been posted.



© MediVisuals, Inc. - Permission to use any image (or parts thereof) posted on this blog in depositions, demand packages, settlement hearings, mediation, trial, and/or any other litigation or non-litigation use can be obtained by contacting MediVisuals at www.medivisuals.com – otherwise copyright laws prohibit their use for those or other purposes.

Disc Herniation and Other Disc Injuries

  
  
  
  
  

By: Robert Shepherd MS, Certified Medical Illustrator, Vice President and Director of Eastern Region Operations, MediVisuals Incorporated 

The term “degenerated disc” is generally used to describe a disc in the early degenerative process.  It is the beginning of a progressive break down of the disc. This condition can be initiated or accelerated by a traumatic event.

degenerated-disc

A disc bulge is a more advanced collapse of the disc to the point that the disc expands beyond its normal contour. It may or may not impinge on the neural structures within the spinal canal or neural foramina. Similarly, a disc bulge can be the immediate or delayed result of a traumatic event, or a traumatic event may exacerbate a preexisting, stable disc bulge.

annular-disc-bulge

A subligamentous herniation is one in which nucleus pulposus has extended through the annulus fibrosus, but has not gone through the posterior longitudinal ligament.

subligamentous-herniation

The term “herniation” is generally used when the nucleus has completely extruded through the annulus fibrosus and posterior longitudinal ligament.

However, it does not matter what the disc pathology is labeled, if it impinges upon, or irritates the neural components, it is a significant injury that will likely require some type of invasive procedure to correct.

 impinge-disc-injury

The disc can either be injured by an immediate tear of the annulus fibrosus and extrusion of the nucleus pulposus during a traumatic event, or they can be the result of a much more gradual process. In order to understand the gradual breakdown of the disc, one must first understand a little of the physiology of a disc. The inner disc relies on exchange of fluid, nutrients and oxygen through the end plate of the adjacent vertebral bodies.

disc-anatomy

During a traumatic event, the endplate may become injured resulting in interference with that exchange.

disc-disruption

As a result of the inability of the disc to obtain the fluid, nutrients, and oxygen it needs, the disc gradually begins to break down - becoming a degenerated disc, followed by a bulging disc, and eventually to a herniated disc. The amount of time involved with the process of the disc breakdown is related to the severity of the initial disc injury.

degeneration-of-disc

Therefore, if a disc injury is not evident until weeks or months after a traumatic event, it does not mean the injury was not a direct result of the traumatic event.

 

© MediVisuals, Inc. - Permission to use any image (or parts thereof) posted on this blog in depositions, demand packages, settlement hearings, mediation, trial, and/or any other litigation or non-litigation use can be obtained by contacting MediVisuals at www.medivisuals.com – otherwise copyright laws prohibit their use for those or other purposes.

Breaking Down Traumatic Arthritis

  
  
  
  
  

By: Robert Shepherd MS, Certified Medical Illustrator, Vice President and Director of Eastern Region Operations, MediVisuals Incorporated

Fractures can result in several long term or permanent complications that can necessitate additional surgical procedures. One of the most common long term debilitating complications is traumatic arthritis. Traumatic arthritis can affect almost any moveable joint in the body. To explain traumatic arthritis more in depth, we will be focusing on the tibiotalar (ankle) joint, as shown in the illustration to the right.

arthritis-tibiotalar-joint

As like most moveable joints, the tibiotalar joint consists of smooth articular bone covered by thick, shock-absorbing articular cartilage.

arthritis-joint-normal

During trauma, the joint surfaces can be driven together resulting in injuries to the cartilage and microfractures of the articular surface (even without obvious intrarticular fracture).

arthritis-injury-joint

The bone and cartilage then undergo changes that result in the progressive breakdown of the joint. As the process advances, the joint becomes painful. In most cases, the only treatment options are joint replacement or fusion.

arthritis-degeneration-joint

The acromioclavicular (AC) joint also frequently falls victim to traumatic arthritis. As the AC joint enlarges (hypertrophy) it impinges on the rotator cuff, which is referred to as subacromial impingement. This can cause irritation or tearing of the rotator cuff and is most often treated by AC joint resection and subacromial decompression.

arthritis-AC-joint-shoulder


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© MediVisuals, Inc. - Permission to use any image (or parts thereof) posted on this blog in depositions, demand packages, settlement hearings, mediation, trial, and/or any other litigation or non-litigation use can be obtained by contacting MediVisuals at www.medivisuals.com – otherwise copyright laws prohibit their use for those or other purposes.

Selecting a Medical Illustrator

  
  
  
  
  

By: Robert Shepherd MS, Certified Medical Illustrator, Vice President and Director of Eastern Region Operations, MediVisuals Incorporated

Just as all treating physicians and/or medical experts are not the same, all medical illustrators are not the same. Attorneys typically go to great lengths to ensure that testifying experts for their cases are adequately credentialed, but many give little thought to applying the same due diligence when selecting a medical illustrator. This can be a big mistake because unlike many “professionals”, there is no basic training, licensing, or certification process that is required for an individual to call themselves a “medical illustrator”. Many less skilled and/or less qualified “medical illustrators” market to attorneys – perhaps because attorneys are less able to detect errors in their work. For these reasons, it is the responsibility of the attorney and/or medical expert to their clients to ensure they enlist the services of a medical illustrator who is qualified to provide those services.

Working with a qualified medical illustrator who has experience in the medical-legal area can be a pleasant, enjoyable experience for the testifying expert as these medical illustrators are able to read and comprehend medical records, review imaging studies, and discuss complicated anatomical and medical terms on a very similar level as the expert. On the other hand, working with an un- or minimally qualified and/or inexperienced medical illustrator can be a frustrating and time consuming task that may require multiple revisions of drafts, ineffective demonstrative aids, or even embarrassment during a hearing because of the discovery of some error or inconsistency during testimony.

It can be difficult to determine the qualifications of a medical illustrator based upon looking at their artwork alone. A copy of a résumé or curriculum vitae should be requested. One of the most basic requirements that the résumé should show would include graduation from one of the below medical illustration graduate programs. There are several medical illustration programs in colleges and various institutes in North America and across the globe; however, only five are currently accredited by the American Medical Association, and Commission on Accreditation of Allied Health Education Programs. Those programs include:

  • Medical College of Georgia - Master of Science in Medical Illustration

  • University of Illinois at Chicago - Master of Science in Biomedical Visualization

  • Johns Hopkins University - Master of Arts in Medical and Biological Illustration

  • University of Texas, Southwestern – Master of Arts in Biomedical Communications

  • University of Toronto - Master of Science in Biomedical Communications

Other criteria that should be evident in a résumé or CV that would help demonstrate at least minimal qualifications are 1) Certification as a medical illustrator as issued by The Board of Certification of Medical Illustrators and 2) Professional Membership in the Association of Medical Illustrators. Both of these require that the individual possess at least minimal medical illustration training and skill levels. Also, just as there are different subspecialties in medicine which require specific and advanced skills and knowledge, specialization in “medical-legal” illustration requires additional knowledge and experience in addition to those required for general medical illustration. For that reason, it is also wise to select a qualified medical illustrator who is not only familiar with illustration and medicine, but also has a significant amount of experience in creating illustrations for litigation purposes.

 


© MediVisuals, Inc. - Permission to use any image (or parts thereof) posted on this blog in depositions, demand packages, settlement hearings, mediation, trial, and/or any other litigation or non-litigation use can be obtained by contacting MediVisuals at www.medivisuals.com – otherwise copyright laws prohibit their use for those or other purposes.

Medical Illustrators as a Member of the Medical-Legal Team

  
  
  
  
  

By: Robert L. Shepherd MS, Certified Medical Illustrator, Vice President and Director of Eastern Region Operations, MediVisuals Incorporated

A very effective way of increasing the effectiveness of expert testimony is by enhancing focus, understanding, and recall by teaming the testifying expert with a qualified medical illustrator, experienced in preparing legal graphics (illustrations, animations, models, etc.). By working together, the medical knowledge and oral skills of the expert can be supported by expertly created medical graphics that greatly clarify complicated anatomical, physiological, and medical subtleties. Together they result in much more effective communication with the decision makers than if verbal testimony or the graphics were used alone (one mode of communication used alone without being supported by the other). In addition, during a period of hours or days of listening to arguments that are typically only verbal, decision makers grasp the opportunity to focus on visuals in the form of illustrations, photographs, models, and/or animations. In fact, information is generally better processed if jury members and other triers of fact can have information presented in a multimodal fashion (i.e. combinations of simultaneous auditory, visual, and tactile stimuli).

The effectiveness of visuals is supported throughout our society by such common phrases as “A picture is worth a thousand words”, and “Seeing is believing.” In addition, numerous manuscripts refer to studies substantiating that recall is greatly increased when the verbal message is supported by visual images. Typically these studies have shown that after varying periods of time information that was delivered by a combination of voice supported by visuals was recalled at a significantly higher percentage than the same message delivered by voice alone.

References

DeBoth, C. J., & Dominowski, R. L. Individual differences in learning: Visual versus
auditory presentation. Journal of Educational Psychology, 1978; Aug 70 (4): 498-503

McCall, J., & Rae, G. Relative efficiency of visual, auditory and combined modes of
presentation in learning of paired-associates. Perceptual and Motor Skills, 1974; June (38) : 955-958.

Multimodal Learning Through Media: What the Research Says. Cisco Web site. http://www.cisco.com/web/strategy/docs/education/Multimodal-Learning-Through-Media.pdf. Accessed August 19, 2008.


© MediVisuals, Inc. - Permission to use any image (or parts thereof) posted on this blog in depositions, demand packages, settlement hearings, mediation, trial, and/or any other litigation or non-litigation use can be obtained by contacting MediVisuals at www.medivisuals.com – otherwise copyright laws prohibit their use for those or other purposes.

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