Medical Exhibits - Demonstrative Evidence Expert Blog - MediVisuals

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

The surgical trauma that a plaintiff has to undergo after the initial bodily injuries following a traumatic event are always major points of emphasis when arguing damages in a personal injury case.  This is certainly the situation with cases that involve broken bones that require invasive surgical procedures to realign broken bone fragments ("reduce") and secure ("fixate") the bones with hardware to keep them properly aligned during healing.  Too often, however, the emphasis is solely on the effects on the bones from these "Open Reduction and Internal Fixation" (ORIF) procedures, and very little emphasis is placed on the surgical disruption of the soft tissues that takes place during these procedures.

In a case involving ORIF of a distal fibula (a.k.a. lateral malleolus) fracture, in order to emphasize the surgical trauma endured by a plaintiff, an attorney may have a visual prepared of a postoperative X-ray.  The visual may consist of only a postoperative X-ray or a print of the X-ray with a corresponding illustration (see the below figure). 

The above images are certainly helpful, but fail to address the intra-operative trauma to the soft tissues that is required to gain access to the bone fragments.  For that purpose, intra-operative illustrations that truthfully depict the soft tissue disruption should be considered (see the below figure) or even an animation showing the procedures such as the one at this link: http://www.medivisuals.com/fibularplatingORIF.aspx

Illustrations or animations that at least touch on the soft tissue disruption allow testifying physicians the opportunity to explain the many tissues traumatized during the procedure and allow insurance adjustors, mediators, and jurors an opportunity to take these additional injuries into consideration when determining the severity of a plaintiff's entire injuries.

Many attorneys considering realistic illustrations such as the one above, express a concern that judges may not allow the images to be used because they are too "graphic" or "inflammatory".  Certainly, counsel should make themselves aware and consider the preferences of certain jurisdictions and specific judges before determining whether an illustration should be developed that realistically depicts injuries or whether diagrammatic (cartoon-like) illustrations should be developed instead.  There are a number of very good arguments to support the use of "realistic" illustrations over "cartoons".  Those arguments as well as other discussions regarding illustration styles will be addressed in future blogs.

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

Injuries to the spinal and paraspinal ligaments and muscles can result from violent side-to-side motions or by violent excessive flexion and extension. The illustration below shows the major ligaments of the neck (anterior longitudinal and interspinal ligaments) in hyperflexion and hyperextension, which can be injured grossly or microscopically.

Click to enlarge

The series of three illustrations in the bottom right corner (which is shown in more detail below), show a close-up view of the spinal anatomy in 1.) the Normal condition, 2.) during Excessive Stretching and 3.) After Healing. In the Normal condition, one can appreciate the close relationship between the muscles, nerves and blood vessels. During Excessive Stretch, small tears occur, which causes bleeding in the muscle fibers. After Healing, scar tissue and inflammation entrap blood vessels and nerves resulting in a permanent state of compromised, painful movement.

The same is true for the lower lumbosacral spine and pelvic regions. In the illustration below, the spinal nerves and their posterior branches are seen in close approximation to the ligaments and joint capsules, which are often involved in the injury. During hyperflexion of the lumbar spine, transient bulging of the intervertebral discs can occur. 

Click to enlarge

The series of illustrations in the lower right corner of the above image, show the normal lumbosacral and pelvic muscles and tendon fibers, which insert on the bones near the associated posterior spinal nerve branches. During Excessive Stretch, a segmental artery and its branches may be involved in hemorrhaging, scarring and occlusion. After Healing, scar tissue and adhesions form, entrapping nerves and blood vessels, causing chronic pain.

In these next illustrations, muscle is shown in sequentially higher magnifications, which can be used to explain excessive stretch injuries in any area of the body.  In the Normal series, the bottom illustration depicts nerves and small body vessels intertwined in muscle with its tendinous attachment to the bone.  The middle illustration shows a magnified view of an individual muscle fiber and the top illustration depicts the relationship of the microscopic myofilaments (actin and myosin) in their normal relaxed position.

In the Excessive Stretch series, the bottom illustration shows the muscle, tendon, blood vessels and nerves as they are excessively stretched. Small hemorrhages are seen escaping from the stretched and torn blood vessels. In the middle illustration, blood is shown escaping into surrounding spaces, reducing oxygen exchange to the muscle and irritating the delicate structures of the muscle fiber. The top illustration depicts the myofilaments, showing the actin and myosin fibers torn and stretched past the point of normal interdigitation.

In the After Healing series, the bottom illustration shows the irregular outline of the scarred and inflammed muscle fiber with small adhesions seen between the blood vessels, nerves and muscle fibers. The middle illustration shows scar tissue and inflammation occluding blood vessels and adhering the delicate structures of the muscle fibers together, limiting motion and causing chronic pain. Lastly, the top illustration depicts the damaged myofilaments. Their normally well-organized, interdigitating arrangement is left destroyed, limiting muscle movement at the most basic level.