Clinical Anatomy and Medical Malpractice-A Narrative Review with Methodological Implications

Abstract

Anatomical issues are intrinsically included in medico-legal methodology, however, higher awareness would be needed about the relevance of anatomy in addressing medico-legal questions in clinical/surgical contexts. Forensic Clinical Anatomy has been defined as "the practical application of Clinical Anatomy to the ascertainment and evaluation of medico-legal problems". The so-called individual anatomy (normal anatomy, anatomical variations, or anatomical modifications due to development, aging, para-physiological conditions, diseases, or surgery) may acquire specific relevance in medico-legal ascertainment and evaluation of cases of supposed medical malpractice. Here, we reviewed the literature on the relationships between anatomy, clinics/surgery, and legal medicine. Some methodological considerations were also proposed concerning the following issues: (1) relevant aspects of individual anatomy may arise from the application of methods of ascertainment, and they may be furtherly ascertained through specific anatomical methodology; (2) data about individual anatomy may help in the objective application of the criteria of evaluation (physio-pathological pathway, identification-evaluation of errors, causal value, damage estimation) and in final judgment about medical responsibility/liability. Awareness of the relevance of individual anatomy (risk of iatrogenic lesions, need for preoperative diagnostic procedures) should be one of the principles guiding the clinician; medico-legal analyses can also take advantage of its contribution in terms of ascertainment/evaluation.

Keywords: anatomical variations; clinical anatomy; forensic clinical anatomy; iatrogenic lesions; individual anatomy; medical liability; medical malpractice; medical responsibility; post-mortem imaging.

Figure 1

Forensic clinical anatomy and medical malpractice hypotheses. The individuality of anatomy is derived from ascertainment methods and must be considered in the evaluation phase for final judgement on medical responsibility/liability.

Figure 2

(A) Cerebellar macro-section showing hemorrhagic infarction in the vascular field of the superior cerebellar artery. (B,C) Double origin of the left superior cerebellar artery at macroscopic examination of the vessels of the brain.

Figure 3

Infant reported to be found dead in the parents’ bed: accidental or abusive trauma? Sudden Infant Death Syndrome? Undiagnosed pathology? (A,B) post-mortem computed tomography, with radiologist’s description of thorax deformation. (C,D) anatomical dissection of the neck and thorax, showing the absence of hemorrhagic infiltrations or fractures/dislocations. (E) Sampling of the whole anterior thoracic wall. (F) post-autopsy computed tomography of the anterior thoracic wall, confirming the absence of traumatic findings. The radiological misdiagnosis was ascribed to artifacts due to previous corpse freezing in an anomalous position. (H: Head; F: Feet; L: Left; R: Right).

Figure 4

Spine trauma. (A) in vivo pre-surgery computed tomography. (B) in vivo post-surgery radiography. (C) sampling of the spine segment. (D) post-autopsy computed tomography of the sampled spine. (E) removing of pedicle screws. (F) general view of the spinal cord, with evidence of hemorrhagic infiltration of the dural sac. (H: Head; F: Feet).