Projection radiography of the clavicle: still recommendable for forensic age diagnostics in living individuals?

Abstract

As superimposition effects often impede the evaluation of the ossification status of the medial clavicular epiphysis in standard posterior-anterior (PA) radiographs, additional oblique images (right anterior oblique, RAO, and left anterior oblique, LAO) are currently recommended to allow for reliable stage assessments. The present study examines the influence of the radiographic projection type on stage determination. To this end, 836 sternoclavicular joints were prospectively obtained during forensic autopsies of bodies aged between 15 and 30 years. Subsequently, three different radiographs (PA, RAO, and LAO) were taken from each specimen and separately evaluated as to the developmental stage of the medial clavicular epiphysis. A forensically established five-stage classification system was used. In 25 % of the cases, the medial clavicular epiphysis depicted in an oblique projection showed a different ossification stage than in the PA projection. In at least 10 % of the cases, a higher ossification stage was observed which would have significant disadvantages in criminal proceedings (ethically unacceptable error). In conclusion, the usage of the current radiographic reference data, which rely upon chest radiographs taken as PA projections, appears to be inadmissible for oblique projections. Projection radiography of the clavicle can therefore no longer be recommended for forensic age estimation practice. As to the question of whether an individual has achieved the age of 18 or 21, computed tomography of the clavicle must be regarded as the exclusive method of choice.

Estimation of forensic age using substages of ossification of the medial clavicle in living individuals

“…Work on age-staging ossification of the medial clavicular bone has attracted particular intention; assessments may be made by X-ray [3,4], CT [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20], ultrasonography [18,21,22], or magnetic resonance imaging [23][24][25]. During the last few years, CT has mainly been performed for research purposes in the forensic sciences; thus, it is recognized that the study of thin sections at high resolution may help eliminate mistakes by allowing more detailed assessments [6,8,10,12].…”

Forensic age estimation in living individuals: methodological considerations in the context of medico-legal practice

“…Stage 2: Ossification center ossified but epiphyseal cartilage not ossified. 119 Schmeling's method has been subjected to numerous validation studies each with specific aims to evaluate not only the accuracy of the method, but also the manner in which it is (or can be) applied, for example: 1) to investigate superimposition effects in standard posterior-anterior radiographs; 120 2) to assess the effect of slice thickness (scan resolution) on the accuracy and precision of stage assignation, and by association age estimation accuracy; 121 and 3) to validate the accuracy of the method in geographically removed individuals (eg, most recently in a Western Australian population 122 ), but there has been empirical assessment of the method in many other populations, including German, 123 Serbian, 124 and Italian. 125 In relation to the aforementioned research relating to applications of the Schmeling method, the following important conclusions were drawn: 1) superimposition effects in the posterior-anterior radiographic imaging of the medial clavicle impede the assessment of fusion stage -the level of error introduced indicates that projection radiography of this structure is inappropriate and that CT is the exclusive imaging modality of choice; 2) optimal multiple detector CT slice thickness (scan resolution) for forensic age estimation purposes is ,1 mm -thick slice CT scans result in lower intraand interobserver accordance; and 3) the Schmeling method is both reproducible and accurate for application in foreign populations.…”

Evaluation of age estimation in forensic medicine by examination of medial clavicular ossification from thin-slice computed tomography images

“…However, if medial clavicular ossification is to be evaluated by projection radiography, the image should be from the posteroanterior (PA) position. This is particularly important, since there are no relevant studies addressing oblique views [21]. Standard PA radiographies may be employed if they have been taken previously or are suitable for the evaluation of at least one of the medial clavicle epiphyses (in cases where superimposition and anatomical shape variants are not present) [20,21].…”

“…Some age estimation studies have adopted an anatomical perspective by assessing ossification by direct skeletal inspection [7][8][9][10][11][12][13][14], whereas other studies have adopted a radiological approach by using technologies such as X-ray [15][16][17][18][19][20][21][22], CT [23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38], ultrasonography [35,[39][40][41], or magnetic resonance imaging [42,43]. CT imaging and projection radiography have significant advantages and are the modalities suggested by AGFAD [6].…”