Int J Legal Med DOI 10.1007/s00414-014-1067-0
ORIGINAL ARTICLE
Projection radiography of the clavicle: still recommendable for forensic age diagnostics in living individuals? Daniel Wittschieber & Christian Ottow & Volker Vieth & Martin Küppers & Ronald Schulz & Juan Hassu & Thomas Bajanowski & Klaus Püschel & Frank Ramsthaler & Heidi Pfeiffer & Sven Schmidt & Andreas Schmeling
Received: 3 July 2014 / Accepted: 8 August 2014 # Springer-Verlag Berlin Heidelberg 2014
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 D. Wittschieber (*) : M. Küppers : R. Schulz : J. Hassu : H. Pfeiffer : S. Schmidt : A. Schmeling Institute of Legal Medicine, University Hospital Münster, Röntgenstraße 23, 48149 Münster, Germany e-mail: [email protected] C. Ottow : V. Vieth Institute of Clinical Radiology, University Hospital Münster, Münster, Germany T. Bajanowski Institute of Legal Medicine, University Hospital Essen, Essen, Germany K. Püschel Institute of Legal Medicine, University Hospital Hamburg-Eppendorf, Hamburg, Germany F. Ramsthaler Institute of Legal Medicine, University Hospital Frankfurt/Main, Frankfurt/Main, Germany F. Ramsthaler Institute of Legal Medicine, University of the Saarland, Homburg/ Saar, Germany S. Schmidt Institute of Legal Medicine, Charité University Hospital, Berlin, Germany
and separately evaluated as to the developmental stage of the medial clavicular epiphysis. A forensically established fivestage 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. Keywords Forensic age diagnostics in the living . Ossification . Clavicle . Radiography . Oblique projections
Introduction Projection radiography of different skeletal regions, such as hand/wrist [10, 25, 26], clavicle [2, 3, 5, 6, 8, 14, 21, 27], teeth [15, 20], iliac crest [32–34], or knee [4, 11], represents an important tool in forensic age diagnostics in living individuals. Different legal age thresholds are covered with these skeletal regions. The age of 18 is one of the most important as it represents the threshold between adult and juvenile penal law in many European countries. To answer the question of whether an individual has reached that age, the Study Group on Forensic Age Diagnostics (AGFAD) of the German Society of Legal Medicine recommends the radiological evaluation of the ossification status of the medial clavicular epiphysis [22] because all other developmental systems, such as
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hand ossification or mineralization of the third molars, may have already completed their growth before the age of 18 [9, 17, 30, 37]. To date, there is only one study using radiography of the clavicle that can be applied as forensic reference study according to AGFAD criteria [21]. In this study, the authors investigated chest radiographs generated in standard posterioranterior (PA) projection and concluded that those radiographs can essentially provide a basis for assessing clavicular ossification. However, if superimposition of pulmonal or skeletal structures impedes evaluation of the sternal extremity of the clavicle in the PA projection, additional oblique images (between 10 and 20° according to [1]) are currently recommended to allow for reliable age estimations [23]. However, a clavicle in PA projection has a different position to the X-ray detector than a clavicle in oblique projection. This might lead to an altered depiction of the medial epiphyseal region that represents the most important part of the clavicle with regard to forensic age diagnostics. Thereby, an incorrect ossification stage assessment could lead to wrong age estimates. In this regard, Garamendi et al. [7] proposed to distinguish between two types of errors that can occur in forensic age estimation practice: technically unacceptable errors and ethically unacceptable errors. The former comprises incorrect age estimates that could lead to a more beneficial criminal treatment of a subject concerned. By contrast, ethically unacceptable errors are incorrect age estimates that could cause disadvantages for individuals undergoing criminal proceedings, e.g., when the age of 18 is wrongly assumed in a minor. Following the legal principle of “in dubio pro reo,” it is necessary in particular to avoid ethically unacceptable errors. The present study therefore investigates the influence of the radiographic projection type on the stage determination of the medial clavicular epiphysis. To this end, the clavicular ossification stages obtained from radiographs taken as PA projections are compared with those taken as oblique projections.
Table 1 Number of cases by age and sex (n=418)
Age group (years)
n Male
n Female
15 16 17 18 19
5 12 8 19 17
6 5 4 9 8
20 21 22 23 24 25 26 27 28 29 30 Σ
20 16 21 25 24 18 29 24 15 22 17 292
7 13 11 11 8 9 6 6 11 4 8 126
LAO projection (left anterior oblique, 15°). Specimens were accordingly positioned on the X-ray detector plane. A wedgeshaped pad (15°) was used for the oblique projections warranting a specimen’s position of 15°. Image evaluation was done at a standard PACS workstation. The degree of ossification of each medial epiphyseal cartilage (n=836) was separately determined applying the classification system by Schmeling et al. as follows [21] (Fig. 1): Stage I Stage II
Ossification center has not ossified yet. Ossification center has ossified. Epiphyseal cartilage has not ossified. Stage III Epiphyseal cartilage has partially ossified. Stage IV Epiphyseal cartilage has completely ossified. Physeal scar is still visible. Stage V Epiphyseal cartilage has completely ossified. Physeal scar is not visible any more.
Materials and methods With approval of all responsible local ethical committees of the participating institutions, the sternoclavicular joints of 418 bodies aged between 15 and 30 years were prospectively obtained in the course of forensic autopsies, shrink-wrapped, and stored at −20 °C. If autopsy revealed a disease affecting skeletal development, this case was not included in the study. The autopsies were carried out at the University Institutes of Legal Medicine of the German cities of Berlin, Essen, Frankfurt am Main, Hamburg, and Münster between 2004 and 2011. Table 1 shows the number of cases by age and sex. Using a digital luminescence radiography system (60 kV), three different radiographs of each specimen were taken: PA projection, RAO projection (right anterior oblique, 15°), and
Cases that could not be assigned to one of these stages, e.g., due to the presence of anatomic shape variants (Fig. 2) or superimposition with other structures (e.g., sternum; Fig. 3), were classified as “not assessable” (n.a.). Stage determinations were done in consensus by two examiners, one forensic physician and one radiologist. Both examiners have several years of experience in forensic age diagnostics, particularly in evaluating radiological image material of the medial clavicular epiphysis. Prior to and during image assessments, the age of the specimens was not known to the examiners to avoid any influence from the aforementioned parameters. All three projection types (PA, RAO, and LAO) were evaluated separately without knowledge of the stage results obtained from other projection types evaluated before.
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Fig. 1 Schematic drawing of the five ossification stages of the medial clavicular epiphysis according to Schmeling et al. [21]. Stage I ossification center has not ossified yet. Stage II ossification center has ossified. Epiphyseal cartilage has not ossified. Stage III epiphyseal cartilage has
partially ossified. Stage IV epiphyseal cartilage has completely ossified. Physeal scar is still visible. Stage V epiphyseal cartilage has completely ossified. Physeal scar is not visible any more
Results
cases (10.0 %) showed a higher ossification stage in the LAO projection compared with the PA projection (TUE and EUE in Table 4; Figs. 5 and 6).
In 525 out of 836 cases (62.8 %), the same ossification stage was found in all three projection types (Table 2), e.g., 168 clavicles showed stage III in the PA, RAO, and LAO image. Table 3 shows the comparison between RAO and PA. In 634 out of 836 cases (75.8 %), the ossification stage found in the RAO projection was the same as in the PA projection. Accordingly, in 202 cases (24.2 %), the RAO projection revealed another ossification stage than the PA projection or the ossification stage was not assessable. Among these 202 cases, there were 18 cases (2.2 %) where the RAO projection showed a lower ossification stage than the PA projection (technically unacceptable errors, TUE in Table 3). In 82 out of the 202 cases (9.8 %), a higher ossification stage was observed in the RAO projection compared with the PA projection (ethically unacceptable errors, EUE in Table 3; Fig. 4). Table 4 shows the comparison between LAO and PA. In 622 out of 836 cases (74.4 %), the ossification stage observed in the LAO projection accorded to the PA projection, while in 214 cases (25.6 %), the LAO projection disaccorded to the PA projection or the ossification stage was not assessable. Among these 214 cases, 16 cases (1.9 %) showed a lower, and 84
Fig. 2 Radiographic depiction of a bowl-shaped variant of the medial clavicular epiphysis that could not be assigned to one of the five ossification stages
Discussion If the skeletal development of the hand is completed, the Study Group on Forensic Age Diagnostics (AGFAD) of the German Society of Legal Medicine recommends the additional examination of the clavicles, preferably by means of projection radiography and/or computed tomography [22]. With regard to radiography, it is known, however, that using standard chest radiography in PA projection, superimpositions of vertebrae, ribs, sternum, and/or pulmonary structures can frequently impede reliable stage determination of the medial clavicular epiphysis. Since numerous PA chest radiographs are therefore not assessable, oblique projections of the clavicle are assumed to be an alternative possibility to allow for reliable age estimations in such cases. Accordingly, an early age estimation study by Jit and Kulkarni describes the usage of such oblique radiographs in doubtful cases [14].
Fig. 3 Medial clavicular epiphysis that could not be assigned to one of the five ossification stages due to superimposition with the upper part of the Manubrium sterni
Int J Legal Med Table 2 Number of cases that showed the same ossification stage in all three projection types (PA, RAO, and LAO)
Stage
PA=RAO=LAO
I II III IV V
2 0 168 13 108
n.a.
234
Σ
525 (62.8 %)
n.a. Not assessable
However, the present study demonstrates that a medial clavicular epiphysis depicted in an oblique projection (RAO or LAO) can show a different ossification stage than in the PA projection. This was the case in about 25 % of the cases. In at least 10 % of the cases, a higher ossification stage was observed in the oblique projection compared with the PA projection. Since a higher ossification stage may lead to disadvantages for individuals undergoing criminal proceedings, these “misclassifications” can be termed as ethically unacceptable errors according to Garamendi et al. [7]. The case example demonstrated in Fig. 6 illustrates the problem. According to current reference data [21], the sole evaluation of the RAO projection would have led to a minimum age of 26 years, although, in the PA projection, the same clavicle shows a stage III which allows the assumption of a minimum age of 16 years. This would be a clear disadvantage in criminal proceedings because, based on the erroneous determination of the age of
Fig. 4 In the PA projection (a), the medial clavicular epiphysis shows unambiguous remnants of a physeal scar defining stage IV (arrows). However, the same clavicle has been independently evaluated as stage V in the RAO projection (b) because the ossification process appeared to be finished and a physeal scar was not visible. Sole evaluation of the RAO projection would have led to a minimum age of 26 years instead of 21 years (ethically unacceptable error)
majority, adult and not juvenile penal law would be applied. Accordingly, this would be a violation of minors’ rights. Hence, the usage of the current radiographic reference data, which rely upon chest radiographs taken as PA projections [21], must be referred to as inadmissible for oblique projections (RAO and LAO). As projection radiography of the clavicle can therefore no longer be recommended for answering the question of whether an individual undergoing criminal proceedings has achieved the age of 18 or 21, computed tomography, if available, must henceforth be regarded as the exclusive method of choice. Besides the absence of superimposition effects, another advantage of the computed tomography is the possibility of applying substages. This additional classification system
Ossification stage (PA)
Table 3 Comparison of ossification stages between PA and RAO projection
Σ
I II III IV V n.a.
I 2 1 0 0 0 2
Ossification stage (RAO) II III IV V n.a. 1 0 0 0 5 2 8 0 0 1 7 221 7 32 35 0 4 34 34 16 0 1 5 121 4 0 15 12 12 254
RAO = PA 2 2 221 34 121 254
RAO ≠ PA 6 10 81 54 10 41
TUE
EUE
1 7 4 6 -
1 8 39 34 -
634 202 18 82 (75.8%) (24.2%) (2.2%) (9.8%)
Using PA and RAO projection, each clavicle was staged according to Schmeling et al. [21]. The black highlighted fields show the number of cases that were found to have a higher ossification stage in RAO than in PA. These cases were summed up to the case number of ethically unacceptable errors (EUE). The gray highlighted fields show the number of cases that were found to have a lower ossification stage in RAO than in PA. These cases were summed up to the case number of technically unacceptable errors (TUE). Cases that could not be assigned to one of the five stages were classified as “not assessable” (n.a.). These cases could not be assigned to either the TUE or the EUE group
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Ossification stage (PA)
Table 4 Comparison of ossification stages between PA and LAO projection
I II III IV V n.a.
I 4 1 1 0 0 2
Ossification stage (LAO) II III IV V n.a. 1 0 0 0 3 2 8 0 0 1 4 215 7 32 43 0 3 26 36 23 0 2 5 113 11 0 15 5 11 262
Σ
LAO = PA 4 2 215 26 113 262
LAO ≠ PA 4 10 87 62 18 33
TUE
EUE
1 5 3 7 -
1 8 39 36 -
622 214 16 84 (74.4%) (25.6%) (1.9%) (10.0%)
Using PA and LAO projection, each clavicle was staged according to Schmeling et al. [21]. The black highlighted fields show the number of cases that were found to have a higher ossification stage in LAO than in PA. These cases were summed up to the case number of ethically unacceptable errors (EUE). The gray highlighted fields show the number of cases that were found to have a lower ossification stage in LAO than in PA. These cases were summed up to the case number of technically unacceptable errors (TUE). Cases that could not be assigned to one of the five stages were classified as “not assessable” (n.a.). These cases could not be assigned to either the TUE or the EUE group
already allows for statements as to the age of majority if a late stage III (stage IIIc) is present [16, 36]. On the other hand, one has to be aware that the accuracy of the stage determination of the medial clavicular epiphysis by means of computed tomography depends on several method-specific influencing factors such as the slice thickness of the images [19] or the degree of qualification of the examiners [35]. Accordingly, a slice thickness of not larger than 1 mm as well as a high degree of specific qualification, including the knowledge about the diversity of anatomic shape variants and major sources of error, were recommended to ensure a maximum of accuracy and diagnostic reliability [19, 35]. The presence of preexisting chest radiographs, e.g., in unaccompanied minor refugees who are often subjected to
tuberculosis screening, represents a special case. As further exposure to radiation is frequently not admissible in those cases, the current reference data for PA projections of the medial clavicular epiphysis are still applicable if at least one medial clavicular epiphysis is assessable [18]. Besides radiography and computed tomography, in recent years, magnetic resonance imaging (MRI) of the clavicle has moved increasingly into focus of forensic age estimation research [12, 13, 24, 28, 29, 31]. As a radiation-free method, the evaluation of the clavicle by MRI is of special interest not only with respect to criminal proceedings but also in terms of civil and asylum law, particularly as to the aforementioned unaccompanied minor refugees. However, comprehensive reference studies according to AGFAD criteria, that allow
Fig. 5 In the PA projection (a), the medial clavicular epiphysis shows an ossification center that appears to be partially fused with the metaphysis (stage III). The arrow indicates the upper rest of the unossified growth plate. The same clavicle has been independently evaluated as stage II in the LAO projection (b) because the ossification center did not have any connection to the metaphysis. Thus, sole evaluation of the LAO projection would have led to a technically unacceptable error
Fig. 6 In the PA projection (a), the medial clavicular epiphysis shows partial osseous fusions between epiphyseal ossification center and metaphysis defining stage III (arrows). However, the same clavicle has been independently evaluated as stage V in the LAO projection (b) because the ossification process appeared to be finished and a physeal scar was not visible. Sole evaluation of the LAO projection would have led to a minimum age of 26 years instead of 16 years (ethically unacceptable error)
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for the application of this promising method in routine forensic age diagnostics, are still missing. Once such clavicular MRI reference data are available, an increasing certainty for forensic age estimations beyond criminal proceedings can be expected.
Conclusions The results of the present study allow the following conclusions for forensic practice: 1. The usage of the current radiographic reference data, which rely upon chest radiographs taken as PA projections [21], must be referred to as inadmissible for oblique projections (RAO and LAO). 2. If there is a choice between the use of projection radiography or computed tomography, projection radiography of the clavicle can no longer be recommended for forensic age estimation practice because, in PA projections, superimposition effects frequently impedes evaluation of the medial end of the clavicle, and in oblique projections, 25 % of the cases show different ossification stages than in the accordant PA projection. 3. 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, at least if this technology is available.
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Int J Legal Med 28. Tangmose S, Jensen KE, Lynnerup N (2013) Comparative study on developmental stages of the clavicle by postmortem MRI and CT imaging. J Forensic Radiol Imaging 1:102–106 29. Tangmose S, Jensen KE, Villa C, Lynnerup N (2014) Forensic age estimation from the clavicle using 1.0 T MRI—preliminary results. Forensic Sci Int 234:7–12 30. Tisè M, Mazzarini L, Fabrizzi G, Ferrante L, Giorgetti R, Tagliabracci A (2011) Applicability of Greulich and Pyle method for age assessment in forensic practice on an Italian sample. Int J Legal Med 125:411–416 31. Vieth V, Schulz R, Brinkmeier P, Dvorak J, Schmeling A (2014) Age estimation in U-20 football players using 3.0 Tesla MRI of the clavicle. Forensic Sci Int 241:118–122 32. Wittschieber D, Schmeling A, Schmidt S, Heindel W, Pfeiffer H, Vieth V (2013) The Risser sign for forensic age estimation in living individuals: a study of 643 pelvic radiographs. Forensic Sci Med Pathol 9:36–43 33. Wittschieber D, Vieth V, Domnick C, Pfeiffer H, Schmeling A (2013) The iliac crest in forensic age diagnostics: evaluation of the
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apophyseal ossification in conventional radiography. Int J Legal Med 127:473–479 Wittschieber D, Vieth V, Wierer T, Pfeiffer H, Schmeling A (2013) Cameriere’s approach modified for pelvic radiographs: a novel method to assess apophyseal iliac crest ossification for the purpose of forensic age diagnostics. Int J Legal Med 127:825–829 Wittschieber D, Schulz R, Vieth V, Küppers M, Bajanowski T, Ramsthaler F, Püschel K, Pfeiffer H, Schmidt S, Schmeling A (2014) Influence of the examiner’s qualification and sources of error during stage determination of the medial clavicular epiphysis by means of computed tomography. Int J Legal Med 128:183–191 Wittschieber D, Schulz R, Vieth V, Küppers M, Bajanowski T, Ramsthaler F, Püschel K, Pfeiffer H, Schmidt S, Schmeling A (2014) The value of sub-stages and thin slices for the assessment of the medial clavicular epiphysis: a prospective multi-center CT study. Forensic Sci Med Pathol 10:163–169 Zabet D, Rérolle C, Pucheux J, Telmon N, Saint-Martin P (2014) Can the Greulich and Pyle method be used on French contemporary individuals? Int J Legal Med. doi:10.1007/s00414-014-1028-7
ORIGINAL ARTICLE
Projection radiography of the clavicle: still recommendable for forensic age diagnostics in living individuals? Daniel Wittschieber & Christian Ottow & Volker Vieth & Martin Küppers & Ronald Schulz & Juan Hassu & Thomas Bajanowski & Klaus Püschel & Frank Ramsthaler & Heidi Pfeiffer & Sven Schmidt & Andreas Schmeling
Received: 3 July 2014 / Accepted: 8 August 2014 # Springer-Verlag Berlin Heidelberg 2014
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 D. Wittschieber (*) : M. Küppers : R. Schulz : J. Hassu : H. Pfeiffer : S. Schmidt : A. Schmeling Institute of Legal Medicine, University Hospital Münster, Röntgenstraße 23, 48149 Münster, Germany e-mail: [email protected] C. Ottow : V. Vieth Institute of Clinical Radiology, University Hospital Münster, Münster, Germany T. Bajanowski Institute of Legal Medicine, University Hospital Essen, Essen, Germany K. Püschel Institute of Legal Medicine, University Hospital Hamburg-Eppendorf, Hamburg, Germany F. Ramsthaler Institute of Legal Medicine, University Hospital Frankfurt/Main, Frankfurt/Main, Germany F. Ramsthaler Institute of Legal Medicine, University of the Saarland, Homburg/ Saar, Germany S. Schmidt Institute of Legal Medicine, Charité University Hospital, Berlin, Germany
and separately evaluated as to the developmental stage of the medial clavicular epiphysis. A forensically established fivestage 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. Keywords Forensic age diagnostics in the living . Ossification . Clavicle . Radiography . Oblique projections
Introduction Projection radiography of different skeletal regions, such as hand/wrist [10, 25, 26], clavicle [2, 3, 5, 6, 8, 14, 21, 27], teeth [15, 20], iliac crest [32–34], or knee [4, 11], represents an important tool in forensic age diagnostics in living individuals. Different legal age thresholds are covered with these skeletal regions. The age of 18 is one of the most important as it represents the threshold between adult and juvenile penal law in many European countries. To answer the question of whether an individual has reached that age, the Study Group on Forensic Age Diagnostics (AGFAD) of the German Society of Legal Medicine recommends the radiological evaluation of the ossification status of the medial clavicular epiphysis [22] because all other developmental systems, such as
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hand ossification or mineralization of the third molars, may have already completed their growth before the age of 18 [9, 17, 30, 37]. To date, there is only one study using radiography of the clavicle that can be applied as forensic reference study according to AGFAD criteria [21]. In this study, the authors investigated chest radiographs generated in standard posterioranterior (PA) projection and concluded that those radiographs can essentially provide a basis for assessing clavicular ossification. However, if superimposition of pulmonal or skeletal structures impedes evaluation of the sternal extremity of the clavicle in the PA projection, additional oblique images (between 10 and 20° according to [1]) are currently recommended to allow for reliable age estimations [23]. However, a clavicle in PA projection has a different position to the X-ray detector than a clavicle in oblique projection. This might lead to an altered depiction of the medial epiphyseal region that represents the most important part of the clavicle with regard to forensic age diagnostics. Thereby, an incorrect ossification stage assessment could lead to wrong age estimates. In this regard, Garamendi et al. [7] proposed to distinguish between two types of errors that can occur in forensic age estimation practice: technically unacceptable errors and ethically unacceptable errors. The former comprises incorrect age estimates that could lead to a more beneficial criminal treatment of a subject concerned. By contrast, ethically unacceptable errors are incorrect age estimates that could cause disadvantages for individuals undergoing criminal proceedings, e.g., when the age of 18 is wrongly assumed in a minor. Following the legal principle of “in dubio pro reo,” it is necessary in particular to avoid ethically unacceptable errors. The present study therefore investigates the influence of the radiographic projection type on the stage determination of the medial clavicular epiphysis. To this end, the clavicular ossification stages obtained from radiographs taken as PA projections are compared with those taken as oblique projections.
Table 1 Number of cases by age and sex (n=418)
Age group (years)
n Male
n Female
15 16 17 18 19
5 12 8 19 17
6 5 4 9 8
20 21 22 23 24 25 26 27 28 29 30 Σ
20 16 21 25 24 18 29 24 15 22 17 292
7 13 11 11 8 9 6 6 11 4 8 126
LAO projection (left anterior oblique, 15°). Specimens were accordingly positioned on the X-ray detector plane. A wedgeshaped pad (15°) was used for the oblique projections warranting a specimen’s position of 15°. Image evaluation was done at a standard PACS workstation. The degree of ossification of each medial epiphyseal cartilage (n=836) was separately determined applying the classification system by Schmeling et al. as follows [21] (Fig. 1): Stage I Stage II
Ossification center has not ossified yet. Ossification center has ossified. Epiphyseal cartilage has not ossified. Stage III Epiphyseal cartilage has partially ossified. Stage IV Epiphyseal cartilage has completely ossified. Physeal scar is still visible. Stage V Epiphyseal cartilage has completely ossified. Physeal scar is not visible any more.
Materials and methods With approval of all responsible local ethical committees of the participating institutions, the sternoclavicular joints of 418 bodies aged between 15 and 30 years were prospectively obtained in the course of forensic autopsies, shrink-wrapped, and stored at −20 °C. If autopsy revealed a disease affecting skeletal development, this case was not included in the study. The autopsies were carried out at the University Institutes of Legal Medicine of the German cities of Berlin, Essen, Frankfurt am Main, Hamburg, and Münster between 2004 and 2011. Table 1 shows the number of cases by age and sex. Using a digital luminescence radiography system (60 kV), three different radiographs of each specimen were taken: PA projection, RAO projection (right anterior oblique, 15°), and
Cases that could not be assigned to one of these stages, e.g., due to the presence of anatomic shape variants (Fig. 2) or superimposition with other structures (e.g., sternum; Fig. 3), were classified as “not assessable” (n.a.). Stage determinations were done in consensus by two examiners, one forensic physician and one radiologist. Both examiners have several years of experience in forensic age diagnostics, particularly in evaluating radiological image material of the medial clavicular epiphysis. Prior to and during image assessments, the age of the specimens was not known to the examiners to avoid any influence from the aforementioned parameters. All three projection types (PA, RAO, and LAO) were evaluated separately without knowledge of the stage results obtained from other projection types evaluated before.
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Fig. 1 Schematic drawing of the five ossification stages of the medial clavicular epiphysis according to Schmeling et al. [21]. Stage I ossification center has not ossified yet. Stage II ossification center has ossified. Epiphyseal cartilage has not ossified. Stage III epiphyseal cartilage has
partially ossified. Stage IV epiphyseal cartilage has completely ossified. Physeal scar is still visible. Stage V epiphyseal cartilage has completely ossified. Physeal scar is not visible any more
Results
cases (10.0 %) showed a higher ossification stage in the LAO projection compared with the PA projection (TUE and EUE in Table 4; Figs. 5 and 6).
In 525 out of 836 cases (62.8 %), the same ossification stage was found in all three projection types (Table 2), e.g., 168 clavicles showed stage III in the PA, RAO, and LAO image. Table 3 shows the comparison between RAO and PA. In 634 out of 836 cases (75.8 %), the ossification stage found in the RAO projection was the same as in the PA projection. Accordingly, in 202 cases (24.2 %), the RAO projection revealed another ossification stage than the PA projection or the ossification stage was not assessable. Among these 202 cases, there were 18 cases (2.2 %) where the RAO projection showed a lower ossification stage than the PA projection (technically unacceptable errors, TUE in Table 3). In 82 out of the 202 cases (9.8 %), a higher ossification stage was observed in the RAO projection compared with the PA projection (ethically unacceptable errors, EUE in Table 3; Fig. 4). Table 4 shows the comparison between LAO and PA. In 622 out of 836 cases (74.4 %), the ossification stage observed in the LAO projection accorded to the PA projection, while in 214 cases (25.6 %), the LAO projection disaccorded to the PA projection or the ossification stage was not assessable. Among these 214 cases, 16 cases (1.9 %) showed a lower, and 84
Fig. 2 Radiographic depiction of a bowl-shaped variant of the medial clavicular epiphysis that could not be assigned to one of the five ossification stages
Discussion If the skeletal development of the hand is completed, the Study Group on Forensic Age Diagnostics (AGFAD) of the German Society of Legal Medicine recommends the additional examination of the clavicles, preferably by means of projection radiography and/or computed tomography [22]. With regard to radiography, it is known, however, that using standard chest radiography in PA projection, superimpositions of vertebrae, ribs, sternum, and/or pulmonary structures can frequently impede reliable stage determination of the medial clavicular epiphysis. Since numerous PA chest radiographs are therefore not assessable, oblique projections of the clavicle are assumed to be an alternative possibility to allow for reliable age estimations in such cases. Accordingly, an early age estimation study by Jit and Kulkarni describes the usage of such oblique radiographs in doubtful cases [14].
Fig. 3 Medial clavicular epiphysis that could not be assigned to one of the five ossification stages due to superimposition with the upper part of the Manubrium sterni
Int J Legal Med Table 2 Number of cases that showed the same ossification stage in all three projection types (PA, RAO, and LAO)
Stage
PA=RAO=LAO
I II III IV V
2 0 168 13 108
n.a.
234
Σ
525 (62.8 %)
n.a. Not assessable
However, the present study demonstrates that a medial clavicular epiphysis depicted in an oblique projection (RAO or LAO) can show a different ossification stage than in the PA projection. This was the case in about 25 % of the cases. In at least 10 % of the cases, a higher ossification stage was observed in the oblique projection compared with the PA projection. Since a higher ossification stage may lead to disadvantages for individuals undergoing criminal proceedings, these “misclassifications” can be termed as ethically unacceptable errors according to Garamendi et al. [7]. The case example demonstrated in Fig. 6 illustrates the problem. According to current reference data [21], the sole evaluation of the RAO projection would have led to a minimum age of 26 years, although, in the PA projection, the same clavicle shows a stage III which allows the assumption of a minimum age of 16 years. This would be a clear disadvantage in criminal proceedings because, based on the erroneous determination of the age of
Fig. 4 In the PA projection (a), the medial clavicular epiphysis shows unambiguous remnants of a physeal scar defining stage IV (arrows). However, the same clavicle has been independently evaluated as stage V in the RAO projection (b) because the ossification process appeared to be finished and a physeal scar was not visible. Sole evaluation of the RAO projection would have led to a minimum age of 26 years instead of 21 years (ethically unacceptable error)
majority, adult and not juvenile penal law would be applied. Accordingly, this would be a violation of minors’ rights. Hence, the usage of the current radiographic reference data, which rely upon chest radiographs taken as PA projections [21], must be referred to as inadmissible for oblique projections (RAO and LAO). As projection radiography of the clavicle can therefore no longer be recommended for answering the question of whether an individual undergoing criminal proceedings has achieved the age of 18 or 21, computed tomography, if available, must henceforth be regarded as the exclusive method of choice. Besides the absence of superimposition effects, another advantage of the computed tomography is the possibility of applying substages. This additional classification system
Ossification stage (PA)
Table 3 Comparison of ossification stages between PA and RAO projection
Σ
I II III IV V n.a.
I 2 1 0 0 0 2
Ossification stage (RAO) II III IV V n.a. 1 0 0 0 5 2 8 0 0 1 7 221 7 32 35 0 4 34 34 16 0 1 5 121 4 0 15 12 12 254
RAO = PA 2 2 221 34 121 254
RAO ≠ PA 6 10 81 54 10 41
TUE
EUE
1 7 4 6 -
1 8 39 34 -
634 202 18 82 (75.8%) (24.2%) (2.2%) (9.8%)
Using PA and RAO projection, each clavicle was staged according to Schmeling et al. [21]. The black highlighted fields show the number of cases that were found to have a higher ossification stage in RAO than in PA. These cases were summed up to the case number of ethically unacceptable errors (EUE). The gray highlighted fields show the number of cases that were found to have a lower ossification stage in RAO than in PA. These cases were summed up to the case number of technically unacceptable errors (TUE). Cases that could not be assigned to one of the five stages were classified as “not assessable” (n.a.). These cases could not be assigned to either the TUE or the EUE group
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Ossification stage (PA)
Table 4 Comparison of ossification stages between PA and LAO projection
I II III IV V n.a.
I 4 1 1 0 0 2
Ossification stage (LAO) II III IV V n.a. 1 0 0 0 3 2 8 0 0 1 4 215 7 32 43 0 3 26 36 23 0 2 5 113 11 0 15 5 11 262
Σ
LAO = PA 4 2 215 26 113 262
LAO ≠ PA 4 10 87 62 18 33
TUE
EUE
1 5 3 7 -
1 8 39 36 -
622 214 16 84 (74.4%) (25.6%) (1.9%) (10.0%)
Using PA and LAO projection, each clavicle was staged according to Schmeling et al. [21]. The black highlighted fields show the number of cases that were found to have a higher ossification stage in LAO than in PA. These cases were summed up to the case number of ethically unacceptable errors (EUE). The gray highlighted fields show the number of cases that were found to have a lower ossification stage in LAO than in PA. These cases were summed up to the case number of technically unacceptable errors (TUE). Cases that could not be assigned to one of the five stages were classified as “not assessable” (n.a.). These cases could not be assigned to either the TUE or the EUE group
already allows for statements as to the age of majority if a late stage III (stage IIIc) is present [16, 36]. On the other hand, one has to be aware that the accuracy of the stage determination of the medial clavicular epiphysis by means of computed tomography depends on several method-specific influencing factors such as the slice thickness of the images [19] or the degree of qualification of the examiners [35]. Accordingly, a slice thickness of not larger than 1 mm as well as a high degree of specific qualification, including the knowledge about the diversity of anatomic shape variants and major sources of error, were recommended to ensure a maximum of accuracy and diagnostic reliability [19, 35]. The presence of preexisting chest radiographs, e.g., in unaccompanied minor refugees who are often subjected to
tuberculosis screening, represents a special case. As further exposure to radiation is frequently not admissible in those cases, the current reference data for PA projections of the medial clavicular epiphysis are still applicable if at least one medial clavicular epiphysis is assessable [18]. Besides radiography and computed tomography, in recent years, magnetic resonance imaging (MRI) of the clavicle has moved increasingly into focus of forensic age estimation research [12, 13, 24, 28, 29, 31]. As a radiation-free method, the evaluation of the clavicle by MRI is of special interest not only with respect to criminal proceedings but also in terms of civil and asylum law, particularly as to the aforementioned unaccompanied minor refugees. However, comprehensive reference studies according to AGFAD criteria, that allow
Fig. 5 In the PA projection (a), the medial clavicular epiphysis shows an ossification center that appears to be partially fused with the metaphysis (stage III). The arrow indicates the upper rest of the unossified growth plate. The same clavicle has been independently evaluated as stage II in the LAO projection (b) because the ossification center did not have any connection to the metaphysis. Thus, sole evaluation of the LAO projection would have led to a technically unacceptable error
Fig. 6 In the PA projection (a), the medial clavicular epiphysis shows partial osseous fusions between epiphyseal ossification center and metaphysis defining stage III (arrows). However, the same clavicle has been independently evaluated as stage V in the LAO projection (b) because the ossification process appeared to be finished and a physeal scar was not visible. Sole evaluation of the LAO projection would have led to a minimum age of 26 years instead of 16 years (ethically unacceptable error)
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for the application of this promising method in routine forensic age diagnostics, are still missing. Once such clavicular MRI reference data are available, an increasing certainty for forensic age estimations beyond criminal proceedings can be expected.
Conclusions The results of the present study allow the following conclusions for forensic practice: 1. The usage of the current radiographic reference data, which rely upon chest radiographs taken as PA projections [21], must be referred to as inadmissible for oblique projections (RAO and LAO). 2. If there is a choice between the use of projection radiography or computed tomography, projection radiography of the clavicle can no longer be recommended for forensic age estimation practice because, in PA projections, superimposition effects frequently impedes evaluation of the medial end of the clavicle, and in oblique projections, 25 % of the cases show different ossification stages than in the accordant PA projection. 3. 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, at least if this technology is available.
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