Search

Unlabelled: In 27 centres across Europe, the prevalence of deforming spinal Scheuermann's disease in age-stratified population-based samples of over 10,000 men and women aged 50+ averaged 8% in each sex, but was highly variable between centres. Low DXA BMD was un-associated with Scheuermann's, helping the differential diagnosis from osteoporosis., Introduction: This study aims to assess the prevalence of Scheuermann's disease of the spine across Europe in men and women over 50 years of age, to quantitate its association with bone mineral density (BMD) and to assess its role as a confounder for the radiographic diagnosis of osteoporotic fracture., Methods: In 27 centres participating in the population-based European Vertebral Osteoporosis Study (EVOS), standardised lateral radiographs of the lumbar and of the thoracic spine from T4 to L4 were assessed in all those of adequate quality. The presence of Scheuermann's disease, a confounder for prevalent fracture in later life, was defined by the presence of at least one Schmorl's node or irregular endplate together with kyphosis (sagittal Cobb angle >40° between T4 and T12) or a wedged-shaped vertebral body. Alternatively, the (rare) Edgren-Vaino sign was taken as diagnostic. The 6-point-per-vertebral-body (13 vertebrae) method was used to assess osteoporotic vertebral shape and fracture caseness. DXA BMD of the L2-L4 and femoral neck regions was measured in subsets. We also assessed the presence of Scheuermann's by alternative published algorithms when these used the radiographic signs we assessed., Results: Vertebral radiographic images from 4486 men and 5655 women passed all quality checks. Prevalence of Scheuermann's varied considerably between centres, and based on random effect modelling, the overall European prevalence using our method was 8% with no significant difference between sexes. The highest prevalences were seen in Germany, Sweden, the UK and France and low prevalences were seen in Hungary, Poland and Slovakia. Centre-level prevalences in men and women were highly correlated. Scheuermann's was not associated with BMD of the spine or hip., Conclusions: Since most of the variation in population impact of Scheuermann's was unaccounted for by the radiological and anthropometric data, the search for new genetic and environmental determinants of this disease is encouraged.

This paper presents updated recommendations of the Study Group on Forensic Age Diagnostics for age estimations in living individuals in criminal proceedings. In order to increase the diagnostic accuracy and to improve the identification of age-relevant developmental disorders, a physical examination, an X-ray examination of the left hand, as well as a dental examination including the determination of the dental status and an X-ray of the dentition should be performed in each case. If the skeletal development of the hand is completed, an additional radiological examination of the clavicles should be carried out. Minimum requirements for reference studies are defined and recommendable studies are listed. Instructions for the examination and the preparation of expert reports are presented. The committee of the study group organizes annual proficiency tests for quality assurance.

Determination of the stage of ossification of the medial clavicular epiphysis is a crucial part of forensic age estimation when evaluating living subjects over 18 years of age. In the present study, we comparatively assessed conventional radiographs and computed tomography (CT) scans of sternoclavicular joints used to perform forensic age assessments in 57 individuals undergoing criminal proceedings. With CT, it was possible to determine the ossification stage of all clavicles studied. In the case of conventional radiography, reliable assessment of ossification stage was not possible in 15 out of 114 clavicles studied due to the superimposition of other structures. Regarding agreement between the methods, both radiography and CT produced identical staging results in 97 out of 99 clavicular epiphyses. In two cases, however, ossification was classified as stage 2 by CT and as stage 3 by conventional radiography. Regarding stages 4 and 5, both methods produced identical staging results in all cases. In forensic age estimation practice, it is necessary that conventional radiographic reference studies be used for ossification stage classification by conventional radiography and that CT reference studies be used for ossification stage classification by CT. Further studies in dead bodies of known age are required to issue a recommendation as to whether conventional radiography using obtained in three planes or CT is the method of choice for the assessment of clavicular ossification.

Radiological analysis of the hand skeleton is a key pillar of forensic age diagnostics in living subjects undergoing criminal proceedings. The present study investigated whether ossification stage classification of selected epiphyses of the hand could provide added value to hand radiograph analysis. Hand radiographs from 265 male and 164 female subjects aged 10-18years old who had been X-rayed due to traumatological indications were therefore assessed. Epiphyseal ossification of selected elements of the hand skeleton (ulna, radius and third metacarpal, basal phalanx, mesophalanx and telephalanx) was graded based on the criteria of the five-stage classification system of Schmeling et al. (Int J Legal Med, 118:5-8, 2004) for clavicular epiphyseal cartilage. Stage 5 (absence of the epiphyseal scar) does not occur in the radius of men before the age of 18. Stage 5 can therefore be regarded as a potential parameter for valid determination of a minimum age of 18 years for forensic age estimation in criminal proceedings.

Assessment of the degree of ossification of the medial clavicular epiphyseal cartilage is of vital importance in forensic age diagnostics of living individuals aged more than 18 years. To date, reference studies on the assessment of clavicular ossification using imaging procedures only relate to conventional radiography and computed tomography (CT). In this study, magnetic resonance (MR) scans of 54 sternoclavicular joints of bodies aged between 6 and 40 years were evaluated prospectively. All of the examined medial clavicular epiphyseal cartilages permitted an assessment of the degree of ossification. Stage 2 was first observed at the age of 15.0 years, the earliest age at which stage 3 was observed was 16.9 years, and stage 4 was first observed at the age of 23.8 years. The observed age intervals of the respective degrees of ossification correspond to the known data from X-ray and CT scan examinations. The achieved results should be examined with a larger number of cases. A modified examination protocol is required for the MR examination of the medial clavicular epiphyseal cartilage for the purpose of forensic age diagnostics of living individuals.

Evaluation of hand ossification is a main pillar of radiological age diagnosis in living subjects. In the present study, we comparatively assessed the Greulich-Pyle and Thiemann-Nitz methods for accuracy of age estimation and degree of acceleration in the respective reference populations. For this, the skeletal age of 649 hand X-rays from German subjects aged 1-18 years was determined by both methods. Accuracy of the age estimates was determined based on regression and measures of certainty. In terms of accuracy, both methods seem to be equally well suited for forensic age diagnostics. The degree of acceleration in the reference populations for the two methods was calculated as the mean difference between the estimated skeletal age and the actual age of a test subject. Compared to the Greulich-Pyle population, the Thiemann-Nitz population was accelerated by 0.44 years in both male and female subjects. When an expert opinion is required and one cannot exclude the possibility that the investigated subject may come from a population with a high acceleration status, the Thiemann-Nitz method should preferably be used to prevent overestimation of age.

The aim of this study was to determine the statistical parameters of deviation in the Thiemann-Nitz method for use in forensic age diagnostics. To this effect, 402 hand radiograms, originally taken in two large German cities between 1983 and 2002 for the purpose of diagnosing trauma, were analyzed. At the time of examination, the patients were aged between 10 and 18 years. The study presents the mean, standard deviation, and median, with lower and upper quartiles, for the skeletal ages of 11.0 through 18.0 years. The simple standard deviations range between 0.2 and 1.2 years. To increase the accuracy of age estimates and improve the identification of age-relevant developmental disorders in forensic age estimation practice, the methods for determining skeletal age should always be combined with a physical and dental examination. In addition, the expert opinion should pay attention to the issue of different modernization levels in relevant populations.

Introduction: Vertebral fracture is a strong risk factor for future spine and hip fractures; yet recent data suggest that only 5-20% of subjects with a spine fracture are identified in primary care. We aimed to develop easily applicable algorithms predicting a high risk of future spine fracture in men and women over 50 years of age., Methods: Data was analysed from 5,561 men and women aged 50+ years participating in the European Prospective Osteoporosis Study (EPOS). Lateral thoracic and lumbar spine radiographs were taken at baseline and at an average of 3.8 years later. These were evaluated by an experienced radiologist. The risk of a new (incident) vertebral fracture was modelled as a function of age, number of prevalent vertebral fractures, height loss, sex and other fracture history reported by the subject, including limb fractures occurring between X-rays. Receiver Operating Characteristic (ROC) curves were used to compare the predictive ability of models., Results: In a negative binomial regression model without baseline X-ray data, the risk of incident vertebral fracture significantly increased with age [RR 1.74, 95% CI (1.44, 2.10) per decade], height loss [1.08 (1.04, 1.12) per cm decrease], female sex [1.48 (1.05, 2.09)], and recalled fracture history; [1.65 (1.15, 2.38) to 3.03 (1.66, 5.54)] according to fracture site. Baseline radiological assessment of prevalent vertebral fracture significantly improved the areas subtended by ROC curves from 0.71 (0.67, 0.74) to 0.74 (0.70, 0.77) P=0.013 for predicting 1+ incident fracture; and from 0.74 (0.67, 0.81) to 0.83 (0.76, 0.90) P=0.001 for 2+ incident fractures. Age, sex and height loss remained independently predictive. The relative risk of a new vertebral fracture increased with the number of prevalent vertebral fractures present from 3.08 (2.10, 4.52) for 1 fracture to 9.36 (5.72, 15.32) for 3+. At a specificity of 90%, the model including X-ray data improved the sensitivity for predicting 2+ and 1+ incident fractures by 6 and 4 fold respectively compared with random guessing. At 75% specificity the improvements were 3.2 and 2.4 fold respectively. With the modelling restricted to the subjects who had BMD measurements (n=2,409), the AUC for predicting 1+ vs. 0 incident vertebral fractures improved from 0.72 (0.66, 0.79) to 0.76 (0.71, 0.82) upon adding femoral neck BMD (P=0.010)., Conclusion: We conclude that for those with existing vertebral fractures, an accurately read spine X-ray will form a central component in future algorithms for targeting treatment, especially to the most vulnerable. The sensitivity of this approach to identifying vertebral fracture cases requiring anti-osteoporosis treatment, even when X-rays are ordered highly selectively, exceeds by a large margin the current standard of practice as recorded anywhere in the world.

Computed tomography scans originally obtained to assess the ossification status of the medial clavicular epiphyses of 40 live subjects for forensic age estimation purposes were analysed. From the data acquired we reconstructed images with slice thicknesses of 1, 3, 5 and 7 mm, and based on the classification of stages by Schmeling et al. (Int J Legal Med 118:5-8, 2004), we determined the ossification stage for each reconstructed slice thickness, separately for both sides. Of the 80 clavicular epiphysial plates examined, seven displayed slice-thickness-dependent differences at certain ossification stages. In one case a slice thickness of 1 mm led to a different diagnosis of the ossification stage than a slice thickness of 3 mm, in three cases the diagnoses differed between the slice thicknesses of 3 and of 5 mm, and in another three cases, between 5 and 7 mm. We therefore conclude that for age estimation purposes, the slice thickness should be 1 mm to ensure maximum accuracy and diagnostic reliability.

The authors retrospectively analyzed 629 CT images of patients aged between 15 and 30 years produced during multiple trauma diagnostics at the Unfallkrankenhaus Berlin. For the purposes of this study, the authors reliably determined the ossification status of the medial epiphysis of the clavicle in 556 cases, using the classification of stages by Schmeling et al. In both sexes, stage 2 was first noted at age 15. In male patients, the earliest occurrence of stage 3 was noted at age 17, in female patients at age 16. Stage 4 was first achieved by both sexes at age 21. Stage 5 was first noted in female patients at age 21 and in male patients at age 22, which is 4 or 5 years earlier than was observed by a comparable study using conventional radiographs. The partial-volume effect in computed tomography using the thick slice scanning mode was discussed as a possible explanation for this early visualization. The question of how slice thickness affects the age intervals between ossification stages identified by CT examinations should be examined in additional studies.

Vertebral fractures are associated with back pain and disability. There are, however, few prospective data looking at back pain and disability following identification of radiographic vertebral fracture. The aim of this analysis was to determine the impact of radiographically identified vertebral fracture on the subsequent occurrence of back pain and disability. Women aged 50 years and over were recruited from population registers in 18 European centers for participation in the European Prospective Osteoporosis Study. Participants completed an interviewer-administered questionnaire which included questions about back pain in the past year and various activities of daily living, and they had lateral spine radiographs performed. Participants in these centers were followed prospectively and had repeat spine radiographs performed a mean of 3.7 years later. In addition they completed a questionnaire with the same baseline questions concerning back pain and activities of daily living. The presence of prevalent and incident vertebral fracture was defined using established morphometric criteria. The data were analyzed using logistic regression with back pain or disability (present or absent) at follow-up as the outcome variable with adjustment made for the baseline value of the variable. The study included 2,260 women, mean age 62.2 years. The mean time between baseline and follow-up survey was 5.0 years. Two hundred and forty participants had prevalent fractures at the baseline survey, and 85 developed incident fractures during follow-up. After adjustment for age, center, and the baseline level of disability, compared with those without baseline prevalent fracture, those with a prevalent fracture (odds ratio [OR] = 1.4; 95% confidence interval [CI] 1.0 to 2.0) or an incident fracture (OR = 1.7; 95% CI, 0.9 to 3.2) were more likely to report disability at follow-up, though the confidence intervals embraced unity. Those with both a prevalent and incident fracture, however, were significantly more likely to report disability at follow-up (OR = 3.1; 95% CI, 1.4 to 7.0). After adjustment for age, center, and frequency of back pain at baseline, compared with those without baseline vertebral fracture, those with a prevalent fracture were no more likely to report back pain at follow-up (OR = 1.2; 95% CI, 0.8 to 1.7). There was a small increased risk among those with a preexisting fracture who had sustained an incident fracture during follow-up (OR = 1.6; 95% CI, 0.6 to 4.1) though the confidence intervals embraced unity. In conclusion, although there was no significant increase in the level of back pain an average of 5 years following identification of radiographic vertebral fracture, women who suffered a further fracture during follow-up experienced substantial levels of disability with impairment in key physical functions of independent living.

Radiological assessment of the degree of ossification of the medial clavicular epiphyseal cartilage plays a vital part in forensic age diagnosis of living adolescents and young adults. A total of 873 plain chest radiographs requested by the staff medical officer for members of staff aged 16-30 at the University Hospital Charité were evaluated retrospectively. Of these X-rays 699 permitted an assessment of ossification of at least 1 side of the clavicle. In addition to the customary stages (1: non-ossified epiphysis, 2: discernible ossification centre, 3: partial fusion, 4: total fusion) a stage 5 was also defined, characterised by the disappearance of the epiphyseal scar following total fusion. The earliest age at which stage 3 was detected in either gender was 16 years. Stage 4 was first observed in women at 20 years and in men at 21 years. In both genders, the earliest observation of stage 5 was at 26 years. It was concluded that plain chest radiographs can essentially be used to assess clavicular ossification. In practice, if overlap in posterior-anterior views impedes evaluation, a lateral view should also be taken to facilitate age estimation. In forensic practice the reference values of the present paper should be applied.

The aim of this analysis was to determine the influence of lifestyle, anthropometric and reproductive factors on the subsequent risk of incident vertebral fracture in men and women aged 50-79 years. Subjects were recruited from population registers from 28 centers across Europe. At baseline, they completed an interviewer-administered questionnaire and had lateral thoraco-lumbar spine radiographs performed. Repeat spinal radiographs were performed a mean of 3.8 years later. Incident vertebral fractures were defined morphometrically and also qualitatively by an experienced radiologist. Poisson regression was used to determine the influence of the baseline risk factor variables on the occurrence of incident vertebral fracture. A total of 3173 men (mean age 63.1 years) and 3402 women (mean age 62.2 years) contributed data to the analysis. In total there were 193 incident morphometric and 224 qualitative fractures. In women, an age at menarche 16 years or older was associated with an increased risk of vertebral fracture (RR = 1.80; 95%CI 1.24, 2.63), whilst use of hormonal replacement was protective (RR = 0.58; 95%CI 0.34, 0.99). None of the lifestyle factors studied including smoking, alcohol intake, physical activity or milk consumption showed any consistent associations with incident vertebral fracture. In men and women, increasing body weight and body mass index were associated with a reduced risk of vertebral fracture though, apart from body mass index in men, the confidence intervals embraced unity. For most variables the strengths of the associations observed were similar using the qualitative and morphometric approaches to fracture definition. In conclusion our data suggest that modification of other lifestyle risk factors is unlikely to have a major impact on the population occurrence of vertebral fractures. The important biological mechanisms underlying vertebral fracture risk need to be explored using new investigational strategies.

The aim of this population-based prospective study was to determine the incidence of limb fracture by site and gender in different regions of Europe. Men and women aged 50-79 years were recruited from population registers in 31 European centers. Subjects were invited to attend for an interviewer-administered questionnaire and lateral spinal radiographs. Subjects were subsequently followed up using an annual postal questionnaire which included questions concerning the occurrence of new fractures. Self-reported fractures were confirmed where possible by radiograph, attending physician or subject interview. There were 6451 men and 6936 women followed for a median of 3.0 years. During this time there were 140 incident limb fractures in men and 391 in women. The age-adjusted incidence of any limb fracture was 7.3/1000 person-years [pyrs] in men and 19 per 1000 pyrs in women, equivalent to a 2.5 times excess in women. Among women, the incidence of hip, humerus and distal forearm fracture, though not 'other' limb fracture, increased with age, while in men only the incidence of hip and humerus fracture increased with age. Among women, there was evidence of significant variation in the occurrence of hip, distal forearm and humerus fractures across Europe, with incidence rates higher in Scandinavia than in other European regions, though for distal forearm fracture the incidence in east Europe was similar to that observed in Scandinavia. Among men, there was no evidence of significant geographic variation in the occurrence of these fractures. This is the first large population-based study to characterize the incidence of limb fracture in men and women over 50 years of age across Europe. There are substantial differences in the descriptive epidemiology of limb fracture by region and gender.

The presence of a vertebral deformity increases the risk of subsequent spinal deformities. The aim of this analysis was to determine whether the presence of vertebral deformity predicts incident hip and other limb fractures. Six thousand three hundred and forty-four men and 6788 women aged 50 years and over were recruited from population registers in 31 European centers and followed prospectively for a median of 3 years. All subjects had radiographs performed at baseline and the presence of vertebral deformity was assessed using established morphometric methods. Incident limb fractures which occurred during the follow- up period were ascertained by annual postal questionnaire and confirmed by radiographs, review of medical records and personal interview. During a total of 40348 person-years of follow-up, 138 men and 391 women sustained a limb fracture. Amongst the women, after adjustment for age, prevalent vertebral deformity was a strong predictor of incident hip fracture, (rate ratio (RR) = 4.5; 95% CI 2.1-9.4) and a weak predictor of 'other' limb fractures (RR = 1.6; 95% CI 1.1-2.4), though not distal forearm fracture (RR = 1.0; 95% CI 0.6-1.6). The predictive risk increased with increasing number of prevalent deformities, particularly for subsequent hip fracture: for two or more deformities, RR = 7.2 (95% CI 3.0-17.3). Amongst men, vertebral deformity was not associated with an increased risk of incident limb fracture though there was a nonsignificant trend toward an increased risk of hip fracture with increasing number of deformities. In summary, prevalent radiographic vertebral deformities in women are a strong predictor of hip fracture, and to a lesser extent humerus and 'other' limb fractures; however, they do not predict distal forearm fractures.

An X-ray of the hand is an important method in forensic science for estimation of the age of juvenile suspects with uncertain date of birth. Relevant X-ray standards for evaluation of skeletal maturity are available for white US Americans as well as for North and Central Europeans. The applicability of these standards to members of ethnic groups different from the reference population has been the subject of controversial discussion. More than 80 publications were analysed with the view to finding out whether skeletal maturation is affected by ethnic identity. It was concluded that skeletal maturation takes place in phases which are identically defined for all ethnic groups. Time-related differences in passing those stages of skeletal maturation within the relevant age group appear to be unaffected by ethnic identity. It is the socioeconomic status of a given population which is of decisive importance to the rate of ossification. The application of X-ray standards to individuals of a socio-economic status lower than that of the reference population usually leads to underestimation of that person's age. In terms of criminal responsibility, this is of no adverse effect on the person concerned.