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In forensic age estimation, CT imaging of the clavicles is used to determine an age over completed 21 years. If ossification of the medial clavicular epiphysis is complete, young men are assumed to be over 21 years of age. The aim of this study is to check the statistical parameters (specificity, predictive probability) for the characteristic "completed ossification of the medial clavicles". 285 male patients who, for various reasons, received a chest CT at the Medical Center of the University of Freiburg between 1st December 2019 and 6th December 2022 were screened for the study, of whom 203 patients were included in the study. The stage of clavicular ossification was classified as stage 1 - 5 according to Schmeling. While 70 out of 71 patients under 21 years of age were correctly estimated to be under 21 years of age, there was one patient whose ossification on one side was classified as stage 4 and who would therefore have been estimated to be over 21 years of age. If only subjects whose ossification stage was the same on both sides are included, the specificity of the test method is 100% and the positive predictive probability is 100%. If patients for whom only one side is stage 4 are also included, the specificity is 98.6%. Thus, only the complete and symmetrical ossification of both clavicles (stage 4 according to the Schmeling classification) in a standardised thin-layer CT can be classified as a reliable indicator of an age over 21 years in young men. In the case of asymmetric ossification of the medial clavicles (stage 4 is not reached on one side), false positive evaluations and the incorrect assumption of an age over 21 years can occur., (© 2024. The Author(s).)

The aim of this study was to investigate the potential of using multidetector computed tomography (MDCT) to measure the bone mineral density (BMD) in the medial meta-epiphyseal region of clavicle (MERC) for adult age estimation. A total of 1064 chest MDCT scans from individuals aged 21 to 102 years were utilized to determine the MERC BMD. The Mimics software was used for the BMD measurements, and the average BMD of both MERC was also calculated. Regression analysis was conducted with chronological age as a dependent variable and MERC BMD as an independent variable to establish a mathematical model for age estimation. The mean absolute error (MAE) was calculated to evaluate the accuracy of the regression model using an independent validation sample. Among all the models, the cubic regression model showed the highest correlation between MERC BMD and chronological age and also provided the most accurate age prediction for both males and females (MAE = 9.41 for males, MAE = 10.38 for females). Our study suggests that BMD measured by MERC can be utilized for age estimation in adults when more reliable indicators are not available., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Aim and Objectives: In forensic age estimation e.g. for judicial proceedings surpassed age thresholds can be legally relevant. To examine age related differences in skeletal development the recommendations by the Study Group on Forensic Age Diagnostics (AGFAD) are based on ionizing radiation (among others orthopantomograms, plain x-rays of the hand). Vieth et al. and Ottow et al. proposed MRI-classifications for the epiphyseal-diaphyseal fusion of the knee joint to define different age groups in healthy volunteers. The aim of the present study was to directly compare these two classifications in a large German patient population., Materials and Methods: MRI of the knee joint of 900 patients (405 female, 495 male) from 10 to 28 years of age were retrospectively analyzed. Acquired T1-weighted turbo spin-echo sequence (TSE) and T2-weighted sequence with fat suppression by turbo inversion recovery magnitude (TIRM) were analyzed for the two classifications. The different bony fusion stages of the two classifications were determined and the corresponding chronological ages assigned. Differences between the sexes were analyzed. Intra- and inter-observer agreements were determined using Cohen's kappa., Results: With the classification of Ottow et al. it was possible to determine completion of the 18th and 21st year of life in both sexes. With the classification of Vieth et al. completion of the 18th year of life for female patients and the 14th and 21st year of life in both sexes could be determined. The intra- and inter-observer agreement levels were very good (κ > 0.82)., Conclusion: In the large German patient cohort of this study it was possible to determine the 18th year of life with for both sexes with the classification of Ottow et al. and for female patients with the classification of Vieth et al. It was also possible to determine the 21st year of life for all bones with the classification of Ottow et al. and for the distal femur with the classification of Vieth et al., (© 2024. The Author(s).)

Bone age assessment (BAA) is crucial in various fields, including legal proceedings, athletic competitions, and clinical medicine. However, the use of X-ray methods for age estimation without medical indication is subject to ethical debate, especially in forensic and athletic fields. The application of magnetic resonance imaging (MRI) with non-ionizing radiation can overcome this limitation in BAA. This study aimed to compare the application value of several MRI modalities of proximal humeral in BAA. A total of 468 patients with shoulder MRIs were retrospectively collected from a Chinese Han population aged 12-30 years (259 males and 209 females) for training and testing, including T 1 weighted MRI (T 1 WI), T 2 weighted MRI (T 2 WI), and Proton density weighted MRI (PDWI). Optimal regression models were established for age estimation, yielding mean absolute error (MAE) values below 2.0 years. The MAE values of T 1 WI were the lowest, with 1.700 years in males and 1.798 years in females. The area under the curve (AUC) and accuracy values of different MRI modalities of 16-year and 18-year thresholds were all around 0.9. For the 18-year threshold, T 1 WI outperformed T 2 WI and PDWI. In conclusion, the three MRI modalities of the proximal humerus can serve as reliable indicators for age assessment, while the T 1 WI performed better in age assessment and classification., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

This paper presents a retrospective analysis of postmortem computed tomography (PMCT) scans of secondary ossification centers in the medial clavicular epiphysis, iliac crest apophysis, proximal humeral epiphysis, distal femoral epiphysis, proximal tibial epiphysis, and distal tibial epiphysis. At the same time, we analyzed PMCT scans of the maxillary and mandibular incisors, canines, premolars, and molars. We assessed 203 corpses, whose age ranged from 2 to 30 years, including 156 males and 47 females. The purpose of our study was to compare the processes of secondary ossification center fusion and permanent tooth maturation. Our research hypothesis was that certain stages of skeletal and dental maturation occur along consistent timelines that can be related to the chronological age. Secondary ossification center fusion was evaluated based on Kreitner and also McKern and Steward's classifications. The process of permanent tooth maturation was evaluated with Demirjian's method. Spearman's correlation coefficients (Rho) were positive in all analyses, which indicates that epiphyseal fusion progresses with age. The strongest relationship between the age and the stages of ossification was observed in the proximal tibial epiphysis (p < 0.001; Rho = 0.93) in females and in the medial clavicular epiphysis (p < 0.001; Rho = 0.77) in males. Studies show the importance of concomitant analysis of skeletal and dental maturation with a subsequent comparison of the results to achieve a greater precision in age estimation. A comparison of the results obtained in the study population of Polish children, adolescents, and young adults with the results of other studies in populations of similar ages showed a number of similarities in the time windows of dental and skeletal maturation. These similarities may help in age estimation., (© 2023. The Author(s).)

Purpose: To evaluate whether there is a mismatch between Risser staging and the proximal humerus ossification system (PHOS); and to analyze the correlation in the skeletal maturity stages between the two humeral epiphyses., Methods: Data from patients aged 10 to 18 years with adolescent idiopathic scoliosis (AIS) seen between 2018 to 2021 were analyzed. In an anteroposterior (AP) spine radiograph the ossification process was evaluated using the Risser classification method and bilateral PHOS (if both humeral epiphyses were visualized). A mismatch between methods was defined as a Risser 0-1 (relatively skeletally immature) with a PHOS 4-5 (skeletally mature), or a Risser 2-5 (relatively skeletally mature) with a PHOS 1-3 (skeletally immature). The McNemar test was used to calculate the significance of the mismatch., Results: A mismatch between Risser and PHOS stages was observed in 28.5% of 105 patients, which was statistically significant (p < 0.001). Of the 49 patients with a Risser 0-1, 55.1% (n = 27) had a PHOS 4-5. None of the patients with a Risser 2-5 had a PHOS 1-3. In the 47 patients in whom both humeri were visualized, the absolute correlation between the left and right PHOS values was 95.7%., Conclusion: Of AIS patients who are relatively skeletally immature according to Risser staging, more than half may be skeletally mature when measured with PHOS. In patients with a Risser 0-1, it is recommended to measure skeletal maturity in an AP spine radiograph using the PHOS method, which may more accurately guide treatment decision-making, without the need to visualize both humeral epiphyses in this radiographic projection., Level of Evidence: IV., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

The AGFAD (Arbeitsgemeinschaft für Forensische Alterdiagnostik, Study Group on Forensic Age Diagnostics) has published several recommendations regarding both technical aspects of computed tomography (CT) of the medial clavicular epiphysis (MCE) and the process of reading and interpreting the CT images for forensic age estimations (FAE). There are, however, no published recommendations regarding CT scan protocols and no dose reference values for CT of the MCE. The objective of this analysis was to assess adherence to AGFAD recommendations among practitioners of FAE and analyse reported dose-relevant CT scan parameters with the objective of helping to establish evidence-based dose reference values for FAE. A systematic literature search was conducted in PubMed and in Google Scholar with specific MeSH terms to identify original research articles on FAE with CT of the MCE from 1997 to 2022. A total of 48 studies were included. Adherence to AGFAD recommendations among practitioners of FAE is high regarding the use of Schmeling main stages (93%), bone window (79%), ≤ 1 mm CT slices (67%), axial/coronal CT images (65%), and Kellinghaus sub-stages (59%). The reporting of CT technique and CT dose-relevant scan parameters is heterogeneous and often incomplete in the current literature. Considering the success achieved by the AGFAD in creating standards of practice of FAE in living subjects, there is potential for the AGFAD to establish standards for radiation protection in FAE as well., (© 2023. The Author(s).)

Purpose: The aim of this study was to assess the impact of arm position in computed tomography (CT) of the clavicle performed for forensic age estimation on clavicular position, image noise, and radiation dose., Methods and Materials: Forty-seven CT scans of the medial clavicular epiphysis performed for forensic age estimation were conducted with either hands and arms held upwards (CT HU, 28 persons) or positioned at the body (CT HD , 19 persons). Presets were identical for both positions (70 mAs/140 kVp; Brilliance iCT, Philips). Each CT scan was reconstructed with an iterative algorithm (i-Dose 4) and evaluated at the middle of the sternoclavicular joint. Clavicular angle was measured on a.p. topograms in relation to a horizontal line. Quantitative image noise was measured in air at the level of medial clavicular epiphysis. Effective dose and scan length were recorded., Results: Hands-up position compared with hands-down position resulted in a lower lateral body diameter (CT HU 41.1 ± 3.6 cm vs. CT HD 44.6 ± 3.1 cm; P = 0.03), a reduced quantitative image noise (CT HU : 39.5 ± 9.2; CT HD : 46.2 ± 8.3; P = 0.02), and lower CTDI vol (5.1 ± 1.4 mGy vs. 6.7 ± 1.8 mGy; P = 0.001). Scan length was longer in patients examined with hands up (HU: 8.5 ± 3.4 cm; HD: 6.2 ± 2.1 cm; P = 0.006). Mean effective dose for CT HU was 0.79 ± 0.32 mSv compared with 0.95 ± 0.38 mSv in CT HD (P = 0.12). Clavicular angle was 17° ± 6° in patients with hands down and 32° ± 7° in patients with hands up (P < 0.001)., Conclusion: By elevated arm positioning, the image quality of clavicular CT scans can be improved while maintaining radiation dose compared with hands down. Clavicular position differs according to the hand position. Thus, positioning patients with elevated hands is advisable for forensic clavicular CT examinations, but multiplanar CT reconstructions should be adjusted to clavicular position and scan length should be reduced to a minimum.

Since forensic age estimation is not a valid medical indication, research on the use of nonionizing methods is increasing. Ultrasonography is a radiological approach that protects patients from radiation exposure and offers special convenience to them. In this study, ultrasonography was used for age estimation by investigating the degree of ossification of the distal radial epiphysis. Its applicability on the Turkish population was investigated. The left wrist of 688 (322 males, 366 females) patients between the ages of 9 and 25 years was prospectively evaluated by ultrasonography. The intra- and interobserver reliabilities in evaluating the distal radial epiphysis and Cohen's kappa statistics show that the interobserver error was very low, and the kappa value was found to be 0.919. Stage 3 and 4 ossification of the distal radial epiphysis was first detected at age 14.3 and 15.3 years in males and 12.7 and 14.8 years in females, respectively. The data obtained may help determine legally critical age limits of 14 and 15. Although it does not seem useful for the age of 18, ultrasonography may be recommended in selected cases as a fast, inexpensive, frequently reproducible radiological method without concern about radiation and without a predictable health risk.

Abstract: Age estimation in forensic medicine practice is of particular importance to the legal systems, and it is one of the current research topics in forensic medicine. Age determination is most frequently performed by radiological methods, but recently, nonionized methods are preferred for nonmedical indications. Therefore, we aimed to examine feasibility of MRI imaging, which provides nonionized, noninvasive, and detailed images, in forensic age estimation and to expand the database on this subject. The MRI images of the patients between the ages of 10 and 25 years, who visited Cukurova University Faculty of Medicine between January 2012 and April 2018 for any reason, were retrospectively analyzed according to the staging method described by Dedouit et al. The stage 5 ossification in distal femoral epiphysis indicated an age over 18 years in both sexes (except for 2 cases of 14 and 15 years). The stage 5 ossification in proximal tibial epiphysis indicated an age older than 18 years (except for 1 male case at the age of 15 years and 2 female cases at the age of 14 and 17 years, respectively). It was determined that stage 1 and stage 2 in both distal femur and proximal tibial epiphysis were last seen in younger than 18 years in both sexes. Our study data show that MRI imaging is a nonionized method that can be used in addition to other radiological methods in determining the age limit of 18 years., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

The evaluation of epiphyseal areas by magnetic resonance imaging (MRI) for forensic age estimation is an important supportive diagnostic method to prevent repeated radiation exposure without a valid medical reason. There are still not enough individuals being analyzed with MRI for age estimation. The aim of this study was to investigate the utility of T1-weighted turbo spin echo (T1-TSE) MRI sequences in determining the degree of ossification of the distal femoral and proximal tibial epiphyses in a Turkish population. In this study, images from 649 patients (335 males and 314 females) aged 10-30 years were retrospectively evaluated with sagittal T1-weighted turbo spin echo (T1-TSE) MRI sequences of the knee. Proximal tibial and distal femoral epiphysis were scored by two different observers twice using the combined staging system described by Schmeling and Kellinghaus. Spearman's rank correlation analysis indicated a significant positive relationship between age and ossification stages of the distal femoral and proximal tibial epiphyses (p < 0.001). The intra- and inter-observer reliabilities in evaluating the femur and tibia were separately determined and gave promising results and Cohen's kappa statistics ranged from κ = 0.886 and κ = 0.961. The minimal ages of patients with stage 4 ossification were 15.1 years for females and 15.8 years for males for the distal tibial epiphysis and 15.4 years for females and 17 years for males for the distal femoral epiphysis. This study show that (T1-TSE) MRI and the applicability and Schmeling and Kellinghaus staging method of the knee can be performed for living 14- to 17-year-old individuals in need of a supportive noninvasive method for estimating forensic age.

Skeletal and dental data for subadult analyses obtained from dry bones or various types of medical images, such as computed tomography (CT) scans or conventional radiographs/x-rays, should be consistent and repeatable to ensure method applicability across modalities and support combining study samples. The present study evaluates observer agreement of epiphyseal fusion and dental development stages obtained on CT scans of a U.S. sample and the consistency of epiphyseal fusion stages between CT scans and projected scan radiographs/scout images (U.S. CT sample), and between dry bones and conventional x-rays (Colombian osteological sample). Results show that both intra- and interobserver agreements of scores on CT scans were high (intra: mean Cohen's kappa=0.757-0.939, inter: mean Cohen's kappa=0.773-0.836). Agreements were lower for dental data (intra: mean Cohen's kappa=0.757, inter: mean Cohen's kappa=0.773-0.0.820) compared to epiphyseal fusion data (intra: mean Cohen's kappa=0.939, inter: mean Cohen's kappa=0.807-0.836). Consistency of epiphyseal fusion stages was higher between dry bones and conventional x-rays than between CT scans and scout images (mean Cohen's kappa=0.708-0.824 and 0.726-0.738, respectively). Differences rarely surpassed a one-stage value between observers or modalities. The complexity of some ossification patterns and superimposition had a greater negative impact on agreement and consistency rates than observer experience. Results suggest ordinal subadult skeletal data can be collected and combined across modalities., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest, (Copyright © 2021 Elsevier B.V. All rights reserved.)

Purpose: The aim of the study was to investigate whether the skeletal age can be evaluated assessed by means of analysis of ossification stage at proximal humeral epiphysis using magnetic resonance imaging (MRI)., Methods: This retrospective study was carried out in the radiology department of a tertiary healthcare center and 1.5-T MRI views of the shoulder obtained from 203 patients aged 8 to 29 years were evaluated. The ossification stage of proximal humeral epiphysis was evaluated on T1-weighted MRI sequences, and its correlation with age was sought., Results: Our series consisted of 77 women (37.9%) and 126 men (62.1%). One hundred forty-seven right humerus (72.4%) and 56 (27.6%) left humerus were examined. The mean age of the patients was 20.60 ± 4.41 years. The patients were in stages 4 (n = 148, 72.9%), 3c (n = 18, 8.9%), 3b (n = 14, 6.9%), 2c (n = 13, 6.4%), and 3a (n = 10, 4.9%). Analysis of the relationship between age and ossification stage of proximal humerus epiphysis indicated that stage increased with the advancement of age. There was a significant correlation between the stage and age variables at a rate of 77% in the positive direction (P < 0.001)., Conclusions: Our results demonstrated that MRI of proximal humeral epiphysis can have valuable implications for estimation of the skeletal age. Future prospective studies must be implemented with patients grouped according to socioeconomic status, nutritional habits, and physical activities to explore the actual investigative potential of MRI., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Magnetic resonance imaging (MRI) for forensic age estimation is among the research issues since it does not lead to radiation exposure. In this study, the ossification stage of the proximal humeral epiphysis was determined retrospectively in 178 male and 109 female individuals in the 12 to 30-year age group using 3.0 T MRI. All images were evaluated with the proton density fat saturated turbo spin echo (PD TSE FS) sequence and the T2 TSE FS sequence. A five-stage scoring system was used following the method of Dedouit et al. The relevant statistics were defined as minimum, maximum, mean ± standard deviation, 95% confidence interval of mean and median and the intra- and interobserver agreement levels were very good (κ > 0.80). There were no significant age differences between males and females in any of the stages (all p-values>0.05). According to the present study, stage 5 was initially observed at age 22 years for both genders. According to our results, it is possible to determine the completion of the 18th year of life in either gender on the shoulder joint. Proximal humeral epiphysis ossification may be used as an additional method for forensic age estimation through MRI., (Copyright © 2020 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Background: The creation of accurate markers for skeletal maturity has been of significant interest to orthopaedic surgeons. They guide the management of diverse disorders such as adolescent idiopathic scoliosis, leg length discrepancy, cruciate ligament injuries, and slipped capital femoral epiphysis. Multiple systems have been described to predict growth using radiographic skeletal markers; however, no such system has yet been developed for the proximal tibia. The purpose of this study was to establish quantitative radiographic parameters within the proximal tibia that can be used to assess degree of skeletal maturity., Methods: From the Bolton Brush collection, 94 children, consisting of 49 girls and 4 boys between the ages of 3 and 18 years old, were followed annually throughout growth with serial radiographs and physical examinations. Final height at maturity was used to calculate the growth remaining at each visit. Multiple measurements for each knee radiograph were performed and correlated with the percentage of growth remaining. Tibial epiphysis width, tibial metaphysis width, and height of the lateral tibial epiphysis were measured on each film and the composite ratios between each of these sets of variables along with their respective accuracy and reliability were calculated. Single and multiple linear regression models were constructed to determine accuracy of prediction. Interobserver and intraobserver studies were performed with 4 investigators ranging from medical student to senior attending and calculated using the intraclass correlation coefficient. All 4 examiners measured all of the subjects and the ratios created were averaged., Results: Tibial epiphysis width, tibial metaphysis width, and height of the lateral tibial epiphysis were all found to be strongly correlated with growth remaining with R values ranging from 0.57 to 0.84. In addition, all 3 ratios were found to be reliable with intraobserver and interobserver intraclass correlation coefficients ranging from 0.92 to 0.94 and 0.80 to 0.94, respectively. A multiple linear regression model demonstrated that combining these 3 ratios allows for a predictive R value of 0.917, showing that these ratios when combined were highly predictive of growth remaining. All findings were independent of sex (P=0.996)., Conclusions: We describe 3 measurements that can easily be obtained on an anteroposterior radiograph of the knee. We demonstrate that ratios of these variables can be measured reliably and correlate closely with remaining growth, independent of sex. Together, we believe that these factors will improve the accuracy of determining growth from lower extremity radiographs that include the proximal tibia., Clinical Relevance: This study provides a new quantitative technique to evaluate growth in the lower extremity, which can inform a range of conditions including adolescent idiopathic scoliosis, leg length discrepancy, cruciate ligament injury, and slipped capital femoral epiphyses.

Various parameters can be used for the estimation of gestational age and maturity with arising challenges in the assessment of decomposed bodies. In order to assess gestational age and thus maturity, the study measured the femoral length, the diameter of the distal femoral epiphysis and the presence of the proximal tibial epiphysis compared to a known clavicle length. The resulting gestational ages were compared and statistically evaluated. As a result, discrepancies between the estimated gestational ages became apparent in some cases when comparing the individual structures to be measured. However, there was a clear tendency towards a lower gestational age calculated based on clavicle length and a higher gestational age calculated based on femoral length and distal femoral epiphysis. With regard to the assessment of maturity, it has been concluded that, if the proximal tibial epiphysis is present, maturity can also be assumed based on the diameter of the distal femoral epiphysis and the length of the femur., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: To expand the database on magnetic resonance imaging (MRI) analysis of distal tibial and calcaneal epiphyses as proposed by Saint-Martin et al. and investigate a more elaborate staging technique to establish regression models for age estimation in a modern Chinese Han population., Materials and Methods: T1-weighted ankle MRIs were retrospectively collected from April 2008 to July 2019, and data from 590 individuals (372 males and 218 females; aged from 8 to 25 years old) were obtained. One-sided sagittal images were assessed because data from both sides were considered coincidental, as no significant differences were found (P > 0.05). Three-stage and six-stage staging techniques were applied separately and subsequently compared. A subset was re-assessed a second time and by a different observer. Regression models were established accordingly., Results: Our results showed very good repeatability and consistency of two staging techniques (all Cohen's kappa values were more than 0.8). By comparison, the values of the coefficient of determination (R 2 ) of the six-stage technique were generally higher than those of the three-stage technique. Compared with the distal tibia and two ankle bones combined, the calcaneus decreased the mean absolute deviation (MAD) with the six-stage technique. In males, incorporating only the calcaneus resulted in a MAD of 2.15 years, with correct classification rates of 87.5% adults and 50.0% among minors. In females, the corresponding results were 1.67 years, 100.0%, and 44.4%, respectively., Conclusions: The six-stage technique may outperform the three-stage technique in MRI analysis of ankle bones for age estimation, while age estimation based on the calcaneus may perform better than that based on the distal tibia or both ankle bones in a modern Chinese Han population.

Background: Despite the critical role the trochlea plays in patellofemoral (PF) pathology, the development of the trochlea is poorly understood. The purpose of this study was 2-fold: (1) Describe quantitative osseous and soft tissue anatomy of the patella and trochlea in skeletally immature cadaveric specimens utilizing known measurements used in PF instability, and (2) evaluate additional measurement techniques in the sagittal plane as they relate to PF morphologic development., Methods: Thirty-one skeletally immature fresh frozen cadaveric knees between the ages of 2 and 11 years old were evaluated using 0.625 mm computed tomography scans. In the axial plane, measurements included condylar height asymmetry, trochlear facet asymmetry, trochlear depth, osseous sulcus angle, cartilaginous sulcus angle, patella sulcus angle, and tibial tubercle-trochlear groove distance. In the sagittal plane, measurements included previously undescribed measurements of trochlear length and condylar height asymmetry which are based on the anterior femoral cortex., Results: Analysis of trochlear morphology using condylar height asymmetry (both axial and sagittal), trochlear facet asymmetry, and trochlear depth and length demonstrated an increase in the size of the medial and lateral trochlea as age increased. There was more variability in the change of size of the medial trochlea (height, length, and facet length) than the lateral trochlea. The osseous sulcus angle, cartilaginous sulcus angle, and patella sulcus angle decreased (became deeper) with age until after 8 years and then plateaued., Conclusions: This cadaveric analysis demonstrated that there is an increase in the medial and lateral trochlear height as age increased by all measurements analyzed. The findings also demonstrate that the shape of the patella and trochlea change concurrently, which suggests that there may be interplay between the 2 during development. These new sagittal measurement techniques evaluating the medial, central, and lateral trochlear height and length with respect to age may help guide clinicians when investigating patellar instability in skeletally immature patients., Levels of Evidence: Level IV.

Background: This study aimed to investigate the efficacy of percutaneous hemiepiphysiodesis for gradual correction of symptomatic juvenile hallux valgus (HV) deformity., Methods: Between 2012 to 2014, 24 patients with symptomatic juvenile HV were treated by combined percutaneous medial drilling hemiepiphysiodesis of the first proximal phalanx and lateral transphyseal screw hemiepiphysiodesis of the first metatarsal at our institution. Twenty-one of 24 patients fulfilled inclusion criteria had a complete radiological and clinical follow-up of at least 2 years. Preoperative and postoperative radiographs of the feet were reviewed for measurements of hallux valgus angle (HVA), intermetatarsal angle (IMA), proximal metatarsal articular angle (PMAA), proximal phalangeal articular angle (PPAA), and metatarsal length ratio (MTLR). Clinical outcomes were assessed using the AOFAS hallux metatarsophalangeal-interphalangeal score., Results: The study included 21 consecutive patients (37 ft) for analysis. The mean age at surgery was 12.0 years (SD = 1.3) and mean follow-up after surgery was 35.1 months (SD = 6.0). With the data available, the HV deformity improved in terms of the reduction of HVA by a mean of 4.7 degrees (P < .001) and the reduction of IMA by 2.2 degrees (P < .001). The PMAA and PPAA also improved significantly in the anteroposterior plane; however, the PMAA difference was insignificant in lateral plane as expected. The mean difference in the MTLR was 0.00 (P = .216) which was indicative of no length discrepancy between first and second metatarsals. The AOFAS score increased from 68.7 to 85.2 (P < .001). In correlation analysis, time to physeal closure was significantly correlated with the final HVA change (r = -.611, P = .003)., Conclusion: Although combined hemiepiphysiodesis does not create a large degree of correction as osteotomy, yet it did improve HV deformity with adequate growth remaining in our series. It is a procedure that can be of benefit to patients with symptomatic juvenile HV from this minimal operative approach before skeletal maturity., Level of Evidence: Level IV, retrospective case series.

The basic law of mechanobiology states that the external form and internal architecture of the skeleton and joints follow the functional stimuli that act upon them. Radiographs and magnetic resonance imaging reflect the loading history of the growing child, enabling an experienced radiologist to analyze the clinical functioning of patients by interpreting imaging studies. Concerning the hip joint, the physes of the coxal femoral end, the coxal femoral epiphysis with its epiphyseal growth plate, as well as the apophysis of the greater trochanter with its trochanteric growth plate, are the essential organ structures subject to internal forces. They determine the definitive geometric shape of the proximal femur. Indirectly they influence the appearance of the acetabulum and the centration of the hip joint., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Skeletal ossification occurs either directly within mesenchymal tissues or indirectly through a template of hyaline cartilage. Between the epiphyses and diaphyses of long bones, hyaline cartilaginous growth plates remain and constitute the progenitor cell reservoir from which the tissue develops toward the diaphysis and determines longitudinal bone size. Growth plates exhibit a characteristic architecture with columnar cell organization and different zonal morphology. The cells increase their volume toward the diaphysis, and eventually the longitudinally arranged septa of extracellular matrix mineralize. Finally, the mineralized cartilage matrix is replaced by lamellar bone. The extracellular matrix is rich in glycosaminoglycans, proteoglycans, and collagen II; at the edges of the growth plates, collagen I, III, and collagen X, especially at the mineralization front, are also present.The geometry of the growth plates is regulated by the local mechanical environment. In general, all plates orient themselves perpendicular to the resulting compressive force vector; grooves, ridges, and lateral angulations are adaptations to withstand shear forces acting on the growth plates. The final shape of the fully grown bone is determined not only by the epiphyseal growth plates but also by their apophyseal counterpart. Both structures respond in a comparable fashion to the local mechanical environment., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Within medical age assessment practice, the indicator "medial clavicular ossification" constitutes crucial evidence capable of excluding age minority "beyond reasonable doubt" concerning age-disputed individuals doubtfully claiming children's rights during legal procedures. Yet, one of its characteristics affects the morphological variability including a fair amount of downright peculiar appearances. As a result, inexperienced examiners are tempted to classify actually not-assessable formations according to the two established developmental typologies of Schmeling et al. and Kellinghaus et al. being at the same time the most frequent systemic error of age-related clavicular taxation. Since a respective overview appears missing, the study extracts not-assessable shape variants of the medial collar bone from a large sample of 2820 male borderline-adults as seen from thin-slice, sternoclavicular computed tomography. The two already highlighted configurations "more than one, medial, secondary ossification centres" and "medial metaphyseal concavity" are found as the most commonly encountered features impeding reliable delineation of staging criteria. In accordance with previous literature, it is emphasized that "qualified" rating of extremitas sternalis claviculae within age assessment practice presupposes "knowledge about the diversity of [its] anatomic shape variants."

There is an increasing demand for age estimations of living persons who are involved in civil and criminal procedures but lack a valid birth certificate indicating their date of birth. Several studies have recommended the application of magnetic resonance imaging (MRI) and assessment of the stage of epiphyseal fusion in age estimation. This study involved retrospective MRI analysis of 335 cases (217 males and 118 females) whose ages ranged from 8 to 28 years (yrs). We assessed the degree of ossification of the proximal tibial epiphysis depending on the classifications of Schmeling and Kellinghaus used for the main stages (I, II, III, IV & V) and substages (IIa, b, c & IIIa, b, c). Significant differences between males and females at stages IIIc, IV and V (p < 0.001) were observed. Additionally, the ossification of the proximal tibial epiphyses occurred earlier in females than in males (2-4 yrs). The mean of ages in stage IV was approximately 18.6 yrs. in females and 22.5 yrs. in males, meaning that stage IV can be used as a valuable forensic marker to determine whether the person in question has reached the age of 18 yrs. We concluded that the application of MRI in the assessment of the ossification status of the proximal tibial epiphysis could be helpful in age estimation for various forensic purposes.

Background: Young athletes with an anterior cruciate ligament (ACL) disruption and limb malalignment pose a treatment dilemma. Little has been published regarding limb malalignment in this population. Our aim is to review the results of combined treatment of an ACL deficient knee and genu valgum in skeletally immature patients., Methods: A retrospective review of skeletally immature patients who underwent transphyseal ACL reconstruction and concomitant hemiepiphysiodesis between 2004 and 2015 by 1 surgeon at a single institution was performed. Included patients had at least a year of growth remaining and were followed to skeletal maturity. Patients with a diagnosis of a connective tissue disorder were excluded. Knee stability, rate of retear, the rate of mechanical axis correction, and time to full correction were determined., Results: Ninety skeletally immature patients underwent transphyseal ACL reconstruction, 8 of which met inclusion criteria. Mean time to correction of the valgus deformity was 13 months (0.4 degree/mo). No patient required additional surgeries for malalignment. All patients had improvement in knee stability. One patient had a retear of their ACL reconstruction, for a failure rate of 13%. Preoperative mechanical lateral distal femoral angle and mechanical axis deviation corrected to near-neutral alignment for all treated limbs and were significantly different (P=0.001) than those measured preoperatively., Conclusions: Promising results were seen for simultaneous correction of genu valgum and transphyseal ACL reconstruction. Treatment of both pathologies in a concomitant surgery can be considered in the appropriate population, with expected results comparable to each procedure in isolation., Level of Evidence: Level IV-case series.

Objective: In the 50 years since a premature partial physeal arrest (a physeal bar) was first excised from an epiphysis there have been no large in-depth studies reporting the results in patients followed to skeletal maturity. This paper reports the results of physeal bar resection surgery in a group of patients followed to skeletal maturity, documenting the restored growth of the affected physis, the affected bone, and the final limb-length discrepancy., Methods: Forty-eight patients underwent physeal bar resection of the distal femur (21), proximal tibia (9), and distal tibia (18) by 1 surgeon (H.A.P.) from 1968 through 1996, and were followed prospectively to skeletal maturity with clinical and radiologic examinations. Factors such as sex, age at time of injury, etiology of the bar, physeal bar location and size, age at time of bar excision, interposition material, and additional surgical procedures were analyzed with respect to physis, bone, and limb growth following bar resection., Results: The mean growth for the entire bone following physeal bar excision was 7.6 cm for the distal femur, 4.7 cm for the proximal tibia, and 7.5 cm for the distal tibia, compared with growth in the contralateral control bone of 6.8 cm in the femur, 5.0 cm in the proximal tibia, and 7.8 cm in the distal tibia. The maximum bone growth following bar excision in a single patient was 21.3 cm for the distal femur, 10.3 cm for the proximal tibia, and 18.6 cm for the distal tibia. The mean limb-length discrepancy at maturity was -1.7 cm for the distal femur, -1.3 cm for the proximal tibia, and -1.1 cm for the distal tibia (all sites combined -1.4 cm). Fourteen patients (29%) had only the 1 bar excision with no other accompanying or subsequent surgery. Thirty-four patients (71%) had 1 to 4 accompanying or subsequent leg length or angular correcting procedures., Conclusions: Physeal bar excision to restore growth when applied to the appropriate patient is a useful, rewarding procedure, reducing the number of surgical limb length equalizing procedures. It is a demanding surgical procedure and requires diligent and careful follow-up until maturity. Additional limb length equalizing surgery is frequently needed., Level of Evidence: Case series, level IV.

Objective: To investigate the effects of long-term diving on the morphology and growth of the distal radial epiphyseal plate in young divers., Study Design: Cohort study., Setting: Guangzhou Sport University., Participants: Thirty-eight professional divers, aged 10 to 17 years, and 25 age-matched volunteers., Interventions: Each subject received a physical examination at the beginning of the study and underwent bilateral magnetic resonance imaging of the wrist. The divers were divided into 2 groups depending on the status of the epiphyseal plate: group A (positive distal radial epiphyseal plate injury) and group B (no positive distal radial epiphyseal plate injury). A third group, group C, consisted of the 25 volunteers., Main Outcome Measures: The frequency of distal radial epiphyseal plate injury and the thickness of the distal radial epiphyseal plate were analyzed across the 3 groups., Results: Twenty-nine cases (29/76, 38.15%) of distal radial epiphyseal plate injury were observed in 20 divers (20/38, 52.63%). The incidence of injury to the right hand was higher than that for the left (P = 0.009). There were statistically significant differences (P = 0.000) among the 3 groups in terms of epiphyseal plate thickness; group A > group B > group C., Conclusions: Distal radial epiphyseal plate injury is common in divers, and more injuries are seen in the right hand. Moreover, growth of the radius was impaired in divers relative to controls. We consider that loading during diving may influence growth of the epiphyseal plate in either a transient or permanent manner.

Bone finite element (FE) studies based on infant post-mortem computed tomography (CT) examinations are being developed to provide quantitative information to assist the differentiation between accidental and inflicted injury, and unsuspected underlying disease. As the growing skeleton contains non-ossified cartilaginous regions at the epiphyses, which are not well characterised on CT examinations, it is difficult to evaluate the mechanical behaviour of the developing whole bone. This study made use of paired paediatric post mortem femoral CT and magnetic resonance imaging (MRI) examinations at two different stages of development (4 and 7 months) to provide anatomical and constitutive information for both hard and soft tissues. The work aimed to evaluate the effect of epiphyseal ossification on the propensity to shaft fractures in infants. The outcomes suggest that the failure load of the femoral diaphysis in the models incorporating the non-ossified epiphysis is within the range of bone-only FE models. There may however be an effect on the metaphysis. Confirmation of these findings is required in a larger cohort of children., Competing Interests: The authors have declared that no competing interests exist.

According to the acknowledged recommendations of the multidisciplinary "Study Group on Forensic Age Diagnostics," the indicator "medial clavicular ossification" carries the potential of delivering decisive evidence to proof age majority "beyond reasonable doubt" regarding age-disputed individuals within legal procedures. Yet, sternoclavicular thin-slice computed tomography, representing its preferred imaging modality, not rarely exhibits peculiar morphologies of the site, sometimes difficult to understand from the usually obtained, axial sections together with coronal reformations. Because of that, we utilized 3D-rendering of acquired CT data in 224 cases with the purpose to gain additional visualization of certain questionable appearances. Concerning reliable classification of medial clavicular ossification in line with the typologies of Schmeling et al. and Kellinghaus et al., it is concluded that such means of illustration contribute to recognition of polygonal or irregular, epiphyseal formations including the not-assessable shape variant "multiple, medial, secondary ossification centres" and of calcification of the articular capsule.

During 2014-2015, Sweden received asylum applications from more than 240,000 people, of which more than 40,000 were termed unaccompanied minors. In a large number of cases, claims by asylum seekers of being below 18 years were not trusted by Swedish authorities. To handle the situation, the Swedish national board of forensic medicine (Rättsmedicinalverket, RMV) was assigned by the government to create a centralized system for medical age assessments. RMV introduced a procedure including two biological age indicators; x-ray of the third molars and magnetic resonance imaging of the distal femoral epiphysis. In 2017, a total of 9617 males and 337 females were subjected to this procedure. No validation study for the procedure was however published, and the observed number of cases with different maturity combinations in teeth and femur were unexpected given the claims originally made by RMV. We present a general stochastic model enabling us to study which combinations of age indicator model parameters and age population profiles are consistent with the observed 2017 data for males. We find that, contrary to some RMV claims, maturity of the femur, as observed by RMV, appears on average well before maturity of teeth. According to our estimates, approximately 15% of the tested males were children. These children had an approximate 33% risk of being classified as adults. The corresponding risk for an adult to be misclassified as a child was approximately 7%. We determine uncertainties and ranges of estimates under reasonable perturbations of the prior.

To estimate forensic age, the Study Group of Forensic Age Diagnostics of the German Association of Forensic Medicine (AGFAD) has recommended the radiological investigation of the medial clavicular epiphysis (MCE). This study aimed to investigate the relation between the maturation of the MCE and age in a contemporary Japanese population using a standard five-stage system by Schmeling et al. and Kellinghaus substage system. A total of 207 cadavers (128 males, 79 females) of known age and sex that underwent postmortem computed tomography (CT) and subsequent forensic autopsy were obtained. The earliest appearance for stage 3c was 18.1 years in the male subjects and 18.4 years in the female subjects. Our results were consistent with those in previous studies and indicate that stage 3c is crucial for medico-legal processes in evaluating age in various countries. Similar studies on the staging of the MCE using CT images in other populations, particularly in Asians, are required., (Copyright © 2018 Elsevier B.V. All rights reserved.)

This work investigates the value of magnetic resonance imaging analysis of proximal epiphyseal fusion in research examining the growth and development of the humerus and its potential utility in establishing forensic age estimation. In this study, 428 proximal humeral epiphyses (patient age, 12-30 years) were evaluated with T1-weighted turbo spin echo (T1 TSE) sequences in coronal oblique orientation on shoulder MRI images. A scoring system was created following a combination of the Schmeling and Kellinghaus methods. Spearman's rank correlation analysis revealed a significant positive relationship between age and ossification stage of the proximal humeral epiphysis (all subjects: rho = 0.664, p < 0.001; males: 0.631, p < 0.001; females: rho = 0.651, p < 0.001). The intra- and inter-observer reliability assessed using Cohen's kappa statistic was κ = 0.898 and κ = 0.828, respectively. The earliest age of epiphysis closure was 17 years for females and 18 years for males. MRI of the proximal humeral epiphysis can be considered advantageous for forensic age estimation of living individuals in a variety of situations, ranging from monitoring public health to estimating the age of illegal immigrants/asylum seekers, minors engaged in criminal activities, and illegal participants in competitive sports, without the danger of radiation exposure.

Age estimation is an actual topic in the area of forensic medicine with a special focus on the age limits of 16 and 18 years. Current research on this topic relies on retrospective data of inhomogeneous populations relating to sex, age range, and socioeconomic status. In this work, we present a 2-year follow-up study for the evaluation of an age estimation method on a prospective magnetic resonance imaging (MRI) knee data collective of a homogeneous population. The study includes 40 male subjects from northern Germany aged 14 to 21 years. Three MRI examinations were evenly acquired within 2 years for each subject. As a first evaluation, a three-stage system was used to assess the ossification status of the knee (I:"open", II:"partially ossified", III:"fully ossified"). Three raters assessed the growth plate of the distal femur, proximal tibia, and proximal fibula based on central 2D slices. A good inter-rater agreement was attained (κ = 0.84). All subjects younger than 18 years were rated as stage I and had a cumulative knee score (SKJ) ≤ 5. Based on the follow-up datasets, new parameters quantifying the intra-individual ossification process were calculated. The results of this follow-up analysis show a different start, end, and speed of each growth plate's maturation as well as an ossification peak for individuals at the age of 16. The generated MRI database provides new insights into the ossification process over time and serves as a basis for further evaluations of age estimation methods.

The most commonly used radiological method for age estimation of living individuals is X-ray. Computed tomography is not commonly used due to high radiation exposure, which raises ethical concerns. This problem can be solved with the use of magnetic resonance imaging (MRI), which avoids the use of ionizing radiation. The purpose of the present study was to evaluate the utility of MRI analysis of the proximal humeral epiphyses for forensic age estimations of living individuals. In this study, 395 left proximal humeral epiphyses (patient age 12-30 years) were evaluated with fast-spin-echo proton density-weighted image (FSE PD) sequences in a coronal oblique orientation on shoulder MRI images. A five-stage scoring system was used following the method of Dedouit et al. The intra- and interobserver reliabilities assessed using Cohen's kappa statistic were κ = 0.818 and κ = 0.798, respectively. According to this study, stage five first appeared at 20 and 21 years of age in males and females, respectively. These results are not directly comparable to any other published study due to the lack of MRI data on proximal humeral head development. These findings may provide valuable information for legally important age thresholds using shoulder MRI. The current study demonstrates that MRI of the proximal humerus can support forensic age estimation. Further research is needed to establish a standardized protocol that can be applied worldwide.

The aim of this study is to develop a new formula for age estimation in a longitudinal study of a sample from the radiological collection of wrist bones of growing infants, children, and adolescents recorded at the Burlington Growth Centre. A sample of 82 individuals (43 boys and 39 girls), aged between 3 and 16 years, were analyzed with a total of 623 X-rays of left hand-wrist bones by measuring the area of carpal bones and epiphyses of the ulna and radius (Bo) and carpal area (Ca). The intra-class correlation coefficient (ICC) and its 95% confidence interval were used to evaluate intra-observer agreement. Hierarchical Bayesian calibration has been adopted to exceed the bias deriving from the classical regression approach used for age estimation in forensic disciplines, since it tends to overestimate or underestimate the age of the individuals. Calibration distributions of the dataset obtained by the evaluation of BoCa (the ratio of Bo and Ca) suggested mean absolute errors (MAE) of 1.07 and 1.34 years in boys and girls, respectively. The mean interquartile range (MIQR) was 1.7 and 2.42 years in boys and girls, respectively. The respective bias of the estimates was β ERR  = - 0.025 and - 0.074. Furthermore, a correspondence between different BoCa values and estimated age with its standard deviation (SD) was calculated for boys and girls, respectively. In conclusion, the Bayesian calibration method appears to be suitable for assessing both age and its distribution in subadults, according to hand-wrist maturity. Furthermore, it can easily incorporate other age predictors, obtaining a distribution of the subjects with multivariate predictors.

Objectives: Compared with frequent studies of skeletal development in chimpanzees, relatively little is known about bonobo skeletal development. This study seeks to explore the relationship between skeletal and dental development in both species of Pan. New data are presented for fusion sites not previously observed in bonobos., Materials and Methods: In a sample of 34 Pan paniscus and 168 Pan troglodytes subadults, state of fusion was recorded for 30 epiphyseal fusion sites using a three-stage system of unfused, midfusion, and complete fusion based on Wintheiser, Clauser, and Tappen. Stage of dental development for permanent mandibular dentition was assessed using the Demrijian, Goldstein, and Tanner method. These data allowed for comparisons of both species of Pan and the two subspecies of P. troglodytes., Results: The sequence of fusion events was generally consistent between the two species, but some exceptions may exist for the knee and ankle. The number of fusion events that occurred after complete dental mineralization was similar in both species. No statistically significant differences were found in the fusion timing for the subspecies of P. troglodytes., Discussion: Bolter and Zihlman suggested that fusion at the acetabulum occurs earlier in Pan paniscus, while fusion of epiphyses at the knee are delayed, compared with P. troglodytes. Our data do not indicate earlier fusion of the acetabulum, but fusion events at the knee may complete later relative to dental mineralization in Pan pansicus. Compared with Homo sapiens, both P. troglodytes and Pan paniscus demonstrate later completion of epiphyseal fusion relative to dental mineralization., (© 2018 Wiley Periodicals, Inc.)

Background: The standard evaluation of epiphyseal involvement in Perthes disease is lateral pillar classification. However, it needs to be compared with contralateral normal hip leading to limited use in bilateral disease. We, therefore, develop a ratio between epiphyseal height and metaphyseal width of affected hips to estimate lateral pillar involvement. This study aimed to assess the height-width ratio of the proximal femoral epiphysis in non-Perthes children, and to find the relationship between the height-width ratio and lateral pillar classification in Perthes disease., Methods: A cross-sectional study was conducted between 2009 and 2015. Phase I included children aged 2 to 15 years who did not have Perthes disease. Phase II included children aged 2 to 15 years who had Perthes disease. Other abnormal proximal femoral epiphysis was excluded. Lateral pillar height and metaphyseal width were independently measured twice by 2 assessors in each phase. Intraobserver and interobserver levels of agreement, height-width ratio and cut-off points to differentiate lateral pillar types were determined., Results: There were 69 children (87 hip radiographs) who had non-Perthes hips, and 18 boys with Perthes disease (20 hip radiographs). Height-width ratio in the non-Perthes group increased from 0.38 to 0.48 at 2 to 10 years of age and remained constant until maturity. Average height-width ratio in lateral pillar A/non-Perthes hip was 0.47±0.05, lateral pillar B or B/C 0.32±0.05, and lateral pillar C 0.18±0.05. Intraobserver and interobserver level of agreements of height-width ratio in Perthes disease were 0.007 (95% confidence interval, -0.030 to 0.043) and 0.006 (95% confidence interval, -0.119 to 0.107), respectively. Cut-off values to differentiate lateral pillar A and B or B/C was 0.40, and to differentiate lateral pillar B or B/C, and C was 0.25 with 90% accuracy and area under receiver operating characteristic curve of 0.9., Conclusions: Height-width ratio is useful for grading severity in unilateral and bilateral Perthes disease. It has excellent reliability and validity with exact cutoff values to estimate lateral pillar classification., Level of Evidence: Level II-diagnostic study.

Background: Understanding skeletal maturity is important in the management of idiopathic scoliosis. Iliac apophysis, triradiate cartilage, hand, and calcaneal ossification patterns have previously been described to assess both peak height velocity (PHV) and percent growth remaining; however, these markers may not be present on standard spine radiographs. The purpose of this study was to describe a novel maturity assessment method based on proximal humeral epiphyseal ossification patterns., Methods: Ninety-four children were followed at least annually throughout growth with serial radiographs and physical examinations. The PHV of each child was determined by measuring the change in height observed at each visit and adjusting for the interval between visits. Percent growth remaining was determined by comparing current to final standing height. The humeral head periphyseal ossification was grouped into stages by 8 investigators ranging from medical student to attending surgeon., Results: The morphologic changes involving the proximal humeral physis were categorized into 5 stages based on development of the humeral head epiphysis and fusion of the lateral margin of the physis. Our novel classification scheme was well distributed around the PHV and reliably correlated with age of peak growth and percent growth remaining with >70% nonoverlapping interquartile ranges. Furthermore, the scheme was extremely reliable with intraclass correlation coefficients of 0.96 and 0.95 for intraobserver and interobserver comparisons, respectively., Conclusions: The humeral head classification system described here was strongly correlated with age of PHV as well as percentage growth remaining. Furthermore, the staging system was extremely reliable in both interobserver and intraobserver correlations suggesting that it can be easily generalized., Clinical Relevance: As a view of the humeral head is almost always present on standard scoliosis spine x-ray at our institution, our classification can be easily adapted by surgeons to gain additional insight into skeletal maturity of patients with scoliosis. We believe that our method will significantly improve the evaluation of the child with scoliosis without increasing radiation exposure, time, or cost.

Hand and wrist radiographs are the most common means for estimating skeletal bone age. There is no widely used scale for estimating skeletal bone age using knee radiographs. Do skeletal bone age estimates from knee-maturity scales correlate sufficiently with both chronologic age and estimates from a hand-wrist scale to potentially substitute for estimates from the latter? The authors reviewed the records of 503 patients 6 to 19 years old who had hand and knee radiographs obtained within 30 days of each other. They analyzed radiographs using the O'Connor knee scale (based on 10 maturation markers) and a new, abbreviated version of the O'Connor scale (based on 7 markers). The authors also analyzed radiographs of the hands of boys 12.5 to 16 years old and girls 10 to 16 years old using the shorthand method. Multivariate linear regression was used for analysis. Inter- and intrarater reliabilities were assessed. Skeletal bone age derived from the O'Connor and abbreviated knee scales correlated with chronologic age (adjusted R 2 =0.88 and 0.90, respectively). Compared with estimates from the hand-wrist scale, estimates were lower by a mean of 0.91 years for boys and 0.38 years for girls when using the O'Connor scale and 0.96 years for boys and 0.52 years for girls when using the abbreviated scale. Inter- and intrarater reliabilities were very good (κ=0.82 and 0.90, respectively) and were substantial at each bony landmark measured. Knee radiographs can be used to estimate skeletal bone age using an abbreviated knee scale. [Orthopedics. 2018; 41(5):e676-e680.]., (Copyright 2018, SLACK Incorporated.)

Medicolegal physicians are increasingly called upon to aid in determining the administrative age group affiliation of refugees with questionable unaccompanied minor claims. According to guidelines for forensic age assessment, age differentiation along the 18-year-old cut-off relies on clavicular ossification. The thin-slice computed tomography scan (TSCTs) of the medial clavicular epiphysis (MCE) is one of the methods contributing to this assessment, though it is not yet universally accepted. The aim of this systematic review was to identify scientific papers where age was assessed using TSCTs of the MCE and to observe whether this examination was reproducible and reliable in estimating a person's age relative to the 18-year-old threshold. A search algorithm was applied to several databases to identify articles in accordance with the PRISMA (Preferred Reporting Items for Systematic-Reviews and Meta-Analyses) statement. One boxplot per article was constructed, separating by stage of maturation and sex. The 13 articles selected represented a sample of 5605 individuals (3396 males, 2209 females) aged 10 to 35 years. All individuals classified as stages 4 and 5 were aged 18 years or older. The same result was obtained concerning stage 3c, except in one article. The results thus appear reliable and reproducible, in particular, with respect to the 18-year-old threshold; medicolegal physicians should be able to estimate that all individuals in stages 4 and 5 are at least 18 years old. Additional studies applied to several other populations in the world should complement the selected studies.

Estimating the forensic age of living individuals is ever more important in forensic practice, due to the ongoing increase of migratory flows, amongst other causes. Using the Greulich and Pyle method on a sample of 1150 individuals of the Spanish population (n = 560, 0-18 years for girls, and n = 590, 0-19 years for boys), the mean difference between the bone and chronological ages was obtained: 0.01 years (- 0.81, + 0.92) for girls and 0.33 years (- 1.15, + 0.34) for boys. For a same class of age and sex, the inherent variability was also evaluated: [Formula: see text] (0.41-1.25) for girls and [Formula: see text]years (0.36-1.76) for boys. To minimise systematic errors with regard to the reference population, adjustment factors are proposed for each age and sex. A sequential classification criterion based on decision trees is postulated to improve reliability in the prediction of maturity. Implementation of the decision criterion in three categories enables the doubtful individuals to be separated into the category of "undetermined" and to satisfactorily classify in the categories of "mature" and "under age": 0.96 (0.86-0.99) specificity; 1.00 (0.92-1.00) specificity; and 1.00 (0.92-1.00) predictive value.

Spondyloepiphyseal dysplasia (SED) exemplifies a group of heritable diseases caused by mutations in collagenous proteins of the skeletal system. Its main feature is altered skeletal growth. Pathomechanisms of SED include: changes in the stability of collagen II molecules, inability to form proper collagen fibrils, excessive intracellular retention of mutant molecules, and endoplasmic reticulum stress. The complexity of this pathomechanism presents a challenge for designing therapies for SED. Our earlier research tested whether such therapies only succeed when applied during a limited window of development. Here, employing an inducible mouse model of SED caused by the R992C mutation in collagen II, we corroborate our earlier observations that a therapy must be applied at the prenatal or early postnatal stages of skeletal growth in order to be successful. Moreover, we demonstrate that blocking the expression of the R992C collagen II mutant at the early prenatal stages leads to long-term positive effects. Although, we could not precisely mark the start of the expression of the mutant, these effects are not significantly changed by switching on the mutant production at the early postnatal stages. By demonstrating the need for early therapeutic interventions, our study provides, for the first time, empirically-based directions for designing effective therapies for SED and, quite likely, for other skeletal dysplasias caused by mutations in key macromolecules of the skeletal system., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Epiphyseal-preservation surgery for osteosarcoma is an alternative method which has been indicated carefully to selected patients. The tumor-devitalised autograft treated with liquid nitrogen procedure is one of the biological reconstruction method to reconstruct the defect after tumor excision. The limb length discrepancy is usually appeared in children with their growth after limb-sparing surgery. This study was aimed to investigated the growth of residual epiphysis following epiphyseal-preservation surgery for childhood osteosarcoma around the knee joint., Methods: We retrospectively reviewed 12 patients with osteosarcoma who underwent epiphysis preserving tumor excision (8 in distal femur and 4 in proximal tibia) and reconstructed by using tumor-devitalized autograft treated with liquid nitrogen. The mean patient age was 11 (range, 6 to 14) years. The mean follow-up period were 63 (range, 41 to 90) months. Epiphysis transverse growth rate, epiphysis-width discrepancy (EWD) and collapse of epiphysis were evaluated by using pre- and post-operative whole standing leg radiographs. A retrospective chart review was performed to investigate functional outcome, complications and oncological status., Results: The mean growth of epiphysis rate was 12.6% (range, 3.3 to 28.0%) of affected side and 12.7% (range, 3.8 to 28.9%) of contralateral side, mean EWD was 0.1 mm (range, - 1.0 to 1.7 mm), mean LLD was + 26.1 mm (range, + 1 to + 48 mm) and two patients with distal femoral reconstruction underwent limb lengthening of tibia. There was no collapse of the residual epiphysis. The mean MSTS score was 27.7 (range, 18 to 30)., Conclusions: Epiphysis transverse growth was not diminished, and there was absence of epiphyseal collapse even after epiphyseal-preservation surgery in this small series of childhood osteosarcoma around the knee. With careful assessment for epiphyseal tumor involvement, epiphyseal-preservation surgery shall be possible, and could be an alternative method worth considering.

Background: To date, reference values for 25-OH-vitamin D, parathyroid hormone (PTH), and calcium in serum of common marmosets (Callithrix jacchus) based on a large sample size are not available., Methods: Serum reference values for these parameters were determined and correlated with sex, age, season of sampling, and time of long bone epiphyseal closure in captive-housed marmosets., Results and Conclusions: The 90% reference range for serum 25-OH-vitamin D is 47.40-370.4 nmol/L, for PTH 2.10-30.51 pmol/L, and for calcium 2.08-2.63 mmol/L. Lower levels of vitamin D were measured in fall compared with the other seasons. Levels of PTH were higher in males than in females, and calcium levels were lower in younger animals compared with older marmosets. No other effects of age, sex, season, or timing of growth plate closure were found., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

In October 2017, the International Olympic Committee hosted an international expert group of physiotherapists and orthopaedic surgeons who specialise in treating and researching paediatric anterior cruciate ligament (ACL) injuries. Representatives from the American Orthopaedic Society for Sports Medicine, European Paediatric Orthopaedic Society, European Society for Sports Traumatology, Knee Surgery and Arthroscopy, International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, Pediatric Orthopaedic Society of North America, and Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte attended. Physiotherapists and orthopaedic surgeons with clinical and research experience in the field, and an ethics expert with substantial experience in the area of sports injuries also participated. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision-making with children and the potential long-term ramifications of the injury. This consensus statement addresses six fundamental clinical questions regarding the prevention, diagnosis, and management of paediatric ACL injuries. The aim of this consensus statement is to provide a comprehensive, evidence-informed summary to support the clinician, and help children with ACL injury and their parents/guardians make the best possible decisions.

Context: Percutaneous epiphysiodesis (PE) around the knee to reduce predicted excessive final height. Studies until now included small numbers of patients and short follow-up periods., Objective and Design: This Dutch multicentre, long-term, retrospective, follow-up study aimed to assess adult height (AH), complications, knee function and patient satisfaction after PE. The primary hypothesis was that PE around the knee in constitutionally tall boys and girls is an effective treatment for reducing final height with low complication rates and a high level of patient satisfaction., Participants: 77 treated adolescents and 60 comparisons., Intervention: Percutaneous epiphysiodesis., Outcome: AH, complications, knee function, satisfaction., Results: In the PE-treated group, final height was 7.0 cm (±6.3 cm) lower than predicted in boys and 5.9 cm (±3.7 cm) lower than predicted in girls. Short-term complications in file search were seen in 5.1% (three infections, one temporary nerve injury), one requiring reoperation. Long-term complications in file search were seen in 2.6% (axis deformity 1.3%, prominent head of fibula 1.3%). No significant difference in knee function was found between treated cases and comparisons. Satisfaction was high in both the comparison and PE groups; most patients in the PE group recommended PE as the treatment for close relatives with tall stature., Conclusion: PE is safe and effective in children with predicted excessive AH. There was no difference in patient satisfaction between the PE and comparison group. Careful and detailed counselling is needed before embarking on treatment., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

It is a fact that in recent years requests have greatly increased to obtain estimates of the legal age of undocumented individuals alleged to be minors who have been forced to enter different European Community countries for socioeconomic reasons or due to war. Spain is one of the countries most affected by this illegal immigration because of its proximity to North Africa. Therefore, it has become necessary to develop new standards which help provide a response to the demands of the justice administration. In recent years, the Superior Justice Court has rejected several pieces of expert evidence on the grounds that the age intervals therein were not sufficiently reliable and that the radiographic techniques used to determine age were invasive, potentially causing harm to the alleged minor. These sentences have caused interest in this field of work to increase within the scientific community. As a result, in order to improve age predictions and, above all, reduce minors' exposure to radiation, this study was created for completion on the Spanish population, using the ultrasound scan as a diagnostic technique. Used as a study sample were the ultrasound images of the proximal sternal epiphysis of the clavicle among 221 individuals of both sexes, of ages ranging from 5 to 30 years. All of the images were classified into 4 stages of fusion, in accordance with the development of metaphyseal closure proposed by Schulz et al. in 2008. The results show differences among the 4 proposed groups for each of the stages of fusion, with the results found in Stage II being especially important because, for both sexes, they would imply that the patient studied has reached an age of over 18 years, which is the legal age of adulthood in Spain, as established by the Spanish Constitution of 1978. Though further research is still recommended, these results, coupled with the use of ultrasound as a non-invasive diagnostic technique, could help solve some of the problems currently arising in justice courts., (Copyright © 2018 Elsevier B.V. All rights reserved.)

In the past, numerous studies have documented the possibility of intraindividual differing appearances of the paired age-marker "medial clavicular ossification" in borderline adults. However, the extent of the divergences is rarely mentioned. Against that the article describes this phenomenon from a large sample of 2595 male persons by means of thin-slice CT imaging of the sternoclavicular regions. For determining the ossification stage of the medial clavicles, the two accepted classifications by Schmeling et al. (five main stages) and Kellinghaus et al. (six substages) were applied and buildings deviating from that labelled as atypical "norm variants". The longstanding observation could be confirmed that intraindividual stage discrepancies of this age indicator are generally moderate and do not exceed one main stage or two substages of the respective classifications. It is concluded that stage determination should be scrutinized, if a dissimilarity seems to show larger differences.

Introduction: Proteus syndrome (PS) is a rare mosaic disorder comprising asymmetric bony and soft tissue overgrowth leading to significant morbidity. Placement of growth inhibition hardware with subsequent epiphyseal arrest improves leg-length and angular deformities in pediatric patients without PS. The purpose of this study was to review the surgical approach and present outcomes, complications, and recommendations in 8 patients with PS and leg-length discrepancy (LLD)., Methods: We conducted a retrospective chart review of 8 patients with PS whose primary reason for surgery was LLD. Patients were eligible if they met clinical diagnostic criteria for PS and if the National Institutes of Health team performed at least 1 of their surgical interventions between 2005 and 2015. Surgical techniques included growth inhibition, with tension band plates, applied ≥1 times, and epiphyseal arrest., Results: Eight patients, followed for an average of 4.6 years (range, 1.0 to 7.1 y) after the index procedure, were included in this analysis. Average age at first LLD surgery was 9.4 years (range, 6.1 to 13.6 y); the average LLD was 3.4 cm (range, 0.4 to 7.0 cm) at presentation, and 5.0 cm (range, 1.8 to 10.0 cm) at the time of the first LLD surgery. Participants underwent 23 total surgeries (range, 1 to 5 per patient) and 7 patients have completed surgical intervention. For the 7 patients who did not require overcorrection the average LLD at the last clinical encounter was 2.6 cm (range, 0.6 to 7.2 cm). We encountered 2 complications: 2 patients developed mild knee valgus, which responded to standard guided growth techniques., Conclusions: This case series suggests that growth inhibition and epiphyseal arrest in children with PS can reduce LLD with few complications. Careful monitoring, rapid mobilization, deep venous thrombosis prophylaxis, and sequential compression devices were also integral elements of our surgical protocol., Level of Evidence: Level IV.

The accurate and precise estimation of skeletal age by a forensic anthropologist is both a professional and judicial requirement. When unknown skeletal remains are referred to the anthropologist, the estimation of the requisite biological attributes (e.g., age and sex) should accordingly be based on the application of population-specific standards (statistical data). Deviations from the latter practice may result in reduced accuracy and compromised identification. Towards informing appropriate forensic practice, the aim of the present study is to develop statistically quantified age estimation models for a contemporary sub-adult Western Australian population based on the timing of fusion in the os coxa and proximal femur. The study sample comprises 562 known age and sex MDCT scans (292 male, 270 female) representing contemporary Western Australian individuals birth through 30 years of age. Scans are viewed in multi-planar reconstructed (MPR) and/or three-dimensionally reconstructed images using OsiriX ® . Fusion status is scored according to a three-stage system across a total of nine sites in the proximal femur and os coxae. Observer accordance, bilateral asymmetry and sex-specific variation in fusion timing are statistically quantified. Polynomial regression is used to formulate age prediction models; transition analysis is used to calculate age ranges and determine the mean age for transition between an unfused, fusing and fused status. Observer accordance in stage assignation is acceptable (ϰ=0.79) and there is no significant bilateral variation in fusion timing. It was found that the mean age of commencement of fusion is significantly earlier (∼2 years) in females. The accuracy (SEE) of the polynomial models ranges from ±3.29 to ±3.80 years and the transition analysis shows that fusion of the iliac crest is delayed in comparison to other attributes of os coxa and proximal femur. Results of the present study confirm that the pelvic girdle and proximal femur can be used to accurately estimate chronological age in the study population., (Copyright © 2017 Elsevier B.V. All rights reserved.)