Forensic Age Estimation According to Fusion of Proximal Humeral Epiphysis in 1367 Living Turkish Subjects’ Radiographs; A Preliminary Study

Special Article - Forensic Case Studies

Austin J Forensic Sci Criminol. 2016; 3(2): 1050.

Forensic Age Estimation According to Fusion of Proximal Humeral Epiphysis in 1367 Living Turkish Subjects’ Radiographs; A Preliminary Study

Erol OB¹, Bayramoglu Z¹*, Ertem F², Sharifov R³, Yılmaz R¹ and Yekeler E¹

¹Department of Radiology, Istanbul University, Turkey

²Istanbul School of Medicine, Istanbul University, Turkey

³Department of Radiology, Bezmialem Vakif University School of Medicine, Turkey

*Corresponding author: Bayramoglu Z, Department of Radiology, Istanbul Medical Faculty, Fatih, 34093, Istanbul, Turkey

Received: May 21, 2016; Accepted: July 22, 2016; Published: July 25, 2016


Purpose: Precisely evaluation of bone age around and after 18years old has distinctive importance for legal issues in Turkey. Closure degree of proximal humeral epiphysis has significant value in this critical age group. We aimed to determine the age groups around this critical age among the male and females.

Methods: Shoulder radiographs of 1367 living Turkish individuals including 590 males and 777 females between 14-20 ages were evaluated according to closure degree of epiphysis divided into four stages; fusion less than one-third of the proximal humeral epiphysis (stage 1), fusion more than one-third to less two-third (stage 2), fusion more than two-third (stage 3), and recently closed (stage 4).

Results: Mean ages in females and males were 14.8 and 16.1 years for stage 1; 15.2 and 16.5 for stage 2; 16.2 and 17.5 for stage 3; 17.3 and 18.6 for stage 4, respectively. Minimum age for stage 4 was 15.6 in females and 17.0 in males. Maximum age for stage 4 was 18.5 in females and 19.6 in males. The mean ages between the age groups and gender were highly significant.

Conclusion: Evaluation of closure degree of proximal humeral epiphysis has a crucial role to differentiate the gender and radiological bone age around legal age of 18 years.

Keywords: Forensic age estimation; Proximal humeral epiphysis; Shoulder radiograph


Age estimation for criminal proceedings has a significant importance in forensic cases. Radiological bone age determination is commonly used in forensic medicine and various forensic cases regarding marriage, social rights and liberty, pediatric judgment, employment, legal age alteration and gender determination.

Age thresholds concerning criminal responsibility varies between countries from 13 to 18. Teenagers may be referred to the forensic medicine for age estimation. Hand and wrist radiographs are used up to 17 years old in girls and 18 years old in males for bone age estimation. Precise evaluation around and after 18 years old has distinctive importance for legal issues in Turkey. Therefore, the next step for bone age determination in this critical age period will be evaluation of proximal humeral epiphysis after closure of radius and ulna epiphyses.

The aim of the present study was to document the age groups according to the fusion degree of proximal humerus epiphysis.


Conventional shoulder radiographs of the living Turkish subjects aged between 14 and 20 which were selected from the PACS (Picture Archiving Communication Systems) between the years 2012 and 2015 were evaluated retrospectively. A total of 1367 left shoulder radiographs with anteroposterior projection were enrolled into this study. The patients had been referred to the Emergency Department and discharged without hospitalization. The age and gender of the patients were confirmed from the hospital registrations. Individuals with a previous disease affecting skeletal development and evolution of the epiphysis such as a chronic disease, long bone fracture, previous radiotherapy, and chronic steroid usage were excluded in addition to the individuals of other nations. We selected the radiographs obtained with anteroposterior projection of glenohumeral joint in addition to humeral external rotation and performed with approximately 60 mA and 15 kVp radiation exposure and optimal magnification demonstrating the proximal humeral epiphysis clearly. Retrospective evaluation of selected appropriate radiographs was performed after the approval of the ethics committee.

The left shoulder radiographs with DICOM (Digital Imaging and Communications in Medicine) format were evaluated on a workstation by consensus of two radiologists (E. OB., Y. E.) blinded to the subjects’ chronological age. A cartilage of proximal humeral epiphysis on radiographs is seen as a thin, radiolucent line between proximal humeral epiphysis and proximal humeral metaphysis. Closure degrees of proximal humeral epiphysis were divided into four groups from stage 1 to 4. Closure of proximal humeral epiphysis less than one-third is labeled as stage 1, more than one-third to less than two-third is labeled as stage 2, and more than two-third is labeled as stage 3. Recently closed proximal humeral epiphysis determined from a coarse indistinct radiopaque contour around the epiphysis and signed as stage 4. Examples for each stage on left shoulder radiographs as DICOM images and schematic drawings are shown in Figure 1. Stages of closure and chronological ages of individuals were recorded and adequate number of male and female subjects for each year from age 15 to 19 included in this study. The data of both males and females is compared among stage groups and gender. Cases causing disagreement between radiologists were excluded. Statistical analysis was performed using SPSS (Statistical Package for the Social Sciences) 21.1 statistical software. Based on the data, the age parameters between all stages and both genders were expressed as minimum, maximum, mean ± standard deviation, standard error, median values. Distribution of the data was evaluated with Kolmogorov-Smirnov test. Differences between the stages and gender were analyzed using Mann-Whitney U test for two independent groups in order to avoid skew distributions. Significance was assessed at p< 0.05. Differences of each stage in males and females were analyzed using one-way ANOVA.