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.

Age estimation is an essential element in the field of forensics and is also of judicial interest in forensic medicine of the living. Despite all the methods, age estimation is often imprecise with many biases, especially in mature individuals. The main objective of our study is to assess the correlation between age and computed tomography bone mineral density of the medial end of the clavicle. A sample of 180 chest multi-slice computed tomography scans without contrast injection performed in living individuals, with suspected respiratory infection, aged 15 to 100 years was used. Bone density measurement was performed on the medial meta-epiphyseal region of the clavicles. A significant negative correlation was found between bone density and age of individuals (p-value < 0.05). The mean absolute error was calculated for men at 13.4 years and 13.1 years for women, which was associated with an absence of bias. Good precision of the estimate for both sexes was also calculated on a subgroup of individuals whose age was greater than 40 years, with average absolute errors of about 12 years, which was associated with an absence of relative error. In view of our preliminary results, the study of bone density of the medial end of the clavicle could be of interest in the estimation of age. Several studies will be necessary to evaluate the reproducibility of these results on independent bone samples and in the estimation of age in the living individual.

Evaluation of the ossification of the medial clavicular epiphysis plays a key role in forensic age estimation. The purpose of the present study was to assess a new numerical cut-off at the age of 18 years, taking into consideration Magnetic Resonance (MR) images of the medial clavicular epiphysis. We analyzed 163 MR scans of Italian subjects aged between 14 and 25 years. Using the data obtained we calculated two ratios: REM-1 (ratio between the length of the whole epiphysis and the length of the metaphysis) and REM-2 (ratio between the length of epiphyseal-metaphyseal fusion and the length of the metaphysis). In 68 out of 163 cases it was not possible to measure REM-2. The reproducibility was demonstrated using the Intraclass Correlation Coefficient (ICC) (Cronbach\'s alpha > 0.80). REM-1 and REM-2 were compared in each category of age (adult and minor) by the Wilcoxon signed-rank test. The cut-off points for measurements of REM-1 and REM-2 were determined by logistic regression. For REM-1, the cut-off scores were 0.83 for all individuals (accuracy = 94.77%) and males (accuracy = 96.05%), and 0.86 for females (accuracy = 92.30%). For REM-2, the cut-off values were 0.40 for all individuals and males (accuracy = 100.00%), and 0.41 for females (accuracy = 100.00%). Finally, receiver operating characteristic (ROC) curves for age classification based on REM-1 and REM-2 were constructed, showing that REM-2 had the highest discriminative power. Thus, a new cut-off model for predicting the age of majority has been introduced, conducting a quantitative analysis thanks to the use of a high-resolution imaging tool.

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.

Determining the ossification stage of the medial clavicular epiphysis by computed tomography represents the currently recommended methodology for the question of whether a living individual has completed the 18th or 21st year of life. In the present study, thin-slice CT scans of 1078 sternoclavicular joints were reconstructed in axial and coronal image series and evaluated according to the two classification systems established for age diagnostics using the clavicle. Both image series (axial and coronal) were analyzed separately. When comparing the results of axial and coronal view, a different ossification stage was found in 35.6% of the clavicles. The results suggest an influence of the imaging plane on the process of stage determination. In order to further approximate the three-dimensional and asymmetrical structure of the epiphyseal ossification center, the usage of at least two different reformation types may be recommended. In practice, only those reference studies should be applied which exactly employed the same number and orientations of the reformation types that are going to be used in the respective routine case.

OBJECTIVE: To discuss current literature evaluating the medial clavicular epiphysis to assess an individual\'s age using various imaging modalities.
METHODS: Four scholarly research databases were searched to find studies that examined living subjects. Several articles were included that used cadavers, and a textbook was used to detail the anatomy of the clavicle. Thirty-nine articles were analyzed.
RESULTS: The literature indicated that several imaging modalities, including conventional radiography, computed tomography, magnetic resonance, and sonography, are being used to evaluate the medial clavicular epiphysis to estimate an individual\'s age in the forensic context. In addition to multiple modalities, researchers are using various staging classification systems, ethnic groups, and interpreter criteria to establish reference data.
CONCLUSIONS: There is a need to determine the age of individuals involved in civil and criminal proceedings who do not have valid birth date documentation. The clavicle is the last bone in the human body to complete fusion. The clavicle begins to fuse in the early teens and completes medial epiphyseal fusion in the late 20s. Clavicle fusion spans the legally significant age range of 18 through 21. Multiple variables influence the final age estimation, including interpreters\' experience, the individual\'s socioeconomic class or area of origin, and limitations within the imaging modalities.
CONCLUSIONS: Computed tomography is the modality of choice for forensic age estimation using the medial clavicular epiphysis. Radiologic technologists should be cognizant of current forensic age estimation practices, and future research should continue to provide reference data to improve accuracy of age estimation in those individuals who lack documentation of their date of birth.

This study aims to describe the epidemiological characteristics and the different anatomo-clinical entities of the fracture-separation of the medial clavicular epiphysis but also to relate the morphological and functional results of bloody reduction followed by osteosuture using non absorbable thread. Five boys and one girl (mean age 14 years) showed a closed and isolated shoulder girdle trauma. Clinical examination and medical imaging, especially CT scan, allowed the diagnosis of epiphyseal separation and to classify the degree of medial clavicular epiphysiseal ossification indicating the direction of displacement as well as the nature of displacement according to the Salter-Harris classification. Bloody reduction followed by osteosuture using non absorbable thread (No. 1 decimal) was performed in 3 patients. One patient underwent cross-pinning the two younger patients were treated orthopedically. The displacement of the clavicle stump was anterior in 3 patients and retro-sternal in 3 patients. Posterior forms were complicated by odynophagia (n = 2) and asymptomatic compression of the subclavian vein (n = 1). One of the posterior forms was associated with an ipsilateral fracture of the medial one third of the clavicle. Consolidation was achieved in all patients with preservation of shoulder mobility. The fracture-separation of the medial end of the clavicle mimes clinically and radiologically the sternoclavicular dislocation. It can be serious because of the risk of visceral and vascular compression in its posterior form. Tomdensitometry is irreplaceable for an accurate diagnosis. Our preference is for bloody reduction followed by osteosuture using non metallic thread.

The evaluation of the ossification of the medial clavicular epiphysis being part of an assigned expert approach according to standard plays an important role within civil and criminal proceedings in assessing whether a person has reached her/his 19th or 22nd year of age. Evaluation of the medial clavicular epiphysis with thin-section CT is one of the methods recommended by the Study Group on Forensic Age Diagnostics of the German Association of Forensic Medicine. In this retrospective study, we evaluated the thin-section CT (section thickness of 0.6 and 1 mm) images of 254 patients (146 male, 108 female) with an age range of 13-28 years according to the Kellinghaus substage system. The mean values of female patients were observed to be about 10 months lower for stage 2a than the mean values of the male patients, about 13 months lower for stage 2b, and about 18 months lower for stage 2c. The earliest appearance for stage 3c was at 19 years in both sexes. Our data from this study were consistent with both our previous studies and the data of other studies. We think that stage 3c is important in determining whether a person has reached the age of 18 or not and, therefore, that the Kellinghaus substage system is a requirement in the assessment of forensic age.

In forensic age estimations of living individuals, computed tomography of the clavicle is widely used for determining the age of majority. To this end, the degree of ossification of the medial clavicular epiphysis can be determined by means of two classification systems complementing each other: a 5-stage system and an additional 6-stage system that further sub-classifies the stages 2 and 3. In recent years, practical experience and new data revealed that difficulties and even wrong stage determinations may occur especially when following the short descriptions of the fundamental 5-stage system only. Based on current literature, this article provides a systematic procedure for identifying the five main ossification stages by listing important preconditions and presenting an algorithm that is comprised of four specific questions. Each question is accompanied by comprehensive and detailed descriptions which specify the criteria used for differentiation. The information is subdivided into \"single-slice view\" and \"multi-slice view.\" In addition, illustrative case examples and schematic drawings facilitate application of the procedure in forensic practice. The pitfalls associated with the criteria of stage determination will be discussed in detail. Eventually, two general rules will be inferred to assign correct ossification stages of the medial clavicular epiphysis by means of computed tomography.