2
1
2021
1682060070609_2965
11-21
https://journal.smdc.edu.pk/index.php/journal/article/download/8/16
https://journal.smdc.edu.pk/index.php/journal/article/view/8
INTRODUCTION
Personal identity means 'establishment of the identity of a person'1. It is a very important task assigned to forensic experts particularly in legal matters where criminal responsibility has to be considered to impose punishment or to grant pr- ivileges of civil rights according to the age group
of the claimant2.To achieve the task of personal identification required in civil and criminal cases, during life and after death, many parameters or biometric identifiers are used. One of these parameters is the determination of age, a very important task and tool3.
In underdeveloped countries, age estimation becomes problematic due to the ignorance of the public towards the importance of registration of births mostly because of illiteracy3. Different m- ethods are in use for the determination of age. These include general appearance, dental and skeletal examination. General appearance inc- luding height, weight, and other body meas- urements are not very helpful in the estimation of age due to wide variations in body size. Dental data is very helpful but not after 16 years of age as most of the dentition has erupted by this time. The eruption of the third molar tooth shows a wide variation from person to person3. Assessment of age of a person based on app- earance and subsequent union of ossification centers of bones provides a reasonably met- hodical and logical technique which is well acknowledged by the medical and legal auth- orities4. Amongst all the determinants of age, radiological examination of bone from ends to completion of the process of ossification is a very accurate and reliable method by the medial experts hence comfortably acceptable to the legal authorities5.
Several studies conducted in various parts of the world on the estimation of age have revealed that there is a reasonable variation amongst the populations. Such variations also exist between the population of the subcontinent and the West6. Hepworth et al, observed that Indians precede English and American people in the union of bones because of hereditary, dietary and socioeconomic factors7.
The degree of maturation of the iliac crest helps estimate age after 18 years of age due to its relatively late completion of maturation8. Radio- logical examination of the iliac crest of a person can be helpful to assess the age in civil and criminal proceedings like identification of an individual, age of attainment of majority for boys and girls for marriage, capital punish-ments, participation in the election through vote casting, and consent for participation in risky sports9.
Due to the paucity of data about this age group from the local population, this study was designed to determine the Roentgen graphic appearance of epiphyseal centers and complete union of iliac crest on the right side of subjects between 17 to 25 years of age of both genders coming to Shalamar Hospital, Lahore. Hence, the main objective of this study was to provide a basic guideline for identification and assessment of the correct age of fusion of iliac crest in the local population. This may ultimately be useful in making criteria at the national level for assessing the age of fusion of iliac crest. This study will help to contribute to the better admin- istration of justice in many civil and criminal cases in Pakistan.
MATERIALS AND METHODS
In this cross-sectional study, radiological examinations (Digital X-Rays) were performed to evaluate the fusion of Iliac Crest in 200 subjects of both genders of 17 – 25 years. The study was conducted at Shalamar Hospital, Lahore.
Inclusion Criteria:
-
Individuals, both and female of all ethnicities and socio-economic groups, with age range of 17 to 25 years with any known documentary evi-dence of birth as CNIC, Form B, birth certificate of the municipal committee or hospital, school certificate, driving license.
-
Individuals with Normal Body Mass Index (BMI) (18.5 to 24).
Exclusion Criteria:
-
Subjects suffering from any chronic illness e.g. congenital heart disease, pulmonary disease, bone disease, or endocrinal disorders. This was excluded by taking history and clinical examination.
-
Chronic drug intake that may interfere with bone growth directly or indirectly e.g. steroids or anti- epileptic drugs.
-
Foreign nationals or children of foreign nationals excluded by history.
-
Subjects having congenital bony deformities.
-
Fractures of Pelvic bone, recent or old.
-
Pregnant women.
-
Individuals having severe malnutrition –weight age less than 60%.
Informed written consent was obtained from these selected subjects before X-ray exposure. Their height, weight, gender, age, and other features were recorded on predesigned Performa. X-rays of the pelvic bone showing an iliac crest in anteroposterior view were taken using a digital X- ray machine. Changes in the epiphysis and dia- physis and the extent of the union were visualized on the right side of the pelvic bone for the iliac crest on the X-ray film. The radiological findings were confirmed by a single consultant radiologist of the Radiology Department Shalamar Hospital Lahore. Skeletal maturity was assessed from stages of the epiphyseal union of the iliac crest and divided into three stages described by Singh and Stevenson as under9,10.
Non-Union: There is a clear gap between epiphyseal and diaphyseal ends which appear as translucent areas on X-rays (Image 1).
Partial union: There is a 'bridging over' or 'knitting together' of the two margins. On X-rays, intervening translucent areas between or on the sides of the bridged areas are distinguishable (Image 2).
Image 1: Non Union
Legend; Date of Birth: 13-4-98 Chronological age: 17 Years, 01 Month, 00 Days
Image 2: Partial Union of Iliac Crest
Legend; Date of Birth: 11-05-98 Chronological age: 17 Years, 00 Months, 02 Days
Complete union: White line formed by fusion of the two fusing layers of epiphysis and diaphysis disappear completely and become merged with normal trabeculae in this region. X-rays reveal the same bony architecture in the epiphyseal and diaphyseal ends and absent epiphyseal scar (Image 3).
Statistical Analysis
Estimation of age from the fusion of iliac crest in both genders is the primary outcome of our study.
Image 3: Complete Union of Iliac Crest
Legend; Date of Birth: 01-10-94 Chronological age: 19 Years, 8Months, 22 Days
2.5
5
.5
71
26
52
Upper Class
study, dependent variables are epiphyseal center appearance and its union.
Independent variables are age in years, gender, and ethnicity. Qualitative data like gender, eth-nicity, SES, occupation, and stage of union were described statistically in frequencies and percentages. Quantitative data like age was described statistically after finding median, mean, and standard deviation.
The age of study subjects was divided into 9 groups starting from 17 through 25 years. Age group 17 was considered as those who had completed their 16 years and few days or months above 16 years but they were less than 17 years, same for the other age groups. Stages of non-union, partial union, and complete union were compared with these age groups for both genders (Tables 3, 4). Socioeconomic status is divided into three levels (high, middle, and low) based on three variables (income, education, and occupation) (Diemer et al., 2013) (Figure 1). Chi-Square test was used to
determine the association of different categorical
Middle Class
Lower Class
143
0 50 100 150 200
factors statistically, with the fusion of the iliac crest. P value of less than 0.05 was cons-idered significant.
Lower
Class
Middle
Class
Upper
Class
Percentage
26
71.5
2.5
N. Value
52
143
5
Percentage N. Value
Figure 1: Descriptive Statistics of Socio-economic Status (n=200)
This data was analyzed by using SPSS 23.0 (Statistical Package for Social Sciences). In our
Figure 2: Histogram depicting Age Distribution in Sample Population (n=200)
RESULTS -
-
Age of the subjects:
200 subjects participated in this study between the ages of 17 through 25 years. For both genders mean
± SD age was 20.41 ± 2.55 years and the median age was 20.00 years as shown in Figure 2 of the Age Histogram with mean and SD values.
-
Age and sex distribution:
The subjects with reference to age were divided into 9 age groups starting from 17 through 25 years. The frequency distribution of the subjects with reference to gender is 132 males (66 %) and 68 females (34%) (Table1).
Gender-wise comparison of descriptive statistics of the numerical variable of this study has been shown in Table 2. The mean ±SD age was 20.67±2.61 years for males and the median age was 20.00 years, while the mean ±SD age was 19.90±2.38 years for females and the median age was 19.00 years. The BMI of all subjects was within the normal range (maximum 25 and min-imum 19) (Table 2).
-
Extent of fusion of iliac crest in different age groups among males:
Table 3 shows that out of 132 males, there were 93 cases (70.45%) of complete fusion with the frequency of (10.5%) in the 17-year age group which gradually increased to 100% in 21-25 years of age groups. There were 21 cases (15.91%) of partial union and all were in 17 to 20 years age groups with the highest frequency (56.3%) in the 18 years age group. While there were only 18 cases (13.64%) of non-union and all were in the 17 to 19- year age groups. The mean ± SD age of complete fusion in males was 20.67± 2.61 years and the median age was 20.0 years. The p value comes out to be 0.000 for males which are significant as it is
<0.05.
-
Extent of fusion of iliac crests in different age groups among females:
Table 4 shows that out of a total of 68 females, there were 40 cases (58.83%) of complete fusion
Table 1: Age and Sex Distribution of the Subjects
Gender
n
Min.
Max.
Mean
S.D.
Male
Age
132
17
25
20.67
2.611
Height (cm)
132
155
193
172.39
7.386
Weight (kg)
132
45
92
64.41
9.112
BMI
132
19
25
21.55
2.359
Female
Age
68
17
25
19.90
2.389
Height
(cm)
68
141
183
158.93
6.712
Weight (kg)
68
40
71
52.91
6.300
BMI
68
19
25
20.81
1.879
Total
Age
200
17
25
20.41
2.558
Height
(cm)
200
141
193
167.81
9.589
Weight (kg)
200
40
92
60.50
9.891
BMI
200
19
25
21.30
2.230
Age (years)
Male
Female
Tot
al
n
%
n
%
n
%
Table 2: Gender Wise Comparison of Descriptive Statistics of Numerical Variables in This Study (n=200)
17
19
63.3
11
36.7
30
100.0
18
16
51.6
15
48.4
31
100.0
19
14
60.9
9
39.1
23
100.0
20
21
72.4
8
27.6
29
100.0
21
11
61.1
7
38.9
18
100.0
22
10
62.5
6
37.5
16
100.0
23
16
76.2
5
23.8
21
100.0
24
13
76.5
4
23.5
17
100.0
25
12
80.0
3
20.0
15
100.0
Total
132
66.0
68
34.0
200
100.0
Mean
20.41
Median
20.00
Std. Deviation 2.558
with the frequency of (33.3 %) in 19-years age group which was up to 100% in age groups of 20- 25 years. There were 21 cases (30.88%) of partial union and all were in the 17 to 19-years age groups with the highest frequency (66.7%) in the 19-year age group. There were only 7 cases (10.29 %) of non-union and all were in the 17 to 18-year age groups. The mean ± SD age of complete fusion in females was 19.90± 2.38 years and the median of age was 19.0 years. The p value comes out to be
0.000 for females which is significant.
An incidence of complete fusion in 104 males (78.8%) out of 132 subjects and 47 females
(69.1%) out of 68 cases was observed (Table 3-4). It was noted that females were one year ahead (20 years) for the fusion of the iliac crest as compared to males (21 years). It was also observed that with the advancement of age, the percentage of comp- lete fusion increased and the percentage of part- ially fused cases decreased. It was also seen that there was a symmetrical fusion of the iliac crest bilaterally on both the right and left sides of the pelvic bone.
-
Association of complete fusion of iliac crests with socioeconomic status, occupation and ethnicity:
Subjects were divided into 3 groups for socio- economic status – upper, lower, and middle class. 52 cases were belonging to the lower class out of which 37 (71.2%) cases showed complete fusion. 143 cases belonged to the middle class out of which 95 (66.4%) cases showed complete fusion of iliac crest. There were only 5 cases (100%) of non- fusion in the upper class. Chi-square test was applied and it was found that it is statistically significant (0.006) relationship between socio economic status and fusion of iliac crest in both male and female (Table 5).
The subjects were divided into 3 groups for occupation- students, employees and laborers. In our study students were in majority in number
(134) followed by 34 employees and 32 laborers. There was a complete union of the iliac crest in 82 students (61.2%) followed by 26 employees (76.5%) and 24 (75.0%) workers. Chi-square test was applied to know the association between nature of occupation with age group in relation to complete fusion of iliac crest and it was found to be statistically non-significant (0.123%) both in males and females (Table 5). The subjects were divided into 3 groups for Ethnicity, Pathan, Punjabi and Urdu speaking. In our study, Punjabi were in majority in number (137) followed by 58 Urdu speaking and 5 Pathan. Complete Union of iliac
Table 3: Frequency of Extent of Fusion of Iliac Crest in different Age Groups among Males
(years)
n
%
n
%
n
%
n
%
17
11
57.9
6
31.6
2
10.5
19
14.39
18
4
25.0
9
56.3
3
18.8
16
12.12
19
3
21.4
2
14.3
9
64.3
14
10.61
20
0
0.0
4
19.0
17
81.0
21
15.91
21
0
0.0
0
0.0
11
100.0
11
8.33
22
0
0.0
0
0.0
10
100.0
10
7.58
23
0
0.0
0
0.0
16
100.0
16
12.12
24
0
0.0
0
0.0
13
100.0
13
9.85
25
0
0.0
0
0.0
12
100.0
12
9.09
Total
18
13.64
21
15.91
93
70.45
132
100.0
Mean
20.67
Median
20.00
Std. Deviation
2.611
Table 4: Frequency of Extent of Fusion of Iliac Crest in Different Age Groups among Females
Age group (years)
Non union
Partial Union
Complete Union
Total
n
%
n
%
n
%
n
%
17
3
27.3%
6
54.5%
2
18.2%
11
16.18%
18
4
26.7%
9
60.0%
2
13.3%
15
22.06%
19
0
0.0%
6
66.7%
3
33.3%
9
13.24%
20
0
0.0%
0
0.0%
8
100.0%
8
11.76%
21
0
0.0%
0
0.0%
7
100.0%
7
10.29%
22
0
0.0%
0
0.0%
6
100.0%
6
8.83%
23
0
0.0%
0
0.0%
5
100.0%
5
7.35%
24
0
0.0%
0
0.0%
4
100.0%
4
5.88%
25
0
0.0%
0
0.0%
3
100.0%
3
4.41%
Total
7
10.29%
21
30.88%
40
58.83%
68
100.0%
Mean
19.90
Median
19.00
Std. Devia
tion
2.389
Non –Union
Complete Fusion
p value
n=68
%
n=132
%
Table 5: Association of Fusion of Iliac Crest with Gender, Socio-Economic Status, Occupation and Ethnicity Variables
Gender
Male
39
29.5%
93
70.5%
Female
28
41.2%
40
58.8%
0.064
S.E. Status
Upper Class
5
100.0%
0
0.0%
Middle Class
48
33.6%
95
66.4%
Lower Class
15
28.8%
37
71.2%
0.006*
Occupation
Student
52
38.8%
82
61.2%
Worker
8
25.0%
24
75.0%
Employee
8
23.5%
26
76.5%
0.123
Ethnicity
Pathan
1
20.0%
4
80.0%
Punjabi
46
33.6%
91
66.4%
Urdu Speaking
21
36.2%
37
63.8%
0.751
* The Chi-square test is significant at the p value < 0.05 level
crest was seen in 4 cases (80%) out of 5 Pathan, 91
cases (66.4%) out of 137 Punjabi and 37 cases (63.8%) out of 52 Urdu speaking subjects. There is no statistically significant ass-ociation between complete fusion of iliac crest and ethnicity. As p value is 0.751 (Table 5).
DISCUSSIONThe results in our study are higher than that of Flecker who observed complete union of the iliac crest at 18 years in males and 15-16 years of age
in females of Australia in 193211. Patel G has shown a lower level of age for ossification i.e. 19-20 for males and 18-19 for females in Gujarat12. Gupta13 noticed complete ossification at 16 years in males and 15 years in females of Kanpur. In Pakistan, only one study had been conducted in Hyderabad city and adjoining areas by Memon et al giving an age of fusion of iliac crest to be 18 years -10 months for males and 17 years-10 months for females2.
The age of fusion in our study is lower than those of Davis and Parson who studied such results in English in 1927 at the age of 23 years in both genders and Stevenson who studied White and Black populations in 1924 where the age of fusion was found to be at 22 -24 years10,14. Bilkey, W. et al noticed complete union at 22 years of age in females without mentioning males in the North East region of India. Cardoso documented the age of complete fusion at 22 years for females and 23 years for males in Portuguese skeletal samples15, 16.
Our findings are very much in tandem with those of Singh (9) showing 20-21 years and Bhise giving the age of fusion to be 21-22 for males and 20-21 for females in Mumbai4. Kalpesh noticed fusion of iliac crest in males at 19-20 years and in females at 18-19 years in Gujrat17. Galastan also noticed in Bengalis the ossification at 19-20 years in males and 17-19 years in females18.
The mean age of fusion of iliac crest in our study is higher in males (20.67±2.61) than females (19.90±2.38). A significant difference with a significant p value less than 0.05 was found for both genders. Although this is in agreement with the generally accepted pattern of earlier fusion in females it is in disagreement with a difference of about 2 years given by various authors over the world19.
-
Association of fusion of iliac crest with socio-economic status:
The difference between the mean ages of the iliac crest was statistically significant for diff-erent socio-economic statuses as seen in Figure 2 and Table 5 where p value is 0.006
According to the list of countries by Human Development Index (HDI) 201420.Pakistan stands at 2nd position in low human develop-ment and 146th among 169 countries on United
Nation's HDI 2014. The human development index (HDI) is the reflection of the comparative index of life expectancy, literacy, education, and standard of living for countries globally. It is a standard parameter of measuring well-being, which helps to distinguish whether a country is developed, developing, or under developing. It also reflects impact of economic policies on quality of life. Higher HDI means a higher socioeconomic status while low HDI indicates low socio-economic status. Bones of the people having poor socio-economic status tend to delay maturation of bone18, 21. Malnutrition plays an important role in the maturation of the skeleton. If the nutritional deficiencies become extreme, skeletal maturation is delayed22. This finding conforms with other studies all over the world21, 22, 23. Patel et al3 did not notice any such relationship of socioeconomic status with the ossification of the iliac crest in his study.
-
Association of fusion of iliac crests with Ethnicity:
Ethnicity has no significant impact on the fusion of the iliac crest as shown in Table 5. There is no statistically significant difference between the mean age of fusion of iliac crest among various ethnicities i.e. Punjabi, Pathan and Urdu speaking persons as p value is > 0.751 which is insignificant. These findings are consistent with those of the previous researchers. Todd and Errico studied Black Americans; Owing Webb researched White and Black Americans24,25. They did not notice any interethnic differences in their studies.
-
Association of fusion of iliac crest with occupation:
Occupation did not appear to significantly influence the probability of having a completely fused iliac crest as the p value is 0.123 which is
not significant. The work to see the effect of oc- cupation on the fusion of iliac crest was based on assumption that increased physical activity associated with higher metabolic rate in hard workers may affect the timing of fusion. These findings are exactly similar to the findings done by previous researchers3. Theintz studied the ef- fect of physical training in swimmers and gym- nastics and found delayed fusion as compared to their adult height and chronological age26. Patel did not notice any such relationship of oc- cupation with the ossification of the iliac crest in his study3.
The factors which affect the skeletal maturity and time of union of ossification centers of the iliac crest must be kept in mind during the assessment of age. For medico-legal purposes, forensic age diagnostics has recommended combining a physical examination of the subject with radiological examination of the iliac crest, left hand and medial and of the clavicle with a dental examination. The factors which need to be considered are the socio-economic factors or HDI, geography and climate as warmer climates tend to have an earlier fusion of the bones. Asians have been reported to have an earlier fusion of the epiphysis as compared to Westerns27. In addition, a new trend for earlier fusion over the last few decades has been reported which could be up to 0.22-0.66 years per decade from the 1960s to 1990s19.
Several methods are used to evaluate the skeletal maturity that involves different parts of the human skeleton. Oxford and Risser's met-hod is based on the pelvis; Risser's method is the only standard method that is used for the determination of skeletal maturity in adolescents over 18 years old. Amongst all the determinants of age, radiological examination of bone ends has
shown accuracy and reliability acceptable to the medical profession and the legal fraternity28.
CONCLUSION
-
Based on the results of this study, it is concluded that the mean age of fusion of iliac crest is 20.41±2.55 in the healthy population coming to Shalamar Hospital, Lahore.
-
Mean age for the fusion of iliac crest for males is 20.67± 2.61 and for females is 19.90± 2.38.
-
There is a difference in the time frame of ossification of the iliac crest in both genders. The females tend to show a difference of about one year earlier than males in respect of fusion of iliac crest.
-
The complete union of the iliac crest in our study is 1-2 years earlier than the population of England and America but almost in tandem with the population of India.
-
The union of the iliac crest occurs symmetrically on both sides of the pelvic bone.
-
Interethnic differences do not appear to have any role in the timing of ossification of the iliac crest.
-
The important role of factors like diet, socio- economic status, HDI, nutritional status in the maturation of skeleton should not be omitted while doing age estimations in criminal proceedings.
Recommendations:
- It is recommended that more elaborate research studies be conducted in different parts of the country on subjects with different socio-economic and nutritional status to find out the difference if any in timeframes of fusion of iliac crest so that a uniform national standard be formulated. This will also help us in establishing the role of nutrition, climate, and geographical factors in ossification times.
-
A group of experts comprising of a forensic expert, dentist, radiologist, and anthropologist should be involved for
estimation of age in criminal proceedings and personal identification.
-
More studies should be conducted on the time frame of ossification of iliac crest using a larger sample size.
-
Extensive research should be carried out to formulate national guidelines for bone age assessment for children in Pakistan, using different methodologies.
Conflicts of interest
The authors have no conflicts of interest to declare.
Contributors
Dr. M. Maqsood designed the study and drafted the manuscript. Dr. M. Zahid Bashir, Dr. Kashif Butt, and Dr. Faizan Maqsood collected and analyzed the data. All authors critically revised and approved the final manuscript.
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Article Title | Authors | Vol Info | Year |