J Korean Med Sci.  2016 Oct;31(10):1538-1545. 10.3346/jkms.2016.31.10.1538.

Ossification of the Medial Clavicular Epiphysis on Chest Radiographs: Utility and Diagnostic Accuracy in Identifying Korean Adolescents and Young Adults under the Age of Majority

• Yoon SH
• Yoo HJ
• Yoo RE
• Lim HJ
• Yoon JH
• Park CM
• Lee SS
• Yoo SH

• KMID: 2468242
• DOI: http://doi.org/10.3346/jkms.2016.31.10.1538

Abstract

The aim of our study was to evaluate the utility and diagnostic accuracy of the ossification grade of medial clavicular epiphysis on chest radiographs for identifying Korean adolescents and young adults under the age of majority. Overall, 1,151 patients (age, 16-30) without any systemic disease and who underwent chest radiography were included for ossification grading. Two radiologists independently classified the ossification of the medial clavicular epiphysis from chest radiographs into five grades. The age distribution and inter-observer agreement on the ossification grade were assessed. The diagnostic accuracy of the averaged ossification grades for determining whether the patient is under the age of majority was analyzed by using receiver operating characteristic (ROC) curves. Two separate inexperienced radiologists assessed the ossification grade in a subgroup of the patients after reviewing the detailed descriptions and image atlases developed for ossification grading. The median value of the ossification grades increased with increasing age (from 16 to 30 years), and the trend was best fitted by a quadratic function (R-square, 0.978). The inter-observer agreements on the ossification grade were 0.420 (right) and 0.404 (left). The area under the ROC curve (AUC) was 0.922 (95% CI, 0.902-0.942). The averaged ossification scores of 2.62 and 4.37 provided 95% specificity for a person < 19 years of age and a person ≥ 19 years of age, respectively. A preliminary assessment by inexperienced radiologists resulted in an AUC of 0.860 (95% CI, 0.740-0.981). The age of majority in Korean adolescents and young adults can be estimated using chest radiographs.

Keyword

Age Estimation; Age of Majority; Clavicle; Epiphysis; Ossification; Radiograph; Diagnostic Accuracy

MeSH Terms

Adolescent
Adult
Age Determination by Skeleton/standards
Area Under Curve
Asian Continental Ancestry Group
Clavicle/*diagnostic imaging
Epiphyses/anatomy & histology/*diagnostic imaging
Female
Humans
Male
Osteogenesis/*physiology
ROC Curve
Radiography, Thoracic
Reference Values
Republic of Korea
Young Adult

Figure

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  Fig. 1 Representative images of each ossification grade. White arrows indicate the cortical line at the medial end of clavicle. Grade 1 (invisible ossification center). The medial end of cortex is concave in shape and has an irregular margin with a thin cortical rim.; Grade 2 (visible ossification center without any ossification of epiphyseal cartilage). (A) The medial end of clavicle is convex in shape and has two layers of radiopaque cortical lines thicker than 1 mm at the full vertical length along with a full sharp radiolucent line with an even thickness which opens at both the top and bottom of the clavicle. (B) Epiphyseal ossification may be present as a less radiopaque density (empty arrow head) at the half of the vertical length; Grade 3 (visible ossification center with partial ossification of epiphyseal cartilage). The medial end of clavicle is convex or flat in shape and has two layers of radiopaque cortical lines thicker than 1 mm at a portion of the vertical length. The vertical radiolucent line has an irregular margin and thickness, which is interrupted (A) or closed by radiopaque area (B) either at the top or bottom; Grade 4 (complete ossification of epiphyseal cartilage with epiphyseal scar). (A) The medial end of clavicle is flat or convex in shape and has a broad cortical line 1-2 mm or thicker. There is no mach band phenomenon. Thin vertical line, epiphyseal scar (white arrow head) is visible adjacent to the cortical line. (B) The lateral margin may be amorphous and density of adjacent bone is mildly increased; Grade 5 (complete ossification of epiphyseal cartilage without epiphyseal scar). The medial end of clavicle is flat or convex in shape and has a thin even cortical line with an adjacent slit-like radiolucent line due to mach band phenomenon (A). The lateral margin of cortical line is even and sharp. The cortical line of medial clavicular end may be thicker up to 2 mm but evenness and sharpness are preserved at its full vertical length (B). Oblique positioning of the sternal facet at X-ray exposure may produce two layers of sharp radiopaque cortical lines thinner than 1 mm which are far apart at center and joined at the top and bottom resulting in a teardrop appearance (C).

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  Fig. 2 Box-whisker plot showing the relationship between age and averaged ossification grades.

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  Fig. 3 Receiver operating characteristic curve on diagnostic accuracy of averaged ossification grades for identifying a person under the age of majority (≤ 18).

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