Age Estimation by X-Ray (Radiological Methods) in Forensic Medicine

Why X-Ray is Useful

• For determining age, skiagrams of the shoulder, elbow, wrist, hip, knee, ankle, pelvis and skull are taken in the anteroposterior (AP) direction.
• Union of epiphyses seen on radiographs appears approximately 6 months earlier than anatomical fusion, because the epiphyseal cartilage becomes very thin and may not show on film near the end of the growth period.
• A persistent scar on X-ray is not evidence of incomplete or recent union.
• Once union begins in a bone, it is completed within 12 to 18 months.

Radiological Methods of Skeletal Age Estimation

1. Study of Ossification Centres

2. Atlas Techniques

• Todd's Atlas
• Greulich and Pyle Atlas - compares the hand/wrist X-ray against a standard atlas of known ages

3. Scoring Techniques (Preferred)

• Acheson's Method (Oxford method)
• Tanner and Whitehouse Method (TW1, TW2, TW3) - scores individual bone maturation
• FELS Method

4. Individual Profile Maturity Technique

Practical X-Ray Approach by Age Group

Wrist and hand are the most studied regions by researchers worldwide.

Stages of Ossification (Important Principles)

• Earliest centres appear at end of 2nd month of pregnancy
• By 11th intrauterine week - 806 centres of bone growth
• At birth - ~450 centres remain
• Adult skeleton has only 206 bones (600 centres have fused)
• Between 2 to 6 years - number of carpal bones visible on wrist X-ray indicates approximate age in years
• By end of 1st year - 2 carpal bones visible on wrist X-ray

Key Ossification and Fusion Times (Table)

Medico-legally critical: Lower end of femur and upper end of tibia fuse at 18-19 years, making them key markers for the 18-year threshold.

Important General Rules

1. Females are ahead of males in skeletal development by up to 1 year; dental development differs only 1-4 months. Female pubis reaches full maturity ~10 years later than the male.
2. Ageing of bones is more accurate for appearance of centres than for union of epiphyses.
3. Secondary centres that appear first are the last to fuse.
4. In upper limb long bones: union occurs earlier at elbow, later at wrist; head of humerus is the last long bone epiphysis to unite.
5. In lower limb: union occurs later at knee, earlier at hip and ankle.
6. Always express skeletal age in plus or minus terms (e.g., 10 ± 1 year).

Specific Bone Age Markers (Beyond Epiphyseal Fusion)

Symphysis Pubis

• Before 20 years - compact bone near surface, marked ridges running transversely
• ~20 years - markedly irregular/uneven surface
• 24-36 years - ridges disappear, granular surface; dorsal and ventral margins defined
• Early 5th decade - oval, smooth surface with raised upper/lower ends; beaded rim develops
• 6th decade - erosion and ventral margin breakdown
• 7th decade - irregularly eroded surface

Sternum

• 4 pieces of sternal body fuse from below upwards between 14-25 years
• Xiphoid unites with sternal body at ~40 years

Skull

• After 25 years - muscular markings become increasingly evident (temporal line, nuchal lines, masseteric attachment)
• Pacchionian depressions deepen with age
• After 50 years - diploe becomes less vascularised, replaced by bone

Sacrum

• Centres appear in upper segments in 3rd foetal month

Radiological Signs of Older Age

• Cortical thinning and progressive rarefaction of the medullary cavity apex (head of humerus and femur)
• Microradiographs of bone useful - based on correlation between age and bone loss through natural remodelling
• Osteoporotic changes: loss of collagenous stroma starts at outer cortex, then zone around marrow cavity; ends of long bones appear fragile
• Fluorosis (chronic fluoride ingestion): increased bone density and weight, lipping of vertebral margins, mottling of teeth

Factors Affecting Ossification (and Thus X-Ray Accuracy)

Limitations

• Estimation becomes increasingly uncertain after age 25 years - accuracy of even 5 years is hard to achieve
• Multiple criteria should always be used together
• A doctor's estimate of age is an opinion, not definitive proof
• Premature ageing may result from illness, malnutrition, anxiety, or grief

FMT Spotters - Key Points

1. 🫀 LIVER CIRRHOSIS

• Liver is small, shrunken, firm and hard in texture
• Surface is nodular - "hobnail" appearance (fine granular or large nodules)
• Cut section shows fibrous bands surrounding nodules
• Color: yellow-green (if fatty/biliary) or brown-red
• Nutmeg liver (chronic congestive) is a precursor - alternate red/yellow areas on section
• Capsule is thickened and wrinkled
• Weight is reduced (normal ~1.5 kg)

• Micronodular (nodules <3 mm) - alcoholic, metabolic
• Macronodular (nodules >3 mm) - post-hepatitis
• Mixed

• Seen in chronic alcoholism - relevant in alcohol-related deaths
• Increased bleeding risk (decreased clotting factors) - can lead to fatal hemorrhage
• Portal hypertension - ascites, varices, splenomegaly
• Pre-existing disease affecting cause of death opinions

2. 🐍 RUSSELL'S VIPER (Daboia russelii)

• Body: Short, stout; flat, heavy, triangular head broader than body
• Head: V-shaped white mark at front - angle pointing forwards
• Color: Whitish body with three rows of diamond-shaped black/brown spots - outer two rows ringed with white edges; dark semilunar spots on belly
• Scales: Small scales on head; entire broad plates on belly; tail plates divided into two rows (sub-caudal plates divided)
• Tail: Short, tapering, narrow
• Pupil: Vertical (slit-like)
• Fangs: Long, canalized (hollow), solenoglyphous
• Heard to hiss loudly and continuously
• Found throughout India

• Activates coagulation factors X and V → DIC, VICC (Venom-Induced Consumption Coagulopathy)
• Local tissue necrosis, severe swelling, hemorrhagic blisters
• Acute kidney injury (AKI) is hallmark
• Thrombocytopenia, MAHA (microangiopathic hemolytic anemia)
• Bilateral ptosis (in some subspecies - neurotoxic component)

3. 📜 SUMMONS (Subpoena)

• Latin: Sub = under; Poena = penalty
• Governed by Sections 63-71 BNSS (formerly Sections 61-69 Cr.P.C.)
• Issued in writing, in duplicate, signed by presiding officer, bearing the seal of the court
• Contains: crime number and name of accused
• Served by: police officer, court officer, or public servant - one copy delivered, receipt signed on other copy (Section 64, BNSS)
• Can also be served by registered post or affixed on conspicuous part of residence
• Subpoena Duces Tecum - requires witness to bring books/documents/things (Sections 94 & 195 BNSS; Section 165 BSA)
• If summoned person is a government servant - sent in duplicate to head of office

• Civil case: Liable to pay damages
• Criminal case: Fine, imprisonment, or bailable/non-bailable warrant
• Imprisonment up to 1 month or fine or both (Section 208, BNS)

4. 🔪 BRAIN KNIFE

• A long, flat, broad-bladed knife with a single sharp edge
• Blade is long (typically 25-30 cm), slightly flexible
• Used to slice large solid organs (brain, liver, kidney, spleen) into thin, uniform sections during autopsy
• Produces clean, smooth sections without tearing tissue
• Allows examination of internal architecture in a single sweep

• Standard tool in the mortuary/post-mortem examination
• Used to slice the brain coronally or in other planes to detect hemorrhages, contusions, tumors, edema
• Helps identify: subdural/extradural hematoma, cerebral edema, infarcts, contusions

5. 🌱 CASTOR (Ricinus communis)

• Euphorbiaceae family; large plant with star-shaped (palmate) leaves
• Seeds: oval, bean-shaped, smooth, shiny with a characteristic caruncle (appendage) at one end; mottled brown/grey with dark streaks
• Contains 2-3 seeds in a spiny capsule (tricoccus)

• Also contains Ricinine (alkaloid) and RCA (ricinus communis agglutinin)

• Burning pain in mouth/throat
• Nausea, vomiting, profuse diarrhea (hemorrhagic)
• Abdominal pain and cramps
• Haematuria, oliguria, anuria
• Hypotension, tachycardia
• Convulsions, coma, death
• Fatal dose of seed: 2-20 seeds in adults; 1 seed can kill a child
• No specific antidote

• Gastroenteritis changes (hemorrhagic)
• Congestion of kidneys, liver, spleen
• Fatty degeneration of liver and kidney

• Used as bioterrorism agent (weaponized ricin - Assassination of Georgi Markov by ricin pellet)
• Homicidal, suicidal, accidental poisoning
• Castor oil (from seeds) is NOT poisonous (ricin is destroyed by heat during processing)

6. 🔫 RIFLE BULLET

• A rifled firearm with a long barrel (typically >16 inches for rifles)
• Inside of bore has spiral grooves (4-7 grooves) = rifling
• Raised portions = lands; lowered portions = grooves
• Rifling causes the bullet to spin on its longitudinal axis → gyroscopic stability → accuracy

• High velocity: ~2500 ft/sec (muzzle velocity)
• Pointed/ogival tip (spitzer shape) vs. revolver's rounded bullet
• Longer and narrower than shotgun pellets or revolver bullets
• Bears land and groove markings imprinted by rifling
• Calibre: expressed in 1/100th inch or mm (e.g., 0.303, 7.62 mm)
• Accuracy range: well over 600 yards

• Entry wound: Small, circular/punched-out, everted edges, tattooing/burning (at close range), smaller than bullet diameter (due to elasticity of skin)
• Exit wound: Larger, irregular, lacerated, ragged - "stellate" - skin blown outward
• Temporary cavity formed by high velocity - larger tissue destruction than entry suggests
• Cavitation effect - extensive internal tissue damage
• Bullet may tumble on entering tissue - causing unpredictable paths

7. 🧠 SUBDURAL HEMORRHAGE (SDH)

• Chronic/Subacute SDH: Tearing of bridging veins (between cortex and dural sinuses)
• Acute SDH: Cortical contusions with arterial bleeding

• Extradural = between skull and dura; due to middle meningeal artery; classic lucid interval; scraped at autopsy
• SDH = no classic lucid interval; often bilateral; washed at autopsy

• Shaken Baby Syndrome - SDH + retinal hemorrhage + no external injury
• Can be non-traumatic - spontaneous (hypertension, aneurysm)
• Important in cases of domestic violence, child abuse, fall from height

8. 🫶 WASHERWOMAN'S HAND (Washer Woman's Hand)

• 2-4 hours: First seen on fingertips
• ~24 hours: Spreads to palm, back of fingers, back of hand
• 4-8 hours: Bleaching of epidermis begins
• ~20 hours: Fully established - sodden, bleached, wrinkled appearance

• Skin becomes sodden, thickened, wrinkled, and white/pale
• Looks like the hands of someone who has washed clothes for long hours
• Earliest in warm water; seen later in cold water
• Areas covered by clothing develop changes more slowly

• Indicates the body has been immersed in water for some time
• Helpful in estimating duration of immersion
• Does NOT prove drowning as cause of death (body may have been thrown in after death)
• Must be correlated with other PM signs of drowning

• Copious froth from mouth/nostrils (emphysema aquosum)
• Cutis anserina ("goose skin") - pilomotor contraction
• Cadaveric spasm - clutching weeds, grass in hand
• Paltauf's hemorrhages - pale pink subpleural hemorrhages
• Postmortem lividity - light pink, on face/chest/hands

9. 🔨 HAMMER

• A heavy striking tool with a metal head and handle
• Head has a flat striking face ("face") and may have a claw or peen

• Produces patterned contusion/laceration - shape of wound may match hammer face
• Wound edges are bruised and contused (unlike incised wounds which have clean edges)
• Tissue bridging across wound (not seen in incised wounds)
• May produce imprint abrasion showing the pattern of the hammer head
• Hair and scalp protect against surface cuts but underlying bone fractures
• Usually associated with assault - homicidal
• Can be confused with fall - need to assess multiplicity, direction of blows, scene evidence