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Updated: Jul 16, 2026

Scanning Skeletal Remains for Bone Mineral Density in Forensic Contexts
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Published on: January 29, 2018

Adult Age Threshold Estimation Using Radiographic Evaluation of Wrist-Hand Skeletal Maturation: A Systematic Review

Ilenia Bianchi1, Martina Focardi2, Andrea Costantino3

  • 1Laboratory of Personal Identification and Forensic Morphology, Department of Health Sciences, University of Florence, 50139 Florence, Italy.

Diagnostics (Basel, Switzerland)
|July 15, 2026
PubMed
Summary

Forensic age estimation using wrist-hand skeletal maturation shows low accuracy at the 18-year threshold. Evidence quality is very low due to bias and heterogeneity, limiting reliable application.

Keywords:
Greulich-PyleTanner-Whitehouseadult age estimationmeta-analysisskeletal maturationwrist-hand X-rays

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Area of Science:

  • Forensic Anthropology
  • Radiology
  • Biometrics

Background:

  • Wrist-hand radiographic skeletal maturation is widely used for forensic age estimation.
  • Its diagnostic accuracy at the legally relevant 18-year threshold is questionable.
  • Limited evidence synthesizes its reliability for adult age estimation.

Purpose of the Study:

  • To quantitatively synthesize evidence on the diagnostic accuracy of wrist-hand skeletal maturation for forensic age estimation.
  • To evaluate sensitivity, specificity, AUC-curve, and Mean Absolute Error (MAE) at the 18-year threshold.
  • To assess the certainty of evidence using GRADE criteria.

Main Methods:

  • Systematic review of 6 databases (1980-2026).
  • Inclusion of studies on individuals ≥16 years with verified chronological age.
  • Data extraction, QUADAS-2 quality assessment, DerSimonian-Laird random-effects modeling, and GRADE certainty assessment.

Main Results:

  • 23 studies (11,425 participants) were included.
  • Pooled MAE was 0.537 years, but derived from high-bias Italian studies.
  • At 18 years, pooled sensitivity was 69.5% and specificity 85.56%, with extreme heterogeneity (I² > 98%).
  • 82.6% of studies had high/unclear patient selection bias; GRADE certainty was VERY LOW.

Conclusions:

  • Wrist-hand skeletal maturation demonstrates low accuracy and high misclassification rates for age estimation at 18 years.
  • Wide prediction intervals and very low certainty evidence preclude confident application.
  • Results require cautious interpretation in forensic contexts, recommending combination with other indicators like dental evidence.