Multi-Rater Agreement Using the Adapted Fracture Healing Scale (AFHS) for the Assessment of Tubular Bones on Conventional Radiographs: Preliminary Study.

Better understanding of the timing of fracture healing may help in cases of interpersonal violence but also of personal identification. The intra- and inter-rater agreement for the adapted fracture healing scale (AFHS) assessing the post-traumatic time interval on radiographs were tested. This is a preliminary study, providing essential information on method reliability for upcoming studies using the AFHS. Five raters (two radiologists, a forensic pathologist, an orthopedist, and an anthropologist) were presented with a test in three parts consisting of 85 radiographs (from 30 adults) of fractures of tubular bones in different stages of healing purposefully selected from more than 1500 radiographs. The raters were firstly asked to assess 15 features describing fracture healing as present, absent, or not assessable. Thereafter, the raters were asked to choose from the AFHS a single-stage best representing the observed healing pattern. The intra- and inter-rater agreement were assessed using single-rating, absolute agreement, two-way mixed-effects intra-class correlation (ICC) coefficients. The intra-rater ICC of radiologist 1 ranged from 0.80 to 0.94. The radiologists' inter-rater ICC ranged from 0.68 to 0.74, while it ranged from -0.01 to 0.90 for the other raters. The good to excellent ICC among the radiologists and forensic anthropologist provides good foundation for the use of the AFHS in forensic cases of trauma dating. The poor to good results for the other physicians indicate that using the AFHS requires training in skeletal anatomy and radiology.

Histologic and radiological analysis on bone fractures: Estimation of posttraumatic survival time in skeletal trauma.

In antemortem fractures, the estimation of the amount of time that has lapsed between the traumatic event and eventual death (the socalled 'posttraumatic survival time' or PTST) can have substantial implications in legal proceedings. It might for instance help to corroborate witness testimonies, to reconstruct the chain of events leading to eventual death or to establish a sequence when multiple traumata in a single individual are encountered. However, PTST estimation of bone trauma is impeded by a myriad of theoretical and practical issues, and is therefore almost invariably considered challenging. A few years ago, a method that combines radiological and histological analysis of fractures to estimate the minimum amount of lapsed PTST in skeletonized remains was proposed. This study aims to test its accuracy on a set of five rib fractures and four skull lesions fractures with known and varying amounts of posttraumatic survival time. In addition, it explores the differences between the assessment on ribs and skull bones and it expands on the proposed method by including computed tomography (CT) scanning. Using conventional radiology and histology, the minimum amount of PTST was accurately estimated in 8 out of 9 of the cases (89%). The one discrepancy between the estimated and known PTST was minimal, being just one day. The precision of the method diminishes as healing advances. It was noted that skull lesions showed less advanced and less well-developed healing features than the lapsed PTST would suggest. Of the three used modalities, conventional radiology proved to be the least accurate. CT scanning proved to be a valuable, sometimes even superior alternative to conventional radiology. Histology was superior to both conventional radiology and CT scanning. The results of our study illustrate the potential of the combined application of radiology and histology to estimate the PSTS in skeletonized human fractures.