age estimation from fusion of ossification centres of bones

1. Age Estimation by Bones
Dr Chetan Kumar
Resident- PG
Baroda Medical College

2. • Chronological age: is the time elapsed since
birth
• Bone age is the degree of maturation of a
person's bones. As a person grows from fetal
life through childhood, puberty, and finishes
growth as a young adult, the bones of the
skeleton change in size and shape. These
changes can be seen by x-ray.

5. The major types of human bones are:
• long (e.g. the arm and leg bones)
• short (e.g. the small bones in the wrists and ankles)
• flat (e.g. the bones of the skull or the ribs)
• irregular (e.g. vertebrae)
• Long, short, and irregular bones develop by endochondral
ossification, where cartilage is replaced by bone.
• Flat bones develop by intramembranous ossification, where
bone develops within sheets of connective tissue.
• Compact cortical bone, representing about 80 percent of the
mature skeleton, supports the body, and features extra
thickness at the midpoint in long bones to prevent the bones
from bending.
• Cancellous bone, whose porous structure with small cavities
resembles sponge, predominates in the pelvis and the 33
vertebrae from the neck to the tailbone.

6. FIRST STUDIES
• 1921- Bardeen examined and described the
changes in form of ossifiction centres in course
of growth; from an initial pointed form to an
adult bone
• 1928 -Hellman made important contribution
• 1937 - significant contribution by Todd who
published “Atlas of skeletal maturation of
hand”
• many subsequent studies were made on basis
of Grehlich & Pyle’s indicators

7. INDIAN STUDIES
• Basu (1938) tackled the problem of epiphyseal union rather than
appearance in Bengalese children. He stated that diaphyseo –
epiphyseal union had a “climatic and racial variability” questioning
the comparability of American Standards. He doubted that “there
may be evolved one common standard for the whole of the
heterogenous population of India”.
• MODI (’57) : The most extensive tabulation for non-whites is that
of Modi for East Indian Children. He has stated that “Owing to the
variations in climatic, dietetic, hereditary and other factors affecting
the people of the different provinces of India it cannot be reasonably
expected to formulate a uniform standard for the determination of
age of the union of epiphyses for the whole of India. However, from
investigations carried out in certain provinces it has been concluded
that age at which the union of epiphyses takes place in Indians is 2-3
years in advance of the age in Europeans and epipyseal unions
earlier in females.

8. Various studies
• Quereshi studies skeletal maturity in Pakistani children
• Murata in his study compared skeletal maturation with
population from U.K., Belgium, North India, South China
and Japan. Japanese children were found to attain skeletal
maturity 1-2 years earlier than present day European and
Chinese children. A relative lack of data for North Indian
population made comparison impossible.
• Galstaun study was done in Bengali population(1930-
’37) and Bajaj et al., study was done at Delhi.
• Greulich- Pyle study was done in children of the upper
socio economic status White children in 1931-1942.

11. X ray showing the skeleton of a newborn. Gaps between bones
indicate cartilage, which will develop into bone tissue as the child
ages

12. “There is nothing called average individual
because each individual is different”

17. illustration depicting the stages of long bone
growth, showing the process of cartilage
calcifying and becoming mature, compact
bone.

20. Stages of Epiphyseal Union
Stage 0 Non union
Stage 1 ¼ united
Stage 2 ½ united
Stage 3 ¾ united
Stage 4 complete union

21. • In females the bone maturity is
advanced because of an advancing
pubertal age. Pubertal age is found
to advance by 4 months per decade
throughout the world.
• Galstaun study indicates that
uniformly the Females bone maturity
has advanced 1 year

22. Why the difference
The difference in appearance & fusion of ossification
centres & with various standard studies could be
due to factors like
• Racial, Genetic, Socio economic,
• Nutritional and Climate factors-which
need to be evaluated.
Generally ossification activities occur earlier in the
Indian population than western
 Skeletal maturation has accelerated in 20th centruy
and the study done by Grehlich, FELS are distant

23. Scar of recent union ?
“The period of fusion indicated by radiographs of
the bony extremities are approximately three
(3) years (?) earlier than the periods of fusion
indicated by anatomical evidence..because
epiphyseal lines can remain visible on the bone
for a considerable time after the radiographs
indicate that fusion has taken place”.
 Actually the difference b/w this stage 1 & 2 is
+ 6 months

28. SCAPULA
CENTRES APPEARANCE FUSION
FOR CORACOID 1st year Puberty
SUB CORACOID for
lateral part of root of
coracoid & upper
1/3rd of Glenoid cavity
10th year Puberty
MARGINS OF GLENOID
CAVITY
Puberty 20-25 yrs
INFERIOR ANGLE Puberty 20-25 yrs
VERTEBRAL BORDER Puberty 20-25 yrs
TWO ACROMION Puberty 20-25 yrs

29. Scapula

30. Scapula (23 yrs)
• krogman says- ‘Though the epiphysis for the medial
border lags in the early twenties, fusion for all three
{acromion, medial border, and inferior angle} is
completed by the Twenty-third year (23).
• The lipping of the circumferential margin of the
acromial facet and glenoid fossa usually begins by 30-
35 yrs and at the clavicular facet begins at 35-40 yrs.
• Appearance of a ‘plaque’ or facet on under side of
acromical process begins by 40-45 yrs
• Increasing demarcation of the triangular area at the
base of scapular spine begins at 50 yrs of age
• Appearance of cristae scapulae occurs 50 yrs & above

31. Clavicle
• As early as 18 yrs, but any time between 18-25 yrs,
the epiphyseal cap begins to unite to the billowed
surface of the medial end of the clavicle.
• Union begins at the approximate centre of the face
and spreads ot the superior margins where it may
progress either anteriorly or posteriorly.
• From 25- 30 yrs the majority of cases are
undergoing terminal union.
• The last site of union is located in the form of a
fissure along the inferior border. With obliteration
of this (31 yrs) the union is completed

32. Ribs & vertebrae
• Centres for Head & Tubercles (No tubercles in
11th & 12th Ribs) and appears at 14 yrs and fuses
at 25 yrs.
• Ossification occurs at upper and lower Ribs and
spreads towards the middle. Thus the last ribs to
become fully united are 4-9th Ribs
• Occurs 2-3 years earlier in females
• The presacral vertebral column is completely
ossified by the 24th year.
• Last signs of maturity occurs in upper Thoracic
vertebrae (T4- T5)
• Striations tend to disappear from surface of
centre starting at 23yr but may persist in lumbar
region for many years

45. Elbow Joint

49. BEFORE BIRTH –
Appearance of
• Head of Humerus,
• Distal end of femur
• Proximal tibia
• Calcaneum,
• Talus
• cuboid

50. Ossification Time Table
Age Male Age Female
2-3 yrs Metacarpals II,III, IV
Distal end of radius
1-2 yrs Metacarpals II,III, IV,
V
3-4 yrs Metacarpal V 2-3 yrs Metacarpal I,
Triquitrum
4-5 yrs Metacarpal I 4-5 yrs Medial epicondyle,
6-7 yrs Lunate 5-6 yrs Lunate
7-8 yrs Trapezoid, Scaphoid,
Head of Radius
6-7 yrs Trapezium,
Trapezoid, Scaphoid
8-9 yrs Trapezium,
Distal Ulna
7-8 yrs Distal Ulna
Medial epicondyle 10-11 yrs Pisiform

53. Table : Comparison of age (in years) of appearance of
ossification centres of males in various studies
Sl. no
BONE Bajaj
(Delhi)
Garn(’67)
50th
percentile
Galstaun
(1930’s)
Bengalis
Greulich-Pyle
Std. (1959) mean
(age in years)
Chennai study
Thesis (2008)
1 Metacarpal I 4 . 2 yrs 2yrs 7mnts 4 yrs 2 Yrs 6 Mnts 4-5 Yrs
2 Metacarpal II 1 . 0 7 yrs 1yrs 7mnts 3-4 yrs 1 Y r 5 M n t s 2-3 yrs
3 Metacarpal III 1 . 0 7 yrs 1yrs 9mnts 3-4 yrs 1 Yr 9 Mnts 2-3yrs
4 Metacarpal IV 1 . 7 yrs 2 yrs 3-4 yrs 2 Yrs 2-3 yrs
5 Metacarpal V 1 .7 yrs 2 yrs 3-4 yrs 2 Yrs 4 mnts 3-4 yrs
6 Trapezium 7.5 yrs 5 yrs 1 mnts 7 yrs 5 Yrs 4 mnts 8-9 yrs
7 Trapezoid N A 6 yrs 3 mnts NA 5 Yrs 4 mnts 7-8 yrs

54. Table : Comparison of age (in years) of appearance of
ossification centres of males in various studies
Sl.
no BONE Bajaj
(Delhi)
Garn(’67)
50th
percentile
Galstaun
(1930’s)
Bengalis
Greulich-Pyle
Std. (1959) mean
(age in years)
Chennai study
Thesis (2008)
8 Scaphoid 8.4 yrs 5 yrs 8 mnts 7-11 yrs 5 Yrs 7-8 yrs
9 Lunate 6.5 yrs 4 yrs 1 mnts 5 yrs 3 Yrs 10 mnts 6-7 yrs
10 Triquitrum 3.7 yrs 2 yrs 5 mnts 3yrs - 4 yrs 2 Yrs 3 mnts 3-4 yrs
11 Pisiform 10yrs 2 mnts N A 9 -12 yrs - - 10-11 Yrs
12 Distal radius 3.5 yrs 10 mnts 1 yr 1 1 M n t s 1-2 yrs
13 Distal ulna 6.5 yrs 5 yrs 5 mnts 8-10 yrs 5 Yr 3 Mnts 7-8 yrs
14 Head of Radius 3.5 yrs 3 yrs 11 mnts 6 yrs 4 Yrs 5-6 yrs
15 Medial
epicondyle
5 yrs 3 yrs 5 mnts 5 yrs 3 Yrs 5 mnts 4-5 yrs

55. STERNUM
• Age related change in morphology of sternal
end of 4th rib can be measured and compared
to standards.
• Ossificatioin of Hyaline cartilages- cartilage
which connects ribs to sternum turns stony
with age- can be considered a general
indicator of age.

56. S
T
E
R
N
U
M
5-6
m
7 m
7 m
10
m
3yr
About 40-45 yrs

63. Risser’s sign
• The Risser sign refers to the amount of calcification of
the human pelvis as a measure of maturity.
• On a scale of 5, it gives a measure of progression
of ossification; the grade of 5 means that skeletal maturity is
reached. Risser sign is based on the observation of an X-ray
image.
• Grade 1 is given when the ilium (bone) is calcified at a level of
25%; it corresponds to pre-puberty or early puberty. Grade 2 is
given when the ilium (bone) is calcified at a level of 50%; it
corresponds to the stage before or during growth spurt.
• Grade 3 is given when the ilium (bone) is calcified at a level of
75%; it corresponds to the slowing of growth.
• Grade 4 is given when the ilium (bone) is calcified at a level of
100%; it corresponds to an almost cessation of growth.
• Grade 5 is given when the ilium (bone) is calcified at a level of
100% and the iliac apophysis is fused to iliac crest; it
corresponds to the end of growth.
• The Risser sign is referenced in clinical decision-making
regarding adolescent idiopathic scoliosis.

75. Appearance and fusion of Hip bone
Bone-region Appearance Fusion
Iliac crest 14 yrs 18-20 yrs
Tri-Radiate cartilage _ _ 11-14 yrs
Ischium 15-17 yrs 19-21 yrs
Pubis 14 yrs 20 yrs
Ischio-pubic ramus _ _ 6 yrs

77. SACRUM
• The five sacral vertebrae remain separated by
cartilage until puberty, ossification of
intervertebral discs starts from below upwards
and the fusion of the sacral segments beocme
complete by 20-25 yrs

85. CHRONOLOGICAL
ORDER OF APPEARANCE
AND FUSION OF
EPIPHYSIS

86. BEFORE BIRTH
In both sexes Appearance of
• Head of Humerus,
• distal femur,
• proximal tibia,
• calcaneum,
• Talus
In Females appearance of Cuboid

87. During first year of life
In both sexes Appearance of
• Hamate, Capitate,
• Head of femur
• Third cuneiform
In Males In Females
Cuboid
Capitulum
Distal Radius
Distal Tibia
Distal Fibula

89. During second year of life
In both sexes Appearance of
• Proximal phalanges of inner four fingers
In Males In Females
Capitulum,
Distal Epiphysis of
Radius
Distal Fibula
First Metacarpal,
Distal Phalanges of
Thumb, Middle & Ring
Fingers,
Tarsal Navicular,
I & II Cuneiforms

90. At age of TWO
In both sexes Appearance of
• Inner four metacarpals, first metaTarsal,
• proximal phalanges of Toes, distal phalanx of
Hallux
In Males In Females
First Metacarpal,
Distal Phalanx of Thumb,
Distal Phalanx of Index
Finger, & First Cuneiform
Proximal Phalanges of
Thumb,
Middle Row of
Phalanges of Fingers

94. At age of THREE appearance of-
In Males In Females
Triquetrum,
Proximal Phalanx of
Thumb,
Middle Phalanges of
Middle & Ring Fingers,
Tarsal Navicular,
II Cuneiform
Patella,
Proximal Fibula,
II Metatarsal,
III Metatarsal,
middle Phalanges of II,
III, & IV toes,
distal phalanges of III &
IV toes

95. X-ray of three-year-old girl showing
the ossification of Triquitrum

96. At age of FOUR
In both sexes Appearance of Fourth Metatarsal
In Males In Females
Appearance of Lunate,
middle Phalanges of
index & little fingers,
Distal Phalanges of
middle & ring fingers,
II metatarsal,
III Metatarsal,
Middle Phalanx of II toe
Appearance of Head of
Radius, fifth metatarsal
Fusion of greater
tubercle to Head of
Humerus

97. At age of FIVE
In Both Sexes Appearance Of Carpal Navicular,
Multangulum Majus, Greater Trochanter, Distal
Phalanx, Distal Phalanx Of II Toe
In Males In Females
Appearance of Head of
Radius, distal phalanx of
little finger, patella,
proximal Fibula, V
Metarasal, middle
Phalanges of III & IV toes,
Distal Phalanges of III &
IV toes
Appearance of medial
epicondyle, distal Ulna,
Lunate,Triquetrum,
Multangulum Minus,
distal Phalanx of
Index finger

98. At age of SIX
In Males In
Females
Fusion of Greater tubercle of
Head of Humerus.
Appearance of
Medial epicondyle,
Distal Ulna,
Multangulum minus.
__
__

99. X-ray of six-year-old girl showing the
ossification of Lunate

100. At age of SEVEN
In
Males
In Females
__
__
Appearance of Distal Phalanx of
little finger.
Fusion of Rami of Ischium and
Pubis

101. X-ray of seven-year-old girl with ossification
center of Medial epicondyle

102. X-ray of 7 yr girl with ossification
center of Trapezium, trapezoid and Scaphoid

103. X-ray of seven-year-old boy with ossification
center of Trapezium and trapezoid

104. At age of EIGHT
In both sexes Appearance of Apophysis of
Calcaneus
In
Males
In Females
__
__ Appearance of Olecranon

105. X-RAY OF EIGHT YEAR-OLD
GIRL SHOWING THE
OSSIFICATION CENTRE OF
DISTAL ULNA

107. X-ray of eight year-old boy showing the ossification
center of Trapezium and Distal ulna

108. At age of NINE
In Males In Females
Fusion of Rami of
Ischium and Pubis
Appearance of
Trochlea,
Pisiform

109. At age of TEN
In Males In Females
Appearance of
Trochlea,
Olecranon
__
___N

110. At age of ELEVEN
In Males In Females
Appearance of Pisiform Appearance of Lateral
Epicondyle

111. At age of TWELVE
In Males Females
Appearance of Lateral
Epicondyle
__
__

112. At age of THIRTEEN
In Males In Females
Fusion of
Capitulum to
Trochlea and
Lateral Epicondyle
Appearance of Proximal
Sesamoid of thumb.
Fusion of Lower conjoint
epiphysis of humerus,
Distal Phalanx of thumb,
Fusion Bodies of Ilium, Ischium
and Pubis.

113. At age of FOURTEEN
In Males
Appearance of Head of Radius, distal phalanx of
little finger, patella, proximal Fibula,
V Metarasal, middle Phalanges of III & IV toes,
Distal Phalanges of III & IV toes

114. At age of FOURTEEN
In Females
Appearance of Acromion, Iliac crest,
Lesser trochanter.
Fusion of Olecranon, Upper Radius, Proximal
phalanx of ring finger, Distal phalanx of thumb,
Head of Femur, Greater Trochanter, Distal Tibia
and Fibula, Apophysis Calcaneus,
First Metatarsal,Proximal phalanges of toes.

115. At age of FIFTEEN
In both sexes Appearance of Sesamoid of little
finger. Fusion of Distal phalanges of
second,third & fourth toes.
In Males
Appearance of Acromion.
Fusion of Ilium, Ischium and Pubis.

116. At age of FIFTEEN (15)
In both sexes Appearance of Sesamoid of little
finger. Fusion of Distal phalanges of
second,third & fourth toes.
In Females
Appearance of Sesamoid of index and little fingers.
Fusion of Medial epicondyle,First
metacarpal,Proximal phalanx of thumb,Distal
phalanges of inner four fingers,Proximal tibia,Outer
four metatarsals,Middle phalanx of second toe,Distal
phalanges of inner four toes.

117. At age of SIXTEEN (16)
In Females
Appearance of Distal sesamoid of thumb,Tuber
Ischii.
Fusion of Inner four metacarpals,Proximal
phalanges of index,middle and little
fingers,middle phalanges of fingers.

118. At age of SIXTEEN
In Males
Fusion of Lower conjoint epiphysis of humerus,
medial epicondyle, Olecranon, Head of Radius,
Distal phalanx of middle finger, Apophysis of
Calcaneus.

119. At age of SEVENTEEN
In both sexes Fusion of Acromion
In Females
Fusion of Upper conjoint epiphysis of humerus,
Distal ulna, Distal femur, Proximal fibula.
Appearance of Distal sesamoid of thumb.

120. At age of SEVENTEEN (17)
In both sexes Fusion of Acromion
In Males
Appearance of Distal sesamoid of thumb.
Fusion of First metacarpal,
Proximal phalanges of thumb and ring finger,
Middle phalanges of Index, Middle and ring finger
Distal phalanges of thumb, Index, ring and little
fingers, Head of femur, Greater trochanter, Distal
tibia and fibula,
Metatarsals, Proximal phalanges of toes, middle
phalanx of second toe, distal phalanx of hallux.

122. At age of EIGHTEEN
In Males In Females
Fusion of Inner four
metacarpals,
Proximal phalanges of
index, middle and little
fingers,
middle phalanges of little
finger,
Proximal tibia.
Fusion of Distal radius.

125. At age of NINETEEN
In Males
Appearance of Sesamoid of index, Tuber ischii.
Fusion of Upper conjoint epiphysis of humerus,
Distal radius and ulna, Distal femur, Proximal
fibula.

135. At age of TWENTY
In both sexes Fusion of Iliac crest.
In Males
Fusion of Tuber Ischii.

136. At age of 21
In both sexes Appearance of Clavicle.
In Females
Fusion of Tuber Ischii.

142. At age of 22
In both sexes Fusion of Clavicle.

157. After 25 years
• If all epiphysis of long bones are united the individual is
most probably >25 years.
• After 25 age estm. becomes more uncertain.
Between 40-60 yrs
The ossification of Hyoid bone.
Fusion of greater cornu with body of hyoid bone
Xiphisternum with body
Lipping of verebrae > 45 yrs
Rarefaction of bones(osteoporosis) after 60 yrs
Calcification of costal cartilage(30) yrs & Laryngeal
cartilage 50+ 12.7 yrs
Changes in Mandible with age

159. Symphyseal surface in Estimation of age
accuracy + 2 years
Below 20yr Symphyseal surface has an even appearance with layer
of compact bone over its surface
20-30 yrs It looks markedly ridged and irregular.- the ridges or
billowing run transeversely and irregular across articular
surface
25- 35 yrs the billowing gradually disappears and the articular
surface in macerated bone presents granular appearance
with well-defined anterior and posterior margins
35-45 yrs The articular surface looks smooth and oval with raised
upper and lower extremities
45-50 yrs Narrow beaded rims develop in and around the margins
of the articular surface showing some erosion
Above 50
yrs
Symphyseal surface presents varying degrees of erosion with
varying degrees of erosion with breaking down of the
ventral margins

161. Skull Sutures In Estimation Of Age
Posterior fontanelle closes b/w birth 1.5 months
Anterior fontanelle closes by second year
2 postero-lateral fontanelles closes within a
short period after birth & antero-lateral
fontanelles within first 6 months.
Metopic suture b/w 2 frontal bones closes b/w
2 yrs-8 yrs but rarely may remain intact
The basi-occiput fuses with basi-sphenoid by
about 18-20 yrs in Females & 20-22 in Males

163. Suture Closure in the Skull
• Closure begins in inner table 5-10 years earlier
than outer table
• In contrast to others the fusion occurs earlier
in Males
• Endocranially suture closure is more uniform
& complete and might not close ectocranially
known as LAPSED UNION – eg sagittal suture
• Estimation of age by sutural closure of skull is
not reliable, it can be given only in decades
• The order of reliability is sagittallamboid
& coronal

164. Order of suture closure in skull
30-40 yrs:- Posterior 1/3rd of sagittal suture-about
40-50 yrs:- Anterior 1/3rd of sagittal suture & lower
half of coronal suture-about
50-60 yrs:- Middle sagittal and upper half of
coronal suture at about
In Lamboid suture fusion activity occurs late and
the progress is also slow, the closure starts about
25-30 yrs near Asterion maximum closure at
about 55 yrs
Squamous part of temporla bone with its
surrounding after 60yrs
Towne’s view useful

166. H
Y
A
O
N
U
K
YOU