Bone age assessment is performed to evaluate growth in pediatric patients and diagnose endocrine disorders. It relies on visual evaluation of hand and wrist skeletal development compared to standard references. Key applications include diagnosing growth disorders and predicting final adult height. Skeletal development is divided into stages from infancy to post-puberty based on characteristics like appearance of ossification centers and epiphyseal fusion. Bone age is assessed by comparing a patient's hand and wrist radiograph to standardized images for their age and sex.

1. Bone Age Assessment
Dr. Muhammad Bin Zulfiqar
Alnoor Diagnostic Centre

2. Introduction
• Bone age assessment is frequently performed
in pediatric patients to evaluate growth and to
diagnose and manage a multitude of
endocrine disorders and pediatric syndromes
• For decades, the determination of bone
maturity has relied on a visual evaluation of
the skeletal development of the hand and
wrist, most commonly using the Greulich and
Pyle atlas

3. Clinical Applications for Skeletal
Determinations
• A single reading of skeletal age informs the
clinician of the relative maturity of a patient at
a particular time in his or her life,
• Integrated with other clinical findings,
separates the normal from the relatively
advanced or retarded

4. Clinical Applications for Skeletal
Determinations
• Successive skeletal age readings –Treatment
response.
• In normal subjects, bone age should be
roughly within 10 per cent of the
chronological age.
• Greater discordance between skeletal age and
chronological age occurs in children who are
obese or who start puberty early, as their
skeletal age is accelerated.

5. Applications
• There are two main applications for
evaluations of skeletal maturation:
1. the diagnosis of growth disorders
2. the prediction of final adult height.
V. Gilsanz /O. Ratib · Hand Bone Age

6. Methods
• Estimation from Hands and Wrist.
• Estimation from hip.
• Estimation from foot
• Elbow and Shoulder

7. Skeletal Developemental
• To facilitate bone age assessments, skeletal
development is divided into six major
categories

8. Stages of Skeletal Maturity
• Infancy (the carpal bones and radial epiphyses);
• Toddlers (the number of epiphyses visible in the long
bones of the hand);
• Pre-puberty (the size of the phalangeal epiphyses);
• Early and Mid-puberty (the size of the phalangeal
epiphyses);
• Late Puberty (the degree of epiphyseal fusion); and,
• Post-puberty (the degree of epiphyseal fusion of the
radius and ulna).

9. Infancy
• Females: Birth to 10 months of age
• Males: Birth to 14 months of age
• All carpal bones and all epiphyses in the
phalanges, metacarpals, radius and ulna lack
ossification in the full-term newborn.
• The ossification centers of the capitate and
hamate become apparent at about 3 months
of age and remain the only useful observable
features for the next six months

10. Infancy

11. Toddlers
• Females: 10 months to 2 years of age
• Males: 14 months to 3 years of age
• The ossification centers for the epiphyses of
all phalanges and metacarpals become
recognizable during this stage, usually in the
middle finger first, and the fifth finger last.

12. Toddlers

13. Toddlers

14. Toddlers

15. Toddlers

16. Pre-puberty
• Females: 2 years to 7 years of age
• Males: 3 years to 9 years of age
• Assessments of skeletal maturity in
prepubertal children are primarily based on
the epiphyseal size of the phalanges as they
relate to the adjacent metaphyses

17. Pre-puberty
• Depiction of the progressive growth of the
width of the epiphyses, which, during this
stage of development, become as wide as the
metaphyses

18. Pre-puberty

19. Pre-puberty

20. Pre-puberty

21. Early and Mid-puberty
• Females: 7 years to 13 years of age
• Males: 9 years to 14 years of age
• As in pre-pubertal children, assessments of
skeletal maturity in early and mid-puberty are
also based on the size of the epiphyses in the
distal phalanges (first) and the middle phalanges
(second).
• The epiphyses at this stage continue to grow and
their widths become greater than the
metaphyses

22. Early and Mid-puberty

23. Early and Mid-puberty

24. Early and Mid-puberty

25. Late Puberty
• Females: 13 years to 15 years of age
• Males: 14 years to 16 years of age
• Assessments of skeletal maturity in this stage
are primarily based on the degree of
epiphyseal fusion of the distal phalanges.

26. Late Puberty
• Fusion of the epiphyses to the metaphyses in
the long bones of the hand tends to occur in
an orderly characteristic pattern, as follows
1. Fusion of the distal phalanges;
2. Fusion of the metacarpals;
3. Fusion of the proximal phalanges; and,
4. Fusion of the middle phalanges.

27. Late Puberty

28. Post-puberty
• Females: 15 years to 17 years of age
• Males: 17 years to 19 years of age
• At this stage, all carpals, metacarpals and
phalanges are completely developed, their
physes are closed
• Assessments of skeletal maturity are based on
the degree of epiphyseal fusion of the ulna
and radius.

29. Post-puberty

30. Age from upper limb examination
• At the wrist and shoulder joint (lower ends of
radius and ulna and head of the humerus)19-20
years.
• At the elbow region: trochlea and capitulum (14
years)-trochlea and capitulum + lower end of the
humerus (15years)
• Lat.epicondyle and head of ulna(17 years).
• Med epicondyles and the head of the radius
(18years)
• Metacarpals and phalanges (16 y in females and
18 years in males).

31. Age from lower limb examination
• Lesser trochanter (16y)-----Greater trochanter
(17y) ------ Head of the femur (18y).
• Lower end of the femur + shaft (21y).
• Upper end of the tibia +shaft (21y).
• Lower end of the tibia +shaft (18 y).
• By foot examination ossific center appears at
calcanium at 6 years and union of epiphysis at the
calcanium at 14 years ,so examining only this
bone gives us a range of 8 years

32. Calcaneal Epiphysis

33. Age from hip bone examination
• Two pubic rami of the hip (6y)
• Suture at the acetabulum (15y).
• Ischeal tuberosity with the ischium (21y).
• Iliac crest with the ilium (23y).

34. After 25 years
• If all epiphysis of long bones are united
individual is more than 25 years.
• After 25 years
– Hyoid bone ossification (40-60 years)
– Xiphisternum with body (60-70 years)
– Skull Sutures (30-60 years)

35. Order of suture closure in skull
• 30-40 years: Posterior 1 / 3rd of sagittal suture
• 40-50 years: Anterior 1 / 3rd of sagittal suture
and lower half of coronal sutures
• 50-60 years: Middle sagittal and upper half of
coronal suture
• Fusion of squamous part of temporal bone >
60 years
• Maximum closure of lambdoid suture at 55

36. THANX