Gaskin Cree M - Skeletal development of the hand and wrist: a radiographic atlas and digital bone age companion

A Radiographic Atlas and Digital Bone Age Companion

Cree M. Gaskin, MD

Associate Professor of Radiology and Orthopaedic Surgery

Vice-Chair, Informatics

Fellowship Director, Musculoskeletal Radiology Fellowship

Director, Musculoskeletal MRI

University of Virginia Health Sciences Center

Charlottesville, Virginia

S. Lowell Kahn, MD, MBA

Interventional Radiologist

Palm Beach Radiology Professionals

JFK Medical Center

West Palm Beach, Florida

J. Christopher Bertozzi, MD

Clinical Instructor

Musculoskeletal Radiology

University of Virginia Health Sciences Center

Charlottesville, Virginia

Paul M. Bunch, MD

Musculoskeletal Radiology

University of Virginia Health Sciences Center

Charlottesville, Virginia

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Library of Congress Cataloging-in-Publication Data

Gaskin, Cree M., author.

Skeletal development of the hand and wrist : a radiographic atlas and digital bone age companion / Cree M. Gaskin, S. Lowell Kahn, Paul M. Bunch

p. ; cm.

ISBN 978-0-19-978205-5

1. Carpal bonesRadiographyAtlases. 2. PhalangesRadiographyAtlases. 3. Skeletal maturityAtlases. I. Kahn, S. Lowell, author. II. Bertozzi, J. Christopher, author. III. Bunch, Paul M., author. IV. Title.

[DNLM: 1. Hand Bonesgrowth & developmentAtlases. 2. Age Determination by SkeletonAtlases. WE 17]

QM117.G37 2011

611.718dc22

2010050983

_______________________________________

This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material.

9 8 7 6 5 4 3 2 1

Printed in the United States of America

on acid-free paper

To Kathy, Anna Kate, Warner, and Audrey the greatest loves of my life.

C.M.G.

To my loving wife, Carrie, and my daughters, Chloe and Ella. Thank you for your unyielding love and support.

S.L.K.

To Joelle, Eva, and Caroline.

J.C.B.

To my parents and teachers.

P.M.B.

Lead Authors: Cree M. Gaskin, MD; S. Lowell Kahn, MD, MBA

Co-Authors: J. Christopher Bertozzi, MD; Paul M. Bunch, MD

Project Consultants: Talissa Altes, MD; Joan McIlhenny, MD; Bennett Alford, MD

This atlas has been a work in progress for the last three years. It not only represents a tremendous effort by many individuals, but a tireless commitment to quality put forth by all of those involved. Without this level of dedication, this atlas would not exist.

A special thank you goes out to Drs. Talissa Altes, Joan McIlhenny, and Bennett Alford of the University of Virginia for ensuring that the work adheres to the highest standards in pediatric bone age interpretation.

Finally, wed also like to acknowledge Dr. Alex Towbin of Cincinnati Childrens Hospital Medical Center, Dr. Ana Gaca of Duke University Medical Center, and Dr. George Bissett of Texas Childrens Hospital for information regarding bone age interpretation at their sites.

Thank you!

Cree M. Gaskin, MD

S. Lowell Kahn, MD, MBA

J. Christopher Bertozzi, MD

Paul M. Bunch, MD

The assessment of skeletal maturity is an important part of the diagnosis and management of pediatric growth disorders. Proper interpretation of bone age studies is important for several reasons. In a child with growth disturbance, estimations of adult height can be made based upon bone age radiographs. If hormonal therapy is being considered, the time of initiation and duration of hormonal therapy depends upon the bone age. Furthermore, certain orthopedic interventions, such as those for scoliosis and limb length discrepancies, may be timed based upon bone age results.

Despite the magnificent technological advancements in radiology, plain radiographs remain the exam of choice for skeletal bone age determination. Bone age studies are ubiquitous in academic and private practice settings, and are no doubt relatively time consuming when examining the subtle changes present within the maturing human hand, comparing them with reference standards, and performing manual calculations to assess whether or not a hand is of appropriate skeletal age.

The Radiographic Atlas of Skeletal Development of the Hand and Wrist, by Drs. Greulich and Pyle, last published in 1959 as a second edition, has long been the reference of choice for bone age interpretation for most practitioners in the United States. The book contains an atlas of male and female reference standards of the left hand through the age of 18 for females and 19 for males. It also includes detailed descriptions of the subtle changes corresponding to each image and reference charts for the appropriate standard deviation values.

Their standards and data were based upon more than two decades of work that began with the Brush Foundation Study of Human Growth and Development, which was organized and led by Professor T. Wingate Todd for more than ten years. The Greulich and Pyle standard images were the result of many years of painstaking work by many individuals who studied hand radiographs obtained serially in thousands of children. Beyond this, they also established age-based standard deviations for their images after analyzing their application to the hand radiographs of hundreds of children. In part due to the daunting task of replacing such standards and related standard deviations, this atlas has remained in widespread use for more than fifty years. Other methods for bone age interpretation do exist, but are not in widespread use in the United States as they have greater inter-reader variability or are significantly more tedious.