Skeletal Development of the Hand and Wrist – A Radiographic Atlas and Digital Bone Age Companion 2011 PDF

Skeletal Development

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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 magnifi cent 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.
Although the value of the Greulich and Pyle atlas itself cannot be overstated, its use in a high-volume, PACS-based, academic or private practice setting can be cumbersome. Rapid review of the images and text in a dark reading room, followed by the performance of manual calculations, is somewhat tedious. As such, it is our goal to modernize the Greulich and Pyle method for pediatric bone age interpretation for the contemporary practice.
This printed atlas contains updated images mined from many thousands of candidate images in our PACS at the University of Virginia. Our selection process was rigorous and took place in several phases. The images were initially clinically interpreted or “aged” by academic sub-specialized pediatric radiologists. Subsequently, the images were painstakingly compared head-to-head through several rounds of a selection process, involving musculoskeletal radiologists, whereby we searched for images that closely matched the developmental details evident on the Greulich and Pyle standard images and accompanying text. Subsequently, the selected images were professionally edited in fine detail with Photoshop ™ to ensure that the developmental features of each bone on each image matched the widely accepted reference standards of Greulich and Pyle’s second edition. The result is an atlas of exceptionally high-quality skeletal radiographic standards which captures both the major and finer details of the accepted standards.
On occasion, individual bones in our standards are purposefully slightly more advanced or delayed relative to their counterparts in Greulich and Pyle’s atlas. These intentional discrepancies are actually refinements to aid the user in determining skeletal age because they overcome one of the limitations of the unedited standards in Greulich and Pyle’s atlas. Occasionally, individual bones in their standards are significantly delayed or advanced relative to the overall age of a given standard. For example, their MALE STANDARD #11 is their 3 year 6 month (42 month) standard, yet it has a 36-month
2nd middle phalanx and a 54-month lunate. The process of reviewing their standards and correlating with the text providing the age of each bone can be an arduous and sometimes ignored task. Failure to correlate with the text, however, can lead to errors in assessment of skeletal age if one only compares a patient’s hand radiograph with the standard images alone. Our atlas does this work for you, as we have edited our standards so that each bone is more consistently age-appropriate. On occasion, we kept some bones slightly advanced or delayed in order to bear necessary resemblance to the Greulich and Pyle standards; however, we labeled such instances on our annotated images to aid the user.
The Greulich and Pyle atlas contained excellent descriptive text to help distinguish adjacent standards based upon various subtleties. One limitation though is that this textual information is somewhat tedious to apply to the images on the opposite pages. Thus, it often goes ignored in an effort to get clinical work done. Our printed atlas contains annotated images, opposite the bare images, that highlight important and subtle features that can be used to distinguish standards that superficially look similar. We hope that this format encourages use of this information so that bone age interpretation may be faster, more accurate, and more educational.
This printed atlas is bundled with the Digital Bone Age Companion (DBAC), which is also available for individual or institutional purchase. The Digital Bone Age Companion (DBAC) is a freestanding Windows ™ application with an incorporated image atlas documenting the development of the human hand for both males and females. This digital format offers additional enhancements which further optimize bone age interpretation. Users can easily zoom-in on subtle radiographic features, set image level and width to their preference, and compare two or three reference standards side-by-side for those difficult cases that superficially look like adjacent standards. Users will also be thrilled to abandon tedious manual calculations for automated and more reliable digital results via the flexible bone age calculator. Trainees will be enabled to rapidly and reliably interpret bone age studies with little attending support. Attending physicians will find resident check-out to be more pleasant and accurate. All users can further expedite their workflow by utilizing the built-in report generator, obviating the need to transpose data and potentially avoiding dictation altogether. The digital format may also be available for integrated use with your Radiology Information System (RIS), such as with Radiant (the RIS for EpicCare, the electronic health record by Epic Systems). Integration further optimizes workflow by expediting the process and reducing user-introduced errors.
Given the broad application of pediatric bone aging, this atlas is not only intended for practicing and training radiologists, but for all of those who employ bone age studies as part of their practice. We hope that you find this atlas as practical and academic as we have found using it at our own institution.

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