Estimating Skeletal Age in Children: A Comprehensive Anatomic Approach Current Concept Review

Abstract

Skeletal maturity is a critical consideration for pediatric orthopedic surgeons, general pediatricians, endocrinologists, metabolic bone disease specialists, rheumatologists, and physiatrists in the development and modification of treatment plans for growing children. Arguably the most widely utilized method of determining skeletal age, the Greulich and Pyle method (GPM), unfortunately has many shortcomings. Between the method reflecting limited population metrics and its reliance on a voluminous hard-copy radiographic atlas, the GPM may not lend itself to widespread use or optimized learning in the modern era of orthopedics. In 2013, the Shorthand Bone Age (SBA) method suggested a simpler approach by demonstrating reliability when just a single feature for each skeletal age, depending on patient sex, was sufficient in providing an accurate bone age estimate reflective of the full GPM. In addition to the SBA, an expanding body of research has emerged over the past two decades, attempting to provide the orthopedic community with simpler yet effective tools to determine skeletal age. In this review, we compare and present the spectrum of current concepts encompassing validated bone age determination methods for each of six commonly imaged anatomic locations: hand/wrist, elbow, shoulder/proximal humerus, hip/pelvis, knee, foot/ankle. All methods are presented visually in table format, with detailed graphic design, quantitative approximations to generate relative consistency between systems, and age-based color-coding for ease of memorization and use. All images are derived from patients presenting to the study institution within the past three months, so as to harness modern image quality and populations while also adhering to the principles and age-based features inherent to each system’s different categories. The purpose of this review is multifaceted: to enable better incorporation of skeletal age considerations into daily practice by caregivers in many disciplines; to enhance awareness regarding the full array of tools that may spare young patients additional and unnecessary radiation; and to serve as a springboard for a mobile application to be utilized in any clinical setting by anyone with a mobile device.