Estimating Skeletal Maturity Using Wrist Radiographs During Preadolescence: The Epiphyseal:Metaphyseal Ratio

Although skeletal maturity is most relevant during adolescence, it has utility in treatment of younger patients in some circumstances, such as scoliosis, limb length discrepancy, or endocrinopathies. Currently, a quick, accurate, and reproducible method of estimating skeletal maturity in preadolescents using wrist radiographs is lacking.Serial anteroposterior wrist radiographs taken at historical growth study visits leading up to the chronological age (CA) associated with 90% of the final height (an enhanced skeletal maturity standard as compared with peak height velocity) were analyzed in 102 children. Epiphyseal and metaphyseal widths of 5 physes were evaluated: distal radius, distal ulna, first metacarpal, third metacarpal, and fifth metacarpal. Ulnar styloid height and radial styloid height were also measured, for a total of 7 epiphyseal:metaphyseal radiographic parameters. Greulich and Pyle (GP) bone age was also measured. A combination of stepwise linear regression and generalized estimating equation analyses was used to produce a skeletal maturity estimation model incorporating demographics (CA and sex) and the epiphyseal:metaphyseal ratios significantly correlated with skeletal maturity.A total of 273 left anteroposterior hand-wrist radiographs from 56 girls (163 radiographs, range 4 to 13 y) and 46 boys (112 radiographs, range 3.8 to 15 y) were included. The demographics+ratios model had better prediction accuracy than GP only and GP with demographics (0.44, 0.87, and 0.47 y mean discrepancy from actual skeletal age, P0.05 for both comparisons). There was no significant difference in the rate of outlier skeletal age estimates, defined as an estimate1 year off from the true skeletal age, between the demographics+ratios model and the demographics+GP model (5.9% vs. 8.4%, P =0.12).When combined with CA and sex data, measurement of the epiphyseal:metaphyseal ratios of the left first and third metacarpals allows for improved skeletal maturity estimation compared with the GP technique.Our modified wrist skeletal maturity system offers a relatively quick and reproducible method for estimating skeletal maturity extending into the juvenile age range. This study is a level III retrospective study of longitudinal human growth data obtained from the Bolton Brush Collection in Cleveland, Ohio.