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Dear,
The 鱨վ has asked us to provide an evidence based document justifying our opposition to the use of bone age assessment for age determination. This report as far as possible will try to avoid medical jargon and express facts in laymans terms. For the purposes of this document I will briefly review the history of bone age estimation, discuss intra and inter-observer error in bone age estimation and discuss variation in pubertal onset as this has a major impact on bone age assessment during adolescence.
Variations in the tempo of physical maturation have long been noted. For instance some children enter puberty before 10 years of age while others are not in puberty until late teenage years. These differences in physical maturation can be quantified by assessing how bones grow and mature. Greulich and Pyle, using hand and wrist X-rays, published an atlas of normal bone ages for healthy children in 1950 based on X-rays taken on children in the 1930s and 1940s ADDIN EN.CITE Greulich19501116Greulich, W.W.Pyle, S.I.Radiographic atlas of skeletal development of the hand and wrist1st ed1950Stanford, CAStanford University Press1. Comparison with X-ray photographs in this atlas currently remains the most common method for estimating bone age. A bone age is defined as advanced when it is older than the patients chronological age and delayed when it is younger. The commonest cause for this is normal variation in pubertal onset. However, many other factors impact on bone age maturation ADDIN EN.CITE Sperling20082226Sperling, MarkPediatric Endocrinology3rd2008Saunders Elsevier978-1-4160-4090-3 2. Obesity tends to advance bone age maturation while malnutrition and conditions that reduce fat mass such as anorexia nervosa delay it. Any chronic illness during childhood may also delay bone age maturation. Severe neglect can also cause bone age delay while placing such children in a more caring environment can result in earlier puberty and an advanced bone age. Thus many factors need to be considered when trying to establish age based on bone age estimation alone.
It should also be noted that the Greulich and Pyle atlas was not only based on a population of children over 70 years ago but comprised only Caucasian children from the United Kingdom. More recently racial differences have been shown in Middle Eastern, Asian and Black American populations with bone age disparities between 6 to 12 months depending on the age when the children were assessed ADDIN EN.CITE ADDIN EN.CITE.DATA 3-5. Other clinical methods have been developed especially those by Tanner and Whitehouse. Over the last decade several computer generated bone age software packages have been developed to reduce the intra-observer and inter-observer error noted with the clinician/ radiologist based estimations ADDIN EN.CITE Santos77717Santos, C.Ferreira, M.Alves, F. C.Cunha, E.Forensic Sciences Centre, Instituto Nacional de Medicina Legal, Largo da Se- Nova, 3000-213 Coimbra, Portugal.Comparative study of Greulich and Pyle Atlas and Maturos 4.0 program for age estimation in a Portuguese sampleForensic Science InternationalForensic Sci IntForensic Science InternationalForensic Sci IntForensic Science InternationalForensic Sci Int276.e1-72121-3Oct 101872-628321816552English6. It is important to note however, that all these methods were designed to assess bone age for medical reasons and NOT for forensic purposes.
All bone age estimation methods have error involved. In other words if the same X-ray is assessed either by the same or different assessors the assigned bone age may vary. Intra-observer error refers to the variation of one clinicians assessment while inter-observer error refers to the variation between different clinicians. Not surprisingly there is greater error with clinician based assessments compared to the computer generated assessments. A number of studies have investigated these effects and in summary have demonstrated an average intra-observer error of between 2 and 9 months and an average inter-observer error between 1 and 12 months ADDIN EN.CITE ADDIN EN.CITE.DATA 5, 7-17 However, these were average errors and the error range in these studies was 0 to over 2 years. Combining both the intra- and inter-observer, variation differences of over 12 months frequently occur. Variation using computer software to define bone ages is less and varies between 0 and 6 months ADDIN EN.CITE Santos77717Santos, C.Ferreira, M.Alves, F. C.Cunha, E.Forensic Sciences Centre, Instituto Nacional de Medicina Legal, Largo da Se- Nova, 3000-213 Coimbra, Portugal.Comparative study of Greulich and Pyle Atlas and Maturos 4.0 program for age estimation in a Portuguese sampleForensic Science InternationalForensic Sci IntForensic Science InternationalForensic Sci IntForensic Science InternationalForensic Sci Int276.e1-72121-3Oct 101872-628321816552English6.
Pubertal variation has a major impact on bone age estimation. Exposure to sex hormones causes bones to mature and ultimately to cease growth via epiphyseal fusion. Earlier puberty and exposure to sex hormones in either gender will lead to more rapid bone maturation and an older bone age for a given chronological age. Like most biological variables puberty occurs in a bell-shaped curve. For boys the normal range for starting puberty (defined as testicular enlargement >3 mls) is between 9 and 14 years and for girls (defined as breast development) between 8 and 13 years ADDIN EN.CITE Sperling20082226Sperling, MarkPediatric Endocrinology3rd2008Saunders Elsevier978-1-4160-4090-3 2. Clinicians involved in pubertal disorders also see many children with much earlier pubertal onset as well as others with substantial pubertal delay into late adolescence. The tempo of puberty is usually similar among individuals and takes 3 to 4 years to complete ADDIN EN.CITE Sperling20082226Sperling, MarkPediatric Endocrinology3rd2008Saunders Elsevier978-1-4160-4090-3 2. Thus there is approximately a 4 to 5 year range for normal puberty to start in both genders and, as expected, a similar difference in bone age estimations is also observed during this time.
Assessment of bone ages at any age has error involved in the interpretation. However, even when the bone age assessment is correct, the bone age may still be normally delayed or advanced relative to the subjects chronological age depending on their pubertal status and thus not accurately reflect chronological age. This is readily shown in the following graph (figure 1). This shows the difference between bone age estimation and chronological age for two different bone age assessments (Greulich and Pyle and the Maturos 4.0 computer program) on a population of 230 subjects aged 12 to 20 years ADDIN EN.CITE Santos77717Santos, C.Ferreira, M.Alves, F. C.Cunha, E.Forensic Sciences Centre, Instituto Nacional de Medicina Legal, Largo da Se- Nova, 3000-213 Coimbra, Portugal.Comparative study of Greulich and Pyle Atlas and Maturos 4.0 program for age estimation in a Portuguese sampleForensic Science InternationalForensic Sci IntForensic Science InternationalForensic Sci IntForensic Science InternationalForensic Sci Int276.e1-72121-3Oct 101872-628321816552English6. For a given bone age, the subjects actual (chronological) age can vary up to 5 years during adolescence using either assessment technique. Thus while there may be a reasonable relationship between chronological age and bone age the large variation makes accurate interpretation of a bone age for forensic reasons difficult. Indeed a recent meta-analysis of bone ages for forensic age determination concluded that the ranges of age estimations derived from different studies are very wide for forensic aims and that the accuracy of age determination in living individuals should not be exclusively based on X-ray methods on the left hand-wrist ADDIN EN.CITE Serinelli19191917Serinelli, S.Panetta, V.Pasqualetti, P.Marchetti, D.Institute of Forensic Medicine, Universita Cattolica del Sacro Cuore, Largo F. Vito, 1-00168 Rome, Italy.Accuracy of three age determination X-ray methods on the left hand-wrist: a systematic review and meta-analysisLegal MedicineLeg Med (Tokyo)Legal MedicineLeg Med (Tokyo)Legal MedicineLeg Med (Tokyo)120-33133Age Determination by Skeleton/mt [Methods]*Age Determination by Skeleton/st [Standards]*Forensic Anthropology/mt [Methods]HumansReproducibility of Results*Wrist/ra [Radiography]May1873-416221377398Meta-Analysis
ReviewEnglish18.
For legal purposes relatively precise age determination is required to define childhood and adulthood. An error of more than one year would lead to the erroneous classification of subjects as either children or adults. Thus age determination requires a test or tests that is/are precise, accurately reflect chronological age and give consistent, reproducible results. This simply is not possible using current bone age assessment methodology.
There is also the issue of appropriateness in the use of radiation. One of the most important principles underpinning all medical imaging is the ALARA principle (As Low As Reasonably Achievable). This requires three factors to be met in the performance of imaging examinations, with a particular emphasis on those using ionizing radiation justification, optimisation and dose limitation. Justification requires any proposed imaging examination to yield a sufficient benefit to the individual to justify the risks incurred by the radiation exposure, and is based on the hypothesis that any radiation exposure, no matter how small, carries with it a certain level of risk (the linear, non-threshold hypothesis, or LNT)19. The Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) has adopted a Code of Practice20 which is progressively being implemented by each Australian jurisdiction through local radiation safety regulations; the Code requires the ALARA Principle to be applied for each imaging examination involving ionizing radiation. As discussed above, the accuracy of X-ray methods to determine age is not reliable and the benefit of their use is not proven; therefore such examinations are not consistent with the ALARA principle and cannot be justified.
In conclusion, there is overwhelming evidence that bone age estimation is too inaccurate to be used for determining chronological age for legal reasons. Inevitably it will result in children misclassified as adults and there is considerable potential harm if this occurs. We would urge that other, more comprehensive approaches to age determination are sought. Bone age assessment should not be used for this purpose in Australia.
Figure 1: Circles represent the Maturos 4.0 computer software assessment of bone age and the dots represent Greulich and Pyle determination of bone age. For a given bone age, there is a wide range of chronological ages. In the example (red arrow) above the chronological range for a bone age of 216 months (18.0 years) was 186 to 243 months (15.5 to 20.3 years)
References
1. Greulich WW, Pyle SI. Radiographic atlas of skeletal development of the hand and wrist. Stanford, CA: Stanford University Press; 1950.
2. Sperling M. Pediatric Endocrinology. 3rd ed: Saunders Elsevier; 2008.
3. Chiang K-H, Chou AS-B, Yen P-S, et al. The Reliability of Using Greulich-Pyle Method to Determine 鱨վ's Bone Age in Taiwan. Tzu Chi Med J 2005;17:417-20.
4. Zhang A, Sayre JW, Vachon L, Liu BJ, Huang HK. Racial differences in growth patterns of children assessed on the basis of bone age. Radiology 2009;250:228-35.
5 . B u k e n a B , S a f a k A A , Y a z 1c i B , B u k e n E , M a y d a A S . I s t h e a s s e s s m e n t o f b o n e a g e b y t h e G r e u l i c h P y l e m e t h o d r e l i a b l e a t f o r e n s i c a g e e s t i m a t i o n f o r T u r k i s h c h i l d r e n ? F o r e n s i c S c i e n c e I n t e r n a t i o n a l 1 7 3 2 0 0 7 ; 1 7 3 : 1 4 6 5 3 .
6 . S a n t o s C , F e r r e i r a M , A l v e s F C , C unha E. Comparative study of Greulich and Pyle Atlas and Maturos 4.0 program for age estimation in a Portuguese sample. Forensic Sci Int;212:276.e1-7.
7. Acheson RM, Vicinus JH, Fowler GB. Studies in the reliability of assessing skeletal maturity from x-rays. 3. Greulich-Pyle Atlas and Tanner-Whitehouse method contrasted. Hum Biol 1966;38:204-18.
8. Cole AJ, Webb L, Cole TJ. Bone age estimation: a comparison of methods. Br J Radiol 1988;61:683-6.
9. Gilli G. The assessment of skeletal maturation. Horm Res 1996;45 Suppl 2:49-52.
10. Johnson GF, Dorst JP, Kuhn JP, Roche AF, Davila GH. Reliability of skeletal age assessments. Am J Roentgenol Radium Ther Nucl Med 1973;118:320-7.
11. King DG, Steventon DM, O'Sullivan MP, et al. Reproducibility of bone ages when performed by radiology registrars: an audit of Tanner and Whitehouse II versus Greulich and Pyle methods. Br J Radiol 1994;67:848-51.
12. Loder RT, Estle DT, Morrison K, et al. Applicability of the Greulich and Pyle skeletal age standards to black and white children of today. Am J Dis Child 1993;147:1329-33.
13. Roche AF, Davila GH. The reliability of assessments of the maturity of individual hand-wrist bones. Hum Biol 1976;48:585-97.
14. Roche AF, Davila GH, Pasternack BA, Walton MJ. Some factors influencing the replicability of assessments of skeletal maturity (Greulich-Pyle). Am J Roentgenol Radium Ther Nucl Med 1970;109:299-306.
15. Roche AF, Rohmann CG, French NY, Davila GH. Effect of training on replicability of assessments of skeletal maturity (Greulich-Pyle). Am J Roentgenol Radium Ther Nucl Med 1970;108:511-5.
16. Vignolo M, Milani S, DiBattista E, Naselli A, Mostert M, Aicardi G. Modified Greulich-Pyle, Tanner-Whitehouse, and Roche-Wainer-Thissen (knee) methods for skeletal age assessment in a group of Italian children and adolescents. Eur J Pediatr 1990;149:314-7.
17. Zachmann M, Frasier SD, McLaughlin J, Hurley L, Nessi P. Importance and accuracy of bone age ratings in a computerized growth evaluation system. Horm Res 1983;18:160-7.
18. Serinelli S, Panetta V, Pasqualetti P, Marchetti D. Accuracy of three age determination X-ray methods on the left hand-wrist: a systematic review and meta-analysis. Leg Med (Tokyo);13:120-33.
19. ICRP, 1991. 1990 Recommendations of the International Commission on Radiological Protection. ICRP Publication 60. Ann. ICRP 21 (1-3)
20. ARPANSA, Code of Practice for Radiation Protection in the Medical Applications of Ionizing Radiation, Radiation Protection Series Publication No. 14, 2008
Dr Paul Hofman Dr Gervase Chaney
President President
Australasian Paediatric Endocrinology Group Paediatrics and Child Health Division Australasian College of Physicians
A/Prof Dinesh Varma Dr David Lord
President President
Royal Australian and New Zealand Royal Australian and New Zealand Society for
College of Radiologists Paediatric Radiology
Professor Michael Ditchfield Dr Donald Payne
Convenor President
Paediatric Imaging Reference Group, RANZCR Australian Society for Adolescent Medicine
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Research Support, N.I.H., ExtramuralEnglishBukena200766617Bukena, Bora Safak, Alp AlperIs the assessment of bone age by the Greulich–Pyle method reliable at forensic age estimation for Turkish children?Forensic Science International 173 Forensic Science International 173146–1531732007 Chiang200533317Chiang, Kuo-HsienChou, Andy Shau-BinYen, Pao-ShengLing, Chang-MingLin, Chao-ChunLee, Chau-ChinChang, Pau-YangThe Reliability of Using Greulich-Pyle Method to Determine 鱨վ's Bone Age in TaiwanTzu Chi Med JTzu Chi Med J417-420172005Zhang200944417Zhang, A.Sayre, J. W.Vachon, L.Liu, B. J.Huang, H. K.Image Processing and Informatics Lab, Department of Radiology, University of Southern California, 1450 San Pablo St, Suite 2100, Los Angeles, CA 90292, USA. aifengz@gmail.comRacial differences in growth patterns of children assessed on the basis of bone ageRadiologyRadiologyRadiologyRadiologyRadiologyRadiology228-352501Adolescent*African AmericansAge Determination by Skeleton/st [Standards]*Age Determination by Skeleton/sn [Statistics & Numerical Data]*Asian Americans*Bone Development/ph [Physiology]ChildChild, Preschool*European Continental Ancestry GroupFemale*Hand/ra [Radiography]*Hispanic AmericansHumansInfantMaleMathematical ComputingReference ValuesRetrospective StudiesSex CharacteristicsSoftware2009Jan1527-131518955510Comparative Study
Research Support, N.I.H., ExtramuralEnglishBukena200766617Bukena, Bora Safak, Alp AlperIs the assessment of bone age by the Greulich–Pyle method reliable at forensic age estimation for Turkish children?Forensic Science International 173 Forensic Science International 173146–1531732007 6J D Acheson196611111117Acheson, R. M.Vicinus, J. H.Fowler, G. B.Studies in the reliability of assessing skeletal maturity from x-rays. 3. Greulich-Pyle Atlas and Tanner-Whitehouse method contrastedHuman BiologyHum BiolHuman BiologyHum BiolHuman BiologyHum Biol204-18383Adolescent*Age Determination by SkeletonChildChild, PreschoolFemale*Hand/ra [Radiography]HumansMaleStatistics as Topic1966Sep0018-71434292293EnglishBukena200766617Bukena, Bora Safak, Alp AlperIs the assessment of bone age by the Greulich–Pyle method reliable at forensic age estimation for Turkish children?Forensic Science International 173 Forensic Science International 173146–1531732007Cole198812121217Cole, A. J.Webb, L.Cole, T. J.Middlesbrough General Hospital, Cleveland.Bone age estimation: a comparison of methodsBritish Journal of RadiologyBr J RadiolBritish Journal of RadiologyBr J RadiolBritish Journal of RadiologyBr J Radiol683-661728*Age Determination by SkeletonChildFemaleHand/ra [Radiography]HumansMaleMethods1988Aug0007-12853416108Comparative StudyEnglishGilli199688817Gilli, G.Olgahospital, Kinderklinik, Stuttgart, Germany.The assessment of skeletal maturationHormone ResearchHorm ResHormone ResearchHorm ResHormone ResearchHorm Res49-5245 Suppl 2*Age Determination by Skeleton/mt [Methods]Bone and Bones/ra [Radiography]HumansObserver Variation19960301-01638805044Comparative Study
ReviewEnglishJohnson197318181817Johnson, G. F.Dorst, J. P.Kuhn, J. P.Roche, A. F.Davila, G. H.Reliability of skeletal age assessmentsAmerican Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl MedAmerican Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl MedAmerican Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl Med320-71182Adolescent*Age Determination by SkeletonChildChild, PreschoolFemaleHand/ra [Radiography]HumansInfantMaleMethodsWrist/ra [Radiography]1973Jun0002-95804351412EnglishKing199415151517King, D. G.Steventon, D. M.O'Sullivan, M. P.Cook, A. M.Hornsby, V. P.Jefferson, I. G.King, P. R.Department of Radiology, Hull Royal Infirmary, UK.Reproducibility of bone ages when performed by radiology registrars: an audit of Tanner and Whitehouse II versus Greulich and Pyle methodsBritish Journal of RadiologyBr J RadiolBritish Journal of RadiologyBr J RadiolBritish Journal of RadiologyBr J Radiol848-5167801*Age Determination by Skeleton/mt [Methods]ChildFemaleHumansMale*Medical AuditMedical Staff, HospitalObserver VariationReproducibility of ResultsTime Factors1994Sep0007-12857953224Comparative StudyEnglishLoder199399917Loder, R. T.Estle, D. T.Morrison, K.Eggleston, D.Fish, D. N.Greenfield, M. L.Guire, K. E.Section of Orthopedic Surgery, University of Michigan, Ann Arbor 48109-0328.Applicability of the Greulich and Pyle skeletal age standards to black and white children of todayAmerican Journal of Diseases of 鱨վAm J Dis ChildAmerican Journal of Diseases of 鱨վAm J Dis ChildAmerican Journal of Diseases of 鱨վAm J Dis Child1329-3314712Adolescent*African Continental Ancestry Group*Age Determination by Skeleton/mt [Methods]Analysis of VarianceChildChild, Preschool*European Continental Ancestry GroupFemaleHand/ra [Radiography]HumansInfantMaleTime FactorsWrist/ra [Radiography]1993Dec0002-922X8249956EnglishRoche197613131317Roche, A. F.Davila, G. H.The reliability of assessments of the maturity of individual hand-wrist bonesHuman BiologyHum BiolHuman BiologyHum BiolHuman BiologyHum Biol585-97483AdolescentAge Determination by Skeleton*Bone DevelopmentChildChild, PreschoolFemale*HandHumansMaleRadiusUlnaWrist/ra [Radiography]*Wrist1976Sep0018-7143185139EnglishRoche197010101017Roche, A. F.Davila, G. H.Pasternack, B. A.Walton, M. J.Some factors influencing the replicability of assessments of skeletal maturity (Greulich-Pyle)American Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl MedAmerican Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl MedAmerican Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl Med299-3061092Adolescent*Age Determination by SkeletonAge FactorsAnalysis of VarianceAtlases as TopicChildChild, PreschoolHand/ra [Radiography]HumansMethodsOsteogenesisTechnology, RadiologicWrist/ra [Radiography]1970Jun0002-95804316029EnglishRoche197017171717Roche, A. F.Rohmann, C. G.French, N. Y.Davila, G. H.Effect of training on replicability of assessments of skeletal maturity (Greulich-Pyle)American Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl MedAmerican Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl MedAmerican Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl Med511-51083Adolescent*Age Determination by Skeleton*Bone Development*Bone and Bones/ra [Radiography]ChildChild, PreschoolFemaleHand/gd [Growth & Development]*Hand/ra [Radiography]HumansMaleMethodsSex FactorsStatistics as TopicWrist/gd [Growth & Development]*Wrist/ra [Radiography]1970Mar0002-95804313463EnglishVignolo199014141417Vignolo, M.Milani, S.DiBattista, E.Naselli, A.Mostert, M.Aicardi, G.Department of Child Welfare and Neonatal Medicine, University of Genoa, Institute G. Gaslini, Italy.Modified Greulich-Pyle, Tanner-Whitehouse, and Roche-Wainer-Thissen (knee) methods for skeletal age assessment in a group of Italian children and adolescentsEuropean Journal of PediatricsEur J PediatrEuropean Journal of PediatricsEur J PediatrEuropean Journal of PediatricsEur J Pediatr314-71495Adolescent*Age Determination by SkeletonBone DevelopmentChildChild, PreschoolFemaleHand/gd [Growth & Development]HumansItalyKnee/gd [Growth & Development]MaleMethodsWrist/gd [Growth & Development]1990Feb0340-61992311626Research Support, Non-U.S. Gov'tEnglishZachmann198316161617Zachmann, M.Frasier, S. D.McLaughlin, J.Hurley, L.Nessi, P.Importance and accuracy of bone age ratings in a computerized growth evaluation systemHormone ResearchHorm ResHormone ResearchHorm ResHormone ResearchHorm Res160-7184*Age Determination by Skeleton*Bone DevelopmentChildChild, PreschoolComputersEvaluation Studies as TopicFemaleHumansMaleMethods19830301-01636642423Comparative StudyEnglish 6J D Acheson196611111117Acheson, R. M.Vicinus, J. H.Fowler, G. B.Studies in the reliability of assessing skeletal maturity from x-rays. 3. Greulich-Pyle Atlas and Tanner-Whitehouse method contrastedHuman BiologyHum BiolHuman BiologyHum BiolHuman BiologyHum Biol204-18383Adolescent*Age Determination by SkeletonChildChild, PreschoolFemale*Hand/ra [Radiography]HumansMaleStatistics as Topic1966Sep0018-71434292293EnglishBukena200766617Bukena, Bora Safak, Alp AlperIs the assessment of bone age by the Greulich–Pyle method reliable at forensic age estimation for Turkish children?Forensic Science International 173 Forensic Science International 173146–1531732007Cole198812121217Cole, A. J.Webb, L.Cole, T. J.Middlesbrough General Hospital, Cleveland.Bone age estimation: a comparison of methodsBritish Journal of RadiologyBr J RadiolBritish Journal of RadiologyBr J RadiolBritish Journal of RadiologyBr J Radiol683-661728*Age Determination by SkeletonChildFemaleHand/ra [Radiography]HumansMaleMethods1988Aug0007-12853416108Comparative StudyEnglishGilli199688817Gilli, G.Olgahospital, Kinderklinik, Stuttgart, Germany.The assessment of skeletal maturationHormone ResearchHorm ResHormone ResearchHorm ResHormone ResearchHorm Res49-5245 Suppl 2*Age Determination by Skeleton/mt [Methods]Bone and Bones/ra [Radiography]HumansObserver Variation19960301-01638805044Comparative Study
ReviewEnglishJohnson197318181817Johnson, G. F.Dorst, J. P.Kuhn, J. P.Roche, A. F.Davila, G. H.Reliability of skeletal age assessmentsAmerican Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl MedAmerican Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl MedAmerican Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl Med320-71182Adolescent*Age Determination by SkeletonChildChild, PreschoolFemaleHand/ra [Radiography]HumansInfantMaleMethodsWrist/ra [Radiography]1973Jun0002-95804351412EnglishKing199415151517King, D. G.Steventon, D. M.O'Sullivan, M. P.Cook, A. M.Hornsby, V. P.Jefferson, I. G.King, P. R.Department of Radiology, Hull Royal Infirmary, UK.Reproducibility of bone ages when performed by radiology registrars: an audit of Tanner and Whitehouse II versus Greulich and Pyle methodsBritish Journal of RadiologyBr J RadiolBritish Journal of RadiologyBr J RadiolBritish Journal of RadiologyBr J Radiol848-5167801*Age Determination by Skeleton/mt [Methods]ChildFemaleHumansMale*Medical AuditMedical Staff, HospitalObserver VariationReproducibility of ResultsTime Factors1994Sep0007-12857953224Comparative StudyEnglishLoder199399917Loder, R. T.Estle, D. T.Morrison, K.Eggleston, D.Fish, D. N.Greenfield, M. L.Guire, K. E.Section of Orthopedic Surgery, University of Michigan, Ann Arbor 48109-0328.Applicability of the Greulich and Pyle skeletal age standards to black and white children of todayAmerican Journal of Diseases of 鱨վAm J Dis ChildAmerican Journal of Diseases of 鱨վAm J Dis ChildAmerican Journal of Diseases of 鱨վAm J Dis Child1329-3314712Adolescent*African Continental Ancestry Group*Age Determination by Skeleton/mt [Methods]Analysis of VarianceChildChild, Preschool*European Continental Ancestry GroupFemaleHand/ra [Radiography]HumansInfantMaleTime FactorsWrist/ra [Radiography]1993Dec0002-922X8249956EnglishRoche197613131317Roche, A. F.Davila, G. H.The reliability of assessments of the maturity of individual hand-wrist bonesHuman BiologyHum BiolHuman BiologyHum BiolHuman BiologyHum Biol585-97483AdolescentAge Determination by Skeleton*Bone DevelopmentChildChild, PreschoolFemale*HandHumansMaleRadiusUlnaWrist/ra [Radiography]*Wrist1976Sep0018-7143185139EnglishRoche197010101017Roche, A. F.Davila, G. H.Pasternack, B. A.Walton, M. J.Some factors influencing the replicability of assessments of skeletal maturity (Greulich-Pyle)American Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl MedAmerican Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl MedAmerican Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl Med299-3061092Adolescent*Age Determination by SkeletonAge FactorsAnalysis of VarianceAtlases as TopicChildChild, PreschoolHand/ra [Radiography]HumansMethodsOsteogenesisTechnology, RadiologicWrist/ra [Radiography]1970Jun0002-95804316029EnglishRoche197017171717Roche, A. F.Rohmann, C. G.French, N. Y.Davila, G. H.Effect of training on replicability of assessments of skeletal maturity (Greulich-Pyle)American Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl MedAmerican Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl MedAmerican Journal of Roentgenology, Radium Therapy & Nuclear MedicineAm J Roentgenol Radium Ther Nucl Med511-51083Adolescent*Age Determination by Skeleton*Bone Development*Bone and Bones/ra [Radiography]ChildChild, PreschoolFemaleHand/gd [Growth & Development]*Hand/ra [Radiography]HumansMaleMethodsSex FactorsStatistics as TopicWrist/gd [Growth & Development]*Wrist/ra [Radiography]1970Mar0002-95804313463EnglishVignolo199014141417Vignolo, M.Milani, S.DiBattista, E.Naselli, A.Mostert, M.Aicardi, G.Department of Child Welfare and Neonatal Medicine, University of Genoa, Institute G. Gaslini, Italy.Modified Greulich-Pyle, Tanner-Whitehouse, and Roche-Wainer-Thissen (knee) methods for skeletal age assessment in a group of Italian children and adolescentsEuropean Journal of PediatricsEur J PediatrEuropean Journal of PediatricsEur J PediatrEuropean Journal of PediatricsEur J Pediatr314-71495Adolescent*Age Determination by SkeletonBone DevelopmentChildChild, PreschoolFemaleHand/gd [Growth & Development]HumansItalyKnee/gd [Growth & Development]MaleMethodsWrist/gd [Growth & Development]1990Feb0340-61992311626Research Support, Non-U.S. Gov'tEnglishZachmann198316161617Zachmann, M.Frasier, S. D.McLaughlin, J.Hurley, L.Nessi, P.Importance and accuracy of bone age ratings in a computerized growth evaluation systemHormone ResearchHorm ResHormone ResearchHorm ResHormone ResearchHorm Res160-7184*Age Determination by Skeleton*Bone DevelopmentChildChild, PreschoolComputersEvaluation Studies as TopicFemaleHumansMaleMethods19830301-01636642423Comparative StudyEnglish D d
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P \ d l t Bone age estimation gc RANZCR medit Normal.dotm Freyana Irani 3 Microsoft Office Word @ F# @ <ղ@ `>B C ՜. +,D ՜. +,` h p
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xd_ProgID _CopySource TemplateUrl Submitter Last Name Submission Type Supplementary
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Organisation Name Individuals Date Received Keyword Status Comments Contact Comments Privacy From email address Submission number , 0x01010078ECC21CFA8F9244BB479F5A6775B302 @ h http://ageassessment/inquiryprocesses/Edited Submissions/20120125_Bone Age Estimation gc RANZCR.docx Hoffman 3 No Dr Paul 2012-01-31T00:00:00Z 4;#;#12;# Cleared for Web Situations which impact on bone age delay; error range, interpretation; the subject's chronological age can vary up to 5 years during adolesence; current bone assessment methodology is unable to give precise results; ethics of radiation; Public p.hofman@auckland.ac.nz 9
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