Assessment of Skeletal Maturity

Fig. 5.1

Left hand and wrist bone age of a 12-year-old female athlete who has had menstrual periods for 15 months demonstrating an advanced skeletal age of 13

Tanner and Whitehouse Method

The Tanner and Whitehouse method also uses a left hand and wrist AP radiograph to determine skeletal age [6]. Certain bones are “regions of interest.” Twenty regions of interest (ROIs) in the hand are examined. Each ROI is divided in three parts: epiphysis, metaphysis, and diaphysis. The development of each ROI is divided into discrete stages, and a numerical score is given for each stage of each bone. By adding the scores of all ROIs, an overall maturity score is obtained and a skeletal age is determined. One author suggests that the Tanner and Whitehouse method may be more accurate than the Greulich and Pyle atlas [7]. In fact, the Tanner and Whitehouse method is used in pediatric endocrinology to determine response to hormone therapy. However, the complexity of this method and the added time to make the calculations are prohibitive for most orthopedic surgeons.

Shorthand Bone Age Method

The shorthand bone age (SBA) method is a simplification of the Greulich and Pyle method. This method was published in 2013 by Heyworth and is based on a single left hand and wrist AP radiograph [8]. Rather than an atlas, two charts are used one for males and one for females. Certain specific findings on the hand and wrist radiograph correlate with specific ages. When using the SBA technique, a single radiographic finding that correlates with skeletal age is identified rather than multiple findings as per the Greulich and Pyle method. The SBA method can be used to determine bone age for males age 12.5 through 16 and for females age 10 through 16 (Fig. 5.2a, b). These ages correspond nicely to the ages of clinical concern with pediatric ACL injuries. Heyworth et al. reported that the SBA method was a simple and clinically efficient alternative to the traditional Greulich and Pyle method [8].

Fig. 5.2

Shorthand bone age in (a) females and (b) males. Radiographic findings that correlate with encircled windows correlate with skeletal age noted in Ref. [8]

Pyle and Hoerr Method

Alternatively, rather than using an additional radiograph of the left hand and wrist, skeletal age can be estimated from the anterior-posterior and lateral knee radiographs compared to the Pyle and Hoerr atlas [9]. This atlas was published in 1969. The organization and design of the atlas follow that of the more commonly known atlas of Greulich and Pyle. Knee radiographs were performed on thousands of children at 3-month intervals from early childhood to maturity on the same children in Ohio that had been utilized to create the hand and wrist atlas. The Pyle and Hoerr atlas was designed by examining knee radiographs in chronologic order to identify progressive maturity indicators and assign a skeletal age. The authors recognized the differences in developmental timing between males and females, but, unlike the Greulich and Pyle atlas, the Pyle and Hoerr atlas published only one set of radiographs for both genders. Each radiograph was assigned two skeletal ages, one for males and one for females. The authors reasoned that the process of maturational changes and the order of appearance of maturational indicators were the same for the two sexes [9]. The Pyle and Hoerr atlas did not include standard deviations. Similar criticisms about ethnicity, diet, and socioeconomic factors relate to the knee atlas as to the hand and wrist atlas. In addition, the knee atlas has not been tested as extensively as the hand and wrist atlas and has not gained widespread popularity. However, if the Pyle and Hoerr atlas is available to the treating surgeon, knee bone age can be considered a useful alternative to the use of more traditional left hand and wrist radiographs.

Physiologic Age

Tanner Staging

Tanner staging is a method to define the physical measurements of a child’s development based on genitalia and pubertal hair [6, 10–12]. For girls, the breast stages are as follows: stage 1, elevation of the papilla only; stage 2, breast bud and enlargement of the areola; stage 3, enlargement of the breast and areola; stage 4, projection of the areola to form a secondary mound; and stage 5, mature stage. The pubic hair stages for girls are as follows: stage 1, no pubic hair; stage 2, sparse growth; stage 3, darker and coarser hair; stage 4, adult-type hair but no spread to the medial surface of the thighs; and stage 5, adult quantity and type (Fig. 5.3). The genitalia stages for boys are as follows: stage 1, prepubescent; stage 2, enlargement of the scrotum and testes and change in texture of the scrotal skin; stage 3, growth of the penis, testes, and scrotum; stage 4, further enlargement and development of the glans; and stage 5, adult size and shape. The pubic hair stages for the boys are as follows: stage 1, no pubic hair; stage 2, sparse growth of hair at the base of the penis; stage 3, darker and coarser hair; stage 4, adult-type hair but no spread to the thighs; and stage 5, adult quantity and type (Fig. 5.4).

Fig. 5.3

Female Tanner staging including breast, areola, and pubic hair development

Fig. 5.4

Male Tanner staging including pubic hair distribution, penile shaft length and width, and testicular diameter and volume

Although Tanner staging is helpful and provides information regarding the physiological age of the patient, Tanner staging does not correlate with skeletal age [13]. In addition, Slough et al. reported that most orthopedic surgeons are unable to accurately and reliably determine Tanner staging [14]. If Tanner staging is indicated in the athlete’s workup by the treating orthopedic surgeon, then evaluation of Tanner staging by the primary care physician or by an endocrinologist may be helpful. In addition, one author reported that the teenage patient can reliably self-assess their Tanner stage using Tanner’s standard photographs [15].

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