Bone Age

1
The major types of human
bones are:
1. long (e.g. the arm and leg bones)
2. short (e.g. the small bones in the wrists and
ankles)
3. flat (e.g. the bones of the skull or the ribs)
4. irregular (e.g. vertebrae)
 Long, short, and irregular bones develop by
endochondral ossification, where cartilage is
replaced by bone.

2
The major types of human
bones are:
 Flat bones develop by intramembranous ossification,
within sheets of connective tissue.
 Compact cortical bone, representing about 80
percent of the mature skeleton, supports the body,
and features extra thickness at the midpoint in long
bones to prevent the bones from bending.
 Cancellous bone, whose porous structure with small
cavities resembles sponge, predominates in the pelvis
and the 33 vertebrae from the neck to the tailbone.

3
Classification of Bone:
 Bones vary in shape and size
 The unique shape of each bone fulfills a
particular need
 Bones are classified by their shape as
long, short, flat, or irregular bone
 Bones differ in the distribution of compact
and spongy osseous tissues
Classification:
Long Bone
 Long bones have a
long shaft and two
distinct ends
 Classification is
based on shape not
size
 Compact bone on
exterior w/ spongy
inner bone marrow
Classification:
Short Bones
 Short bones are
roughly cubelike
 Thin compact bone
layer surrounding
spongy bone mass
 Short bones are often
carpal, tarsal and
sesamoid bones
Classification:
Flat Bones
 Flat bones are thin,
flattened and usually
curved
 Parallel layer of
compact bone with
spongy bone layer
between
 Skull, sternum and
ribs are examples
Classification:
Irregular Bone
 Irregular bones don’t
fit into the previous
categories
 Complicated shapes
 Consist of spongy
bone with a thin layer
of compact
 Examples are hip
bones & vertabrae
Gross
Anatomy
 Landmarks
on a typical
long bone
 Diaphysis
 Epiphysis
 Membranes

 Membranes
 Periosteum
 Endosteum
Diaphysis
 Long tubular
diaphysis is the shaft
of the bone
 Collar of compact
bone surrounds a
central medullary or
marrow cavity
 In adults, cavity
contains fat
Epiphysis
 The epiphyses are
the ends of the bone
 The joint surface of
the epiphysis is
covered with articular
cartilage
 Epiphyseal line
separate diaphysis
and epiphysis
Blood Vessels
 Unlike cartilage bone
is well vascularized
 Nutrient arteries serve
the diaphysis
 The nutrient artery
runs inward to supply
the bone marrow and
the spongy bony
Medullary cavity
 The interior of all
bones consists largely
of spongy bone
 The very center of the
bone is an open
cavity or marrow
cavity
 The cavity is filled
with yellow bone
marrow
 Membranes
 Periosteum covers
outer bone surface
 Consists of dense
irregular connective
tissue & osteoblasts
 Contain nerve fiber
blood and lymph
vessels secured by
Sharpey’s fibers
 Endosteum covers
internal bone surfaces
Short, Irregular and Flat Bones
 Bones consist of thin
layers of compact
bones over spongy
bone
 No shaft, epiphysis or
marrow cavity
 Spongy area between
is a diploe
 Flat sandwich of bone
16
17
18
SKELETAL MATURATION
 In early fetal life, a long bone is preceded by a
model of hyaline cartilage.
 The areas where the bone formation or ossifications
start in the cartilaginous model are known as
centers of ossification.
 These centers may be primary or secondary.
 As a rule primary centers appear before birth and
the secondary centers after birth.
 A typical long bone ossifies in three parts, the two
ends from secondary centers and the intervening
shaft from a primary center.
19
SKELETAL MATURATION
 Many flat bones, including the carpal bones,
ossify entirely from this primary center
 All of the long bones develop secondary centers
that appear in the cartilage of the extremities of
the bone
 The bone ossified from the primary center is the
diaphysis, while the bone ossified from the
secondary center is the epiphysis

20
SKELETAL MATURATION
 As the secondary center is progressively
ossified, the cartilage is replaced by bone until
only a thin layer of cartilage, the epiphyseal
plate, separates the diaphyseal bone from the
epiphysis.
 The part of the diaphysis that abuts on the
epiphysis is referred to as the metaphysis and
represents the growing end of the bone

21
22
23
SKELETAL MATURATION
 The secondary centers are also known as epiphyseal
centers of ossification and the age at which they first
become visible on a radiographs is known as the
date of appearance of the epiphysis.
 These epiphyseal centers appear at different ages in
different parts of the skeleton. In early stages of
ossification, an epiphysis appears as an irregular
nodule on the radiographs.
 Sometimes ossification starts from several centers
simultaneously, e.g. patella, but these soon merge
into a single bony mass.
24
SKELETAL MATURATION
 The epiphyseal ossification spreads and gradually
replaces the cartilaginous epiphysis except where it
is adjacent to diaphysis.
 The cartilage which persists between the epiphysis
and the diaphysis is known as the epiphyseal disc.
 It appears as a narrow translucent band in a
radiographs.
 The cartilage of this disc grows and is progressively
replaced by bone which is added to the end of the
diaphysis.
25
SKELETAL MATURATION
 Growth in length of the bone ceases when the cells
of the cartilage cease to multiply, bone from the
metaphysis then extends across the epiphyseal
disc. Osseous contiguity is thus established
between the epiphyseal and the diaphyseal
ossification.
 It appears as a narrow translucent band in a
radiographs.

26
SKELETAL MATURATION
 The cartilage of this disc grows and is progressively
replaced by bone which is added to the end of the
diaphysis.
 Growth in length of the bone ceases when the cells
of the cartilage cease to multiply, bone from the
metaphysis then extends across the epiphyseal
disc.
 Osseous contiguity is thus established between the
epiphyseal and the diaphyseal ossification.

27
SKELETAL MATURATION
 This is known as the "fusion of the epiphysis" in
radiological terms.
 The bone formed at the site of epiphyseal disc is
particularly dense and is recognizable on the
radiographs of young and even middle-aged adults.
 Knowledge of this prevents confusion with fracture
lines.

28
29
 SKELETAL MATURATION
 The growing skeleton is sensitive to relatively slight
and transient illnesses and to periods of malnutrition.
 Proliferation of cartilage at the metaphysis slows
down during starvation and illness, but degeneration
of cartilage cells in the columns continues, producing
a dense line of provisional calcification which later
becomes bone with thicker trabeculae called "lines of
arrested growth" as seen in X-rays.

30
 SKELETAL MATURATION
 Harris lines, also known as
growth arrest lines, are lines
of increased bone density
that represent the position of
the growth plate at the time
of insult to the organism and
formed on long bones due
to growth arrest.
 They are only visible by
radiograph or in cross-
section.
31
Prenatal Formation of
Bony Skeleton
 Bone Tissue will replace Cartilage Tissue
 Initial Cartilage Tissue is resilient and
flexible, allowing for increased mitosis.

 THE STEPS:
 Intramembranous Ossification:
 Endochondral Ossification:
Intramembranous Ossification
 Intramembranous ossification results in
the formation of most bones of the skull
and the clavicles (flat bones)
 Fibrous connective tissue membranes
formed by mesenchymal cells serve at the
initial supporting structures on which
ossification begins at the eighth week of
development
Intramembranous Ossification
 Formation of an
ossification center
in the fibrous
membrane
 Centrally located
mesenchymal cells
cluster and
differentiate into
osteoblasts, forming
the ossification center
Intramembranous Ossification
 Formation of the
bone matrix within
the fibrous
membrane
 Osteoblasts begin to
secrete osteoid; it is
mineralized within a
few days
 Trapped osteoblasts
become osteocytes
Intramembranous Ossification
 Formation of the
woven bone and the
periosteum
 Accumulating osteoid
forms a network which
encloses local blood
vessels
 Vascularized
mesenchyme forms on
the external face of
woven bone to become
periosteum
Intramembranous Ossification
 Bone collar of
compact bone forms
 Trabeculae just deep to
the periosteum thicken,
forming a woven collar
which is later replaced
with mature lamellar
bone
 Spongy bone persists
internally and its
vascular tissue
becomes red marrow
Endochondral Ossification
 Most bones form by the process of
endochondral ossification
 Process begins late in the second month
of development
 Process uses hyaline cartilage “bones” as
the pattern for bone construction
 During this process cartilage is broken
down as ossification proceeds
Endochondral Ossification
 The formation of long bone typically begins at
the primary ossification center of the hyaline
cartilage shaft
 The perichondrium (fibrous connective tissue
layer) becomes infiltrated by blood vessels
converting it to vascularized periosteum
 The increase in nutrition enables the
mesenchyme cells to differentiate into osteoblast
cells
39
Endochondral Ossification
 Formation of a bone
collar around
hyaline cartilage
model
 Osteoblasts of the
new periosteum
secrete osteoid
against the hyaline
cartilage along the
diaphysis
40
Endochondral Ossification
 Cartilage in the center
of the diaphysis
calcifies
 Calcification of cartilage
blocks nutrients and
chondrocytes die
 Matrix deteriorates and
cavities develop
 Bones stabilized by
collar; growth occurs at
epiphysis 41
Endochondral Ossification
 Invasion of the internal
cavities by the periosteal
bud and spongy bone
 Bud contains nutrient
artery & vein, lymphatics,
nerve fibers, red marrow
elements, osteoblasts and
osteoclasts
 Spongy bone forms
42
Endochondral Ossification
 Formation of the
medullary cavity as
ossification continues
 Secondary ossification
centers form in
epiphyses
 Cartilage in epiphyses
calcifies and deteriorates
opening cavities for entry
of periosteal bud
43
Endochondral Ossification
 Ossification of the
epiphyses
 Hyaline cartilage remains
only at epiphyseal plates
 Epiphyseal plates
promote growth along
long axis
 Ossification chases
cartilage formation along
length of shaft 44
46
Age Assessment

47
Chronological age vs Bone age

 Chronological age: is the time elapsed since

birth
 Bone age is the degree of maturation of a
person's bones. As a person grows from fetal life
through childhood, puberty, and finishes growth
as a young adult, the bones of the skeleton
change in size and shape.

48
Skeletal Age Assessment

49
Skeletal Age Assessment
 Hand-wrist radiograph
 Most standardized method
 Shows predictable and scheduled
 pattern of appearance, ossification & union.

50
"BONE AGE" ESTIMATION
 Bone age is the degree of maturation of a child's
bones. As a person grows from fetal life and finishes
growth as a young adult, the bones of the skeleton
change in size and shape.
 These changes can be seen by x-ray. The "bone
age" of a child is the average age at which children
reach this stage of bone maturation.
 A child's current height and bone age can be used
to predict adult height.

51
BONE AGE" ESTIMATION
 For most people, their bone age is the same as their
biological age but for some individuals, their bone age
is a couple years older or younger.
 Those with advanced bone ages typically hit a growth
spurt early on but stop growing early sooner while
those with delayed bone ages hit their growth spurt
later than normal.

52
Bone Age Assessment
Methods
 The most commonly used bone age assessment
methods are the Greulich-Pyle (GP) (1) and
Tanner-Whitehouse 2 (TW2) (2) methods, both of
which involve left hand and wrist radiographs.
 Radiographs of the hand and wrist are suitable for
bone age assessment because the hand and wrist
possess many bones and taking radiographs of the
hand and wrist is easy.

53
Bone Age Assessment
Methods
 There are several reasons for using left hand and wrist
radiographs for bone age assessment rather than right
hand and wrist radiographs.
 Most people are right-handed, and therefore, the right
hand is more likely to be injured than the left hand.
 It was determined that physical measurements
should be performed on the left side rather than
the right side of the body at the conferences of
physical anthropologists in the early 1900s

54
Bone Age Assessment
Methods
 The hand and wrist bones consist of the
 Radius and ulna,
 19 short bones (5 metacarpals and 14 phalanges)
 7 carpals.
 Bones are formed by endochondral ossification in
the radius, ulna and short bones and by
intramembranous ossification in the carpal bones.

55
Greulich-Pyle (GP)
 The GP method is an atlas method in which bone
age is evaluated by comparing the radiograph of the
patient with the nearest standard radiograph in the
atlas.
 The GP method was developed using radiographs
of upper-middle class Caucasian children in
Cleveland, Ohio, United States, and the radiographs
were obtained between 1931 and 1942.

56
Greulich-Pyle (GP)
 It has recently been reported that secondary sex
characteristics in current boys and girls begin earlier
than they did several decades ago in the United
States
 It may be difficult to assess bone age accurately in
current children using the GP method.

57
Greulich-Pyle (GP)

58
59
60
61
Tanner-Whitehouse 2
 The TW2 method was developed using radiographs
of average socioeconomic class children in the
United Kingdom, and the radiographs were collected
in the 1950s and 1960s.
 There are actually three different TW2 methods:
the radius-ulna-short bones (RUS) method for
evaluating the 13 long or short bones (i.e., the
radius, ulna and short bones of the first, third
and fifth fingers),

62
Tanner-Whitehouse 2
 The carpal method for evaluating the 7 carpals
 20-bones method for evaluating the 13 long or
short bones and 7 carpals.
 The standard deviation of bone age calculated
using the RUS method was approximately 1
year from the age of 5 years in both sexes to 14
years in girls and 16 years in boys.

63
Tanner-Whitehouse: Problems
and Common Errors
 The most significant sources of error are
 poor positioning of the hand when the radiograph is
taken, which alters the radiographic appearance of
the epiphysis and makes interpretation unnecessarily
difficult.
 Lack of consistency in repeat ratings of the same film
by one or more observers (intra- and inter-observer
error).

64
 Comparison between the GP
and TW2 methods
 The scoring method of the TW2 method is more objective
than the atlas method, and therefore, the TW2 method is
considered to have higher reproducibility than the GP
method.
 It has been reported that the intra-observer variation was
greater for the GP method than the TW2 method (95%
confidence interval, −2.46 to 2.18 vs. −1.48 to 1.43,
respectively).
 However, assessment using the TW2 method required a
longer time than the GP method. It’s reported that the
average time required for TW2 and GP assessments was
7.9 min and 1.4 min, respectively
65