SKELETAL MATURITY
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384 ANNOTATIONS SKELETAL MATURITY Tm degree of maturity of the skeleton is of interest occasionally to the clinician and constantly to those investigating growth and development. Such workers are increasingly aware of the shortcomings of present methods, which are four in number : (1) Comparison of radiographs of the hand and wrist with standard films typical of different ages. An " atlas " of such ‘ films was published as long ago as 1902 by Wilms.l (2) Measurement of the size of the bone images on a radio- graph.2-,’ This method is little used because it is inaccurate and time-consuming. (3) Radiography of all the joints on one side of the body, counting the ossified centres.6 7 This is expensive and is impracticable as a routine procedure. (4) A method, based on (1), in which the equilibrium of bone maturation is determined by recording the individual range in various bones. This is known as the red graph method. 8 It is complex and does not take into consideration structural changes in epiphyses. Investigations by these methods have yielded one vjtal piece of information : there are sometimes considerable differences between the stage of maturation of different areas of the body. Maresh 9 has shown that the long bones do not all grow at the same rates, nor fully mature at the same end-point. The cause of these differences is not clear. Today the inspectional technique is most commonly used. It is based on the fundamental work of Todd, o who published an atlas and standard of reference in 1937 after discussions with Hellman 11 and Flory.12 Todd described the exact image changes in the radiographs of the growing ends of long bones. His publication concerned the hand and wrist, but he prepared excellent unpublished descriptions and standards for the elbow, shoulder, hip, knee, and foot. In 1950 Greulich and Pyle 13 revised the atlas and added descriptions of the maturing round bones of the carpus. This atlas is at present the standard work of reference. In addition there is an atlas of standards of Dutch children by Speijer,14 and a report by Mackay,l5 relating to East African children, which reveals another difficulty-the part played by racial, nutritional, and other influences. Acheson16 has pointed to the shortcomings of the inspectional technique. These are : (a) A fixed pattern of first appearance and subsequent development of centres is presupposed. The order in which certain centres appear is known normally to vary widely, and thus comparison of films with the standards is difficult and a large subjective error inevitable. (b) The time interval between the standard films is too long. Coarse grouping is an essential of the method, but this intro- duces further subjective errors. (c) Two sets of standard films are needed since the two sexes mature at different rates. (d) Acheson points out that bone cannot decrease in size during growth ; so, he argues, skeletal maturity should not be measured with time as a. yardstick, but should have units of its own. Acheson writes : " To speak of the mean skeletal maturity status of a group of children aged 21/2 years as ’ skeletal age 30 months,’ is no more reasonable than to speak of their mean weight as being ’ ponderal age 30 1. Wilms, M. Fortschr. Röntgenstr. 1902, Ergänzungsband 9. 2. Carter, T. M. J. educ. Psychol. 1926, 17, 237. 3. Baldwin, B. T. Univ. Ia Stud. Child Welf. 1928, 4, 1. 4. Sawtell, R. O. Amer. J. Dis. Child. 1929, 37, 61. 5. West, E. D. Harv. Teach. Res. 1936, 6, 162. 6. Sontag, L. W., Lipford, J. J. Pediat. 1943, 23, 391. 7. Lurie, L., Levy, S., Lurie, M. L. Ibid, p. 131. 8. Pyle, S. I. Ibid, 1948, 32, 125. 9. Maresh, M. M. Personal communication. 10. Todd, T. W. Atlas of Skeletal Maturation. Part I : The Hand. St. Louis. 1937. 11. Hellman, M. Amer. J. phys. Anthrop. 1928, 11, 223. 12. Flory, C. D. Monog. Soc. Res. Child. Developm. 1936, 1, 3. 13. Greulich, W. W., Pyle, S. I. Atlas of Skeletal Development of the Hand and Wrist. Stanford, 1950. 14. Speijer, B. Beteknis en Bepaling van de skeletleestijd Sijthoff. Leiden, 1950. 15. Mackay, D. H. Trans. R. Soc. trop. Med. Hyg. 1952, 46, 135. 16. Acheson, R. M. J. Anat. 1954, 88, 488. months.’ " Both processes are correlated with time, but not closely ; and he describes a new method of assessing maturity in which each round bone and epiphysis is considered regardless of the ossification pattern ; small increases of maturity are recorded ; the same standards are used for both sexes ; and finally maturation is given a yardstick of its own, the units being termed Oxford maturity units. This method was used in a pilot study of 97 children from the Oxford child health surveyY Since then Acheson et al.18 have applied it to some 600 children from birth to 5 years of age. Scores are given to bones in the hand and wrist-joint for each definite change in shape, maturity indicators described by workers already mentioned being used. The principle is that the sum total of the units scored by any bone will indicate its degree of maturity. The knee is also used, and indicators are suggested on the basis of 1200 serial films of this joint. (Sick’s 19 account of this joint was not sufficiently detailed.) Stuart 20 and his co-workers in Boston, finding the wrist unsatisfactory, are analysing their compre- hensive data with a view to producing information on the maturation of the knee ; and we understand that another group in the U.S.A. have just completed an atlas on this joint. Acheson is careful to emphasise that his method of computation is experimental. At present it is uncertain whether we can legitimately assume that round-bone and epiphyseal development proceed at a parallel rate. Again, different bone areas of the body may mature at different rates ; so should " maturity indicators " for one area be added to those for another in order to give a truer picture of the total maturity ? As Krogman 21.has said, a 100% level of morphological maturity is inevitable in the healthy human, and accord- ingly Acheson suggests that when the whole age-range of the growing human is investigated it would be logical to express skeletal maturity as a percentage. (Some workers hold that final adult height can be predicted by assessing skeletal maturity during growth.22) Acheson’s work shows the need for considering skeletal maturity in terms other than time ; and it clearly points the way out of the present unsatisfactory situation. NO SOVEREIGN REMEDY IT can be harder work to ameliorate symptoms than to prescribe a complete and perfect remedy. Problem families, according to the fourth Southampton survey 23 on the subject, have no single cause, and there is no single remedy for them ; nevertheless, the authors of the survey-Mr. E. T. Ashton, Mr. C. J. Thomas, and Prof. P. Ford (all of the department of economics of the University of Southampton)-do not suggest that the amelioration of symptoms need be given up. They were asked by Dr. H. C. Maurice Williams, medical officer of health for Southampton, to study the problem family " in the administrator’s sense "-in the sense, that is, of the- problems requiring solution they present from day to day. The survey team have analysed all the cases brought up to, and accepted by, the Southampton social rehabili- tation committee as problem families between Jan. 1, 1952, and Dec. 31, 1953. There were 104 such families, but, as is pointed out, behind this " accepted " group is a much larger group of marginal cases. Many of the difficulties of these families can be traced to the character, initial endowment, and emotional and educational history, of family members, and to the emotional rela- tions between them : and such intricate personal matters cannot easily be expressed in averages, and the truth 17. Stewart, A. M., Russell, W. T. Med. Offr, 1952, 88, 5. 18. Acheson, R. M., Kemp, F. H., Parfit, J. Lancet, 1955, i, 691. 19. Sick, C. Fortschr. Röntgenstr. 1902, Ergänzungsband 9. 20. Stuart, H. C. Personal communication. 21. Krogman, W. M. Child Developm. 1950, 21, 25. 22. See Lancet, 1952, ii, 328. 23. Problem Families. Oxford: Blackwell. Pp. 51. 4s.
Transcript of SKELETAL MATURITY
384 ANNOTATIONS
SKELETAL MATURITY
Tm degree of maturity of the skeleton is of interestoccasionally to the clinician and constantly to those
investigating growth and development. Such workersare increasingly aware of the shortcomings of presentmethods, which are four in number :
(1) Comparison of radiographs of the hand and wrist withstandard films typical of different ages. An " atlas " of such
‘
films was published as long ago as 1902 by Wilms.l(2) Measurement of the size of the bone images on a radio-
graph.2-,’ This method is little used because it is inaccurateand time-consuming.
(3) Radiography of all the joints on one side of the body,counting the ossified centres.6 7 This is expensive and is
impracticable as a routine procedure.(4) A method, based on (1), in which the equilibrium of
bone maturation is determined by recording the individualrange in various bones. This is known as the red graphmethod. 8 It is complex and does not take into considerationstructural changes in epiphyses.
Investigations by these methods have yielded one vjtalpiece of information : there are sometimes considerabledifferences between the stage of maturation of differentareas of the body. Maresh 9 has shown that the longbones do not all grow at the same rates, nor fully matureat the same end-point. The cause of these differences isnot clear.
Today the inspectional technique is most commonlyused. It is based on the fundamental work of Todd, owho published an atlas and standard of reference in 1937after discussions with Hellman 11 and Flory.12 Todddescribed the exact image changes in the radiographsof the growing ends of long bones. His publicationconcerned the hand and wrist, but he prepared excellentunpublished descriptions and standards for the elbow,shoulder, hip, knee, and foot. In 1950 Greulich and
Pyle 13 revised the atlas and added descriptions of thematuring round bones of the carpus. This atlas is at
present the standard work of reference. In additionthere is an atlas of standards of Dutch children bySpeijer,14 and a report by Mackay,l5 relating to EastAfrican children, which reveals another difficulty-thepart played by racial, nutritional, and other influences.
Acheson16 has pointed to the shortcomings of the
inspectional technique. These are :
(a) A fixed pattern of first appearance and subsequentdevelopment of centres is presupposed. The order in whichcertain centres appear is known normally to vary widely,and thus comparison of films with the standards is difficult anda large subjective error inevitable.
(b) The time interval between the standard films is too long.Coarse grouping is an essential of the method, but this intro-duces further subjective errors.
(c) Two sets of standard films are needed since the two sexesmature at different rates.
(d) Acheson points out that bone cannot decrease in sizeduring growth ; so, he argues, skeletal maturity should notbe measured with time as a. yardstick, but should have unitsof its own.
Acheson writes : " To speak of the mean skeletal
maturity status of a group of children aged 21/2 years as’ skeletal age 30 months,’ is no more reasonable than tospeak of their mean weight as being ’ ponderal age 301. Wilms, M. Fortschr. Röntgenstr. 1902, Ergänzungsband 9.2. Carter, T. M. J. educ. Psychol. 1926, 17, 237.3. Baldwin, B. T. Univ. Ia Stud. Child Welf. 1928, 4, 1.4. Sawtell, R. O. Amer. J. Dis. Child. 1929, 37, 61.5. West, E. D. Harv. Teach. Res. 1936, 6, 162.6. Sontag, L. W., Lipford, J. J. Pediat. 1943, 23, 391.7. Lurie, L., Levy, S., Lurie, M. L. Ibid, p. 131.8. Pyle, S. I. Ibid, 1948, 32, 125.9. Maresh, M. M. Personal communication.
10. Todd, T. W. Atlas of Skeletal Maturation. Part I : TheHand. St. Louis. 1937.
11. Hellman, M. Amer. J. phys. Anthrop. 1928, 11, 223.12. Flory, C. D. Monog. Soc. Res. Child. Developm. 1936, 1, 3.13. Greulich, W. W., Pyle, S. I. Atlas of Skeletal Development of
the Hand and Wrist. Stanford, 1950.14. Speijer, B. Beteknis en Bepaling van de skeletleestijd Sijthoff.
Leiden, 1950.15. Mackay, D. H. Trans. R. Soc. trop. Med. Hyg. 1952, 46, 135.16. Acheson, R. M. J. Anat. 1954, 88, 488.
months.’ " Both processes are correlated with time, butnot closely ; and he describes a new method of assessingmaturity in which each round bone and epiphysis isconsidered regardless of the ossification pattern ; smallincreases of maturity are recorded ; the same standardsare used for both sexes ; and finally maturation is given ayardstick of its own, the units being termed Oxford
maturity units.This method was used in a pilot study of 97 children
from the Oxford child health surveyY Since thenAcheson et al.18 have applied it to some 600children from birth to 5 years of age. Scores are given tobones in the hand and wrist-joint for each definite changein shape, maturity indicators described by workers alreadymentioned being used. The principle is that the sum totalof the units scored by any bone will indicate its degreeof maturity. The knee is also used, and indicators aresuggested on the basis of 1200 serial films of this joint.(Sick’s 19 account of this joint was not sufficientlydetailed.) Stuart 20 and his co-workers in Boston, findingthe wrist unsatisfactory, are analysing their compre-hensive data with a view to producing information onthe maturation of the knee ; and we understand thatanother group in the U.S.A. have just completed anatlas on this joint.Acheson is careful to emphasise that his method of
computation is experimental. At present it is uncertainwhether we can legitimately assume that round-boneand epiphyseal development proceed at a parallel rate.Again, different bone areas of the body may mature atdifferent rates ; so should " maturity indicators " forone area be added to those for another in order to givea truer picture of the total maturity ?As Krogman 21.has said, a 100% level of morphological
maturity is inevitable in the healthy human, and accord-ingly Acheson suggests that when the whole age-rangeof the growing human is investigated it would be logicalto express skeletal maturity as a percentage. (Someworkers hold that final adult height can be predicted byassessing skeletal maturity during growth.22) Acheson’swork shows the need for considering skeletal maturityin terms other than time ; and it clearly points the wayout of the present unsatisfactory situation.
NO SOVEREIGN REMEDY
IT can be harder work to ameliorate symptoms than toprescribe a complete and perfect remedy. Problemfamilies, according to the fourth Southampton survey 23on the subject, have no single cause, and there is no
single remedy for them ; nevertheless, the authors ofthe survey-Mr. E. T. Ashton, Mr. C. J. Thomas, andProf. P. Ford (all of the department of economics of theUniversity of Southampton)-do not suggest that theamelioration of symptoms need be given up. They wereasked by Dr. H. C. Maurice Williams, medical officer ofhealth for Southampton, to study the problem family" in the administrator’s sense "-in the sense, that is, of the-problems requiring solution they present from day to day.The survey team have analysed all the cases brought
up to, and accepted by, the Southampton social rehabili-tation committee as problem families between Jan. 1,1952, and Dec. 31, 1953. There were 104 such families,but, as is pointed out, behind this " accepted " groupis a much larger group of marginal cases. Many of thedifficulties of these families can be traced to the character,initial endowment, and emotional and educationalhistory, of family members, and to the emotional rela-tions between them : and such intricate personal matterscannot easily be expressed in averages, and the truth17. Stewart, A. M., Russell, W. T. Med. Offr, 1952, 88, 5.18. Acheson, R. M., Kemp, F. H., Parfit, J. Lancet, 1955, i, 691.19. Sick, C. Fortschr. Röntgenstr. 1902, Ergänzungsband 9.20. Stuart, H. C. Personal communication.21. Krogman, W. M. Child Developm. 1950, 21, 25.22. See Lancet, 1952, ii, 328.23. Problem Families. Oxford: Blackwell. Pp. 51. 4s.
