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Applicability of Shoulder, Olecranon, and Wrist-based Skeletal Maturity Estimation Systems to the Modern Pediatric
Ryan J Furdock1, Andy Kuo2, Kallie J Chen1
1Department of Orthopaedics; University Hospital Cleveland Medical Center.
Insights
New skeletal maturity systems for upper extremity bones show race and sex-based differences in pediatric skeletal age estimation. These findings highlight the need for updated assessments in diverse modern populations.
Area of Science:
- Pediatric Radiology
- Skeletal Development
- Forensic Anthropology
Background:
- Established upper extremity skeletal maturity systems (PHOS, OAOS, mFWS) were developed using historical, predominantly White pediatric data.
- These systems showed superior or equivalent performance to traditional methods (Greulich and Pyle) in historical cohorts.
- Their applicability and accuracy in diverse, modern pediatric populations remain unevaluated.
Approach:
- A retrospective review of 540 anteroposterior shoulder, lateral elbow, and hand/wrist radiographs from four pediatric cohorts (White males, Black males, White females, Black females).
- Evaluated peripubertal individuals (males 9-17 years, females 7-15 years), with five nonpathologic radiographs randomly selected per age and joint.
- Skeletal age estimates from PHOS, OAOS, and mFWS were compared against chronological age and between cohorts, including historical data.
Key Points:
- High inter- and intra-rater reliability (≥0.79) was observed for all radiographic parameters.
- Significant discrepancies in skeletal age estimation were noted: White males showed delayed skeletal age for PHOS and OAOS compared to historical males.
- Black males and females demonstrated advanced skeletal age with mFWS compared to historical counterparts, while Black females were skeletally advanced for PHOS compared to historical females.
Conclusions:
- The proximal humerus ossification system (PHOS), olecranon apophyseal ossification system (OAOS), and modified Fels wrist skeletal maturity system (mFWS) exhibit mild discrepancies in skeletal age estimation.
- These variations are dependent on patient race and sex when applied to contemporary pediatric populations.
- Findings suggest a need for caution and potential recalibration of these systems for diverse modern use.
Background:
The proximal humerus ossification system (PHOS), olecranon apophyseal ossification system (OAOS), and modified Fels wrist skeletal maturity system (mFWS) were recently developed or updated using a historical, mostly White, pediatric population. These upper extremity skeletal maturity systems have demonstrated skeletal age estimation performance superior or equivalent to Greulich and Pyle in historical patients. Their applicability to modern pediatric populations has not yet been evaluated.
Methods:
We reviewed anteroposterior shoulder, lateral elbow, and anteroposterior hand and wrist x-rays of 4 pediatric cohorts: White males, Black males, White females, and Black females. Peripubertal x-rays were evaluated: males 9 to17 years and females 7 to 15 years. Five nonpathologic radiographs for each age and joint were randomly selected from each group. Skeletal age estimates made by each of the 3 skeletal maturity systems were plotted against the chronological age associated with each radiograph and compared between cohorts, and with the historical patients.
Results:
Five hundred forty modern radiographs were evaluated (180 shoulders, 180 elbows, and 180 wrists). All radiographic parameters had inter- and intra-rater reliability coefficients at or above 0.79, indicating very good reliability. For PHOS, White males had delayed skeletal age compared with Black males (Δ-0.12 y, P =0.02) and historical males (Δ-0.17 y, P <0.001). Black females were skeletally advanced compared with historical females (Δ0.11 y, P =0.01). For OAOS, White males (Δ-0.31 y, P <0.001) and Black males (Δ-0.24 y, P <0.001) had delayed skeletal age compared with historical males. For mFWS, White males (Δ0.29 y, P =0.024), Black males (Δ0.58 y, P <0.001), and Black females (Δ0.44 y, P <0.001) had advanced skeletal age compared with historical counterparts of the same sex. All other comparisons were not significant ( P >0.05).
Conclusions:
The PHOS, OAOS, and mFWS have mild discrepancies in skeletal age estimates when applied to modern pediatric populations depending on the race and sex of the patient.
Level Of Evidence:
Level III - retrospective chart review.
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