(1997) 24:25761. doi: 10.1111/j.1556-4029.2012.02294.x. For this reason, in the TW3 method, skeletal age evaluation ends at 15 years in women and 16.5 years in men (while in the TW2 set, 18 and 19 years, respectively, with a bone maturity anticipation of 2.53 years) (120). [3][21], Images in the Greulich and Pyle atlas came from healthy white boys and girls enrolled in the Brush Foundation Study for Human Growth and Development between the years 1931 and 1942. (1994) 7:1415. doi: 10.1210/jc.2006-1645, 13. It is important that not a simple comparison but an in-depth bone-by-bone evaluation is needed in order to properly characterized bone maturation. Effective dose and energy imparted in diagnostic radiology. Biological maturation of youth athletes: assessment and implications. doi: 10.1002/mpo.2950210104, 40. Final height in boys with untreated constitutional delay in growth and puberty. Pietka E, McNitt-Gray MF, Kuo ML, Huang HK. Sustained decrease in bone-age-to-chronological-age (BA:CA) ratio through 5 years 3 Mean BA:CA ratio decreased throughout the study; . (1997) 131(1 Pt 1):3440. 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. It's usually done by taking a single X-ray of the left wrist, hand, and fingers. In 2008, a new fully automated system was introduced, known as BoneXpert (Visiana, Denmark), with a reading time between 1.5 and 4 min. For this reason, pediatricians should evaluate patients on the bases of all the available knowledge about the child, particularly their personal growth history. Regardless of the method used, an appropriate and standardized hand positioning procedure and radiographic image acquisition are required in order to better describe the skeletal maturation. Viii + 339 pp. The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics recommend using the World Health Organization (WHO) growth charts for children younger than two years and the CDC growth charts for children older than two years.5 The CDC growth charts are a population-based reference that include data from bottle-fed and breastfed infants. Thodberg HH. doi: 10.1007/BF02171555, 116. Computer-assisted phalangeal analysis in skeletal age assessment. doi: 10.2214/ajr.167.6.8956565, 97. J Paediatr Child Health. By evaluating the data obtained from bone age in the clinical setting, it is possible to distinguish three main groups of subjects: patients with delayed bone age, patients with bone age appropriate to chronological age, and patients with advanced bone age (3, 810). Finally, the bone age (BA) is an assessment of the degree of skeletal maturation. (2008) 28:1016. They should stay still for 23 seconds so the X-ray image is clear. When a child experiences earlier than normal puberty timing, the child would be expected to follow a height percentile above their final adult height percentile. Int Clin Psychopharmacol. Assessing bone age is also important to predict adult height. However, bone age itself cannot be considered the only absolute and incontrovertible datum to define the chronological age (6879); therefore, limits and accuracy of this examination in predicting chronological age, especially in relation to different ethnic groups and underlying diseases, need to be considered. These tables have been formulated on bone age assessment according to the standards of Greulich and Pyle. (2014) 40:60710. Growth Horm IGF Res. Growth and reproductive outcomes in congenital adrenal hyperplasia. doi: 10.1530/EJE-15-0608, 60. The BayleyPinneau method uses a series of tables that are indexed according to gender, chronological age, and skeletal age. 2nd ed. The best time to start and stop such therapies can be determined based on a patient's bone age. Typically, children with this condition have a delayed bone age with a preserved or increased weight for age. Angle Orthod. Pearson's correlation analysis revealed that was strong . 2 SDs), a range of 5 years. [5] For example, a patient's bone age may be less than their chronological age suggesting a delay in growth as may be caused by a growth hormone deficiency. Assessment of bone age is often required during international immigration programs (68, 69). Ontell FK, Ivanovic M, Ablin DS, Barlow TW. chronological age and bone age in both genders (Females r=0.778; p-value < 0.001, Males r=0.816; p-value < 0.001). (2010) 60:5525. In order to improve the accuracy and reproducibility of this method, changes and improvements have been made over the years. (1998) 75:4929. There are extremes to be mindful of, Kutney added. N Engl J Med. Forensic Sci Int. Therefore, while in the TW1 version, the score is derived from the evaluation of all the 20 bones selected, in the TW2 update, three different ways are distinguished: 20 bones score (as in TW1), RUS score (radius, ulna, and metacarpal bones and phalanx), and CARPAL, limited to carpus bones. As sex steroid levels rise during puberty, bone maturation accelerates. The bone age study can help evaluate how fast or slowly a child's skeleton is maturing, which can help doctors diagnose conditions that slow down or speed up physical growth and development. Bone age is an interpretation of skeletal maturity. Treatment of the various types of spinal muscular atrophy with approved therapies resulted in an array of improvements, according to a review of 22 studies. 71. (2014) 238:8390. A fuller description of the use of bone age films from the University of Utrecht. Ossification centers are defective, appearing in an irregular and mottled pattern, with multiple foci that coalesce to give a porous or fragmented appearance. Tanner JM, Gibbons RD. Variability in the order of ossification of the bony centers of the hand and wrist. Deviations from these patterns, or other signs of delayed bone growth need to be investigated by a specialist, Kutney stated. [5] Other techniques for estimating bone age exist, including x-ray comparisons of the bones of the knee or elbow to a reference atlas and magnetic resonance imaging approaches. Karger editor. As known, operator variability (intravariability) is defined by the degree of variability in the interpretation of same data performed at two different times by the same operator. Thus, some authors suggest that, whenever possible, the same method should be used, favoring TW2 method if possible (93). Numerous scales have been produced that can convert bone maturity score into bone age for different European and non-European populations (7, 114119). Hand Bone Age. (2004). Heyman R, Guggenbuhl P, Corbel A, Bridoux-Henno L, Tourtelier Y, Balencon-Morival M, et al. They can be seen on an X-ray because they're softer and contain less mineral, making them appear darker on an X-ray image than the rest of the bone. J Pak Med Assoc. Int J Androl. Garn SM, Rohmann CG. A renal anomaly? Skeletal age of individuals with Down syndrome. Not only hormones but also gender might affect this process. doi: 10.1016/j.jpeds.2013.11.065, 23. It is based on a computerized system obtained from a series of measurements provided by a large reference population. The Knee Joint as a Biological Indicator", "Rate of Appearance of Ossification Centers from Birth to the Age of Five Years", "Use of cervical vertebral dimensions for assessment of children growth", "Management of the Child Born Small for Gestational Age through to Adulthood: A Consensus Statement of the International Societies of Pediatric Endocrinology and the Growth Hormone Research Society", "2 to 20 years: Girls Stature-for-age and Weight-for-age percentiles", "2 to 20 years: Boys Stature-for-age and Weight-for-age percentiles", "Physical Development, Ages 11 to 14 Years", "Bone age and onset of puberty in normal boys", "Overgrowth SyndromesEvaluation, Diagnosis, and Management", "An approach to constitutional delay of growth and puberty", http://www.jfsmonline.com/text.asp?2019/5/4/177/272723. (2011) 13:12033. Bone age assessment: a large scale comparison of the Greulich and Pyle, and Tanner and Whitehouse (TW2) methods. Among these, three methods were the most representative and used worldwide: The GreulichPyle method, the TannerWhitehouse, and the Fels method. In Sweden, many asylum applications in 2016 were made by lone refugee children, thus requiring novel proposed guidelines. Horm Res Paediatr. (1975) 64:8538. The images obtained by hand and wrist X-ray reflect the maturity of different bones. Eur J Paediatr Dent. (127) started a computerization project of reading using phalanxes length compared to atlas. Moreover, a deficit of thyroid hormones or an excess of corticosteroids causes a cell division reduction in the proliferation zone, inducing a growth delay. Apart from the ability to assess the chronological age of a person, the evaluation of growth remaining in a person can be extremely beneficial to a clinician in different circumstances, as previously discussed. Soegiharto BM, Cunningham SJ, Moles DR. Skeletal maturation in Indonesian and white children assessed with hand-wrist and cervical vertebrae methods. Herman-Giddens ME. 28. Midparental height growth velocity should be calculated to evaluate a child's growth vs. potential height. 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. New York, NY: Springer (2012). doi: 10.1080/03014469000001142, 117. This system does not take into account the state of carpus bones maturation and allows a bone age assessment between 2.5 and 17 years and 2.0 and 15.0 years for male and female individuals, respectively. p. 293753. London. They add length and width to the bone. Reference standards for this method were published in 1950 and 1960; however, from these initial publications, several studies have shown a shift toward an earlier bone maturation process in the general population worldwide (16). In multiple linear regression analysis, advanced bone age was most strongly associated with higher Tanner stage of sexual development, and higher weight, height or BMI percentile. Automatic bone age measurement using computerized image analysis. Most children with short or tall stature have normal variants of growth. The bone mineral density (BMD) of the lumbar spine (L1-L4) was measured by dual energy x-ray absorptiometry (Hologic QDR 1000) in 135 healthy caucasian children, aged 1-15 yr, and values were correlated with age, height, weight, body surface, bone age, pubertal status, calcium intake, vitamin D supplementation, and serum bone gla protein. Note: All information on KidsHealth is for educational purposes only. Greulich WW. Basel; Freiburg; Paris; London; New York, NY; New Delhi; Bangkok; Singapore; Tokyo; Sydney, NSW: Karger Publishers (2002) doi: 10.1159/isbn.978-3-318-00778-7. Karyotyping in girls might also be reasonable because short stature and delayed puberty may be the only symptoms in some girls with Turner syndrome. doi: 10.1007/s11102-010-0246-3, 26. These methods differ according to the technique of the procedure and particularly to peculiar advantages and disadvantages (Table 1). (1999) 81:1723. Br J Radiol. Premature thelarche in the setting of high lavender oil exposure. Data obtained by hand and wrist radiography during bone age assessment are also used in many nonmedical fields for example in sports (64) and for national policy in many countries (10). Arends NJ, Boonstra VH, Mulder PG, Odink RJ, Stokvis-Brantsma WH, Rongen-Westerlaken C, et al. Background radiation: natural and man-made. (2015) 7:1827. Available online at: http://www.ice.gov/doclib/foia/dro_policy_memos/agedeterminationproceduresforcustodydecisionsaug202004.pdf. medicolegal cases). The chronological age for confirming puberty onset using the elbow was 12.2 years in boys and 10.3 years in girls. Tanner JM. Puberty onset according to elbow occurred slightly earlier than expected. Growth Hormone Deficiency. Aicardi G, Vignolo M, Milani S, Naselli A, Magliano P, Garzia P. Assessment of skeletal maturity of the hand-wrist and knee: a comparison among methods. doi: 10.1515/jpem.2010.138, 63. BMJ Case Rep. (2015) 2015:bcr2015212216. [3] However, most pediatric radiologists still use the Greulich and Pyle technique for estimating bone age in infancy. Crowne EC, Shalet SM, Wallace WH, Eminson DM, Price DA. (2009). This information, associated to the characterization of the shape and changes of bone components configuration, represent an important factor of the biological maturation process of a subject. Advanced bone age and hyperinsulinemia in overweight and obese children. Springfield, IL: Charles C. Thomas. Over the years, this system has been refinished by moving from an initial system known as TannerWhitehouse method 1 (TW1) to two subsequent methods known as TannerWhitehouse 2 (TW2) and 3 (TW3) (3, 113, 114). Bone health in children with inflammatory bowel disease: adjusting for bone age. According to our experience in the field, the best approach might be the Greulich-Pyle (GP) method. Chronological age and bone age were 8.7 4.0 and 8.8 4.3 years, respectively, for the entire population. It is defined by the age expressed in years that corresponds to the level of maturation of bones. Nowadays, many methods are available to evaluate bone age. The mean growth velocity ranges from 8 to 10 cm/year, roughly +2 to +4 SD for chronological age, and results in increased heights, between +1.5 and +2.5 SD for age on average. doi: 10.4158/EP13193.OR, 52. Using an atlas-based method gives a great possibility of intra- and interoperator variability (142). Bone age represents a common index utilized in pediatric radiology and endocrinology departments worldwide for the definition of skeletal maturity for medical and non-medical purpose. Thus, the variability in the bone age at onset of puberty was greater than the variability in the chronological age at onset of puberty ( Fig. During late puberty, the fusion of the epiphyses to the metaphyses in the long bones of the hand tends to occur in a characteristic pattern: (3) fusion of the proximal phalanges, and. (2016) 31:939. doi: 10.1590/S1806-83242005000300010, 36. doi: 10.1297/cpe.23.27, 55. Pediatr Radiol. (1987) 79:7434. (2005) 32:31625. (1999) 51:16872. Hassel &Farman (1995)[27] developed an index based on the second, third, and fourth cervical vertebrae (C2, C3, C4) and proved that atlas maturation was highly correlated with skeletal maturation of the hand-wrist. (1995) 126:54550. Furthermore, the image was digitized and transformed into a series of mathematical coefficients produced mostly from standard image of the left hand and wrist X-rays. Olesen T, Egeblad M, Dige-Petersen H, Ahlgren P, Nielsen AM, Vesterdal J. Somatic manifestations in children suspected of having been maltreated. [4] Other uses of bone age measurements include assisting in the diagnosis of medical conditions affecting children, such as constitutional growth delay, precocious puberty, thyroid dysfunction, growth hormone deficiency, and other causes of abnormally short or tall stature. (1996) 45 Suppl 2:428. (2006) 22:110. Horm Res. A growth velocity that is less than normal should prompt further investigation. Although the Khamis-Roche method is considered an accurate predictor, it is not as accurate as methods using the bone age. Bone age is measured in years, most often using the Greulich-Pyle scale. Radiographic evaluation of skeletal maturation. Extensive clinical experience: nonclassical 21-hydroxylase deficiency. For example, according to Martin et al. Med Phys. Tanner JM. Arch Dis Child. doi: 10.1002/1520-6300(200009/10)12:5<610::AID-AJHB5>3.0.CO;2-D. 82. Bone age should be compared with chronologic age to help narrow the differential diagnosis of short or tall stature. defects in bone mineralization process (commonly found in osteochondrodysplasia). doi: 10.1109/42.108597, 128. X-rays are commonly done in doctors offices, radiology departments, imaging centers, and dentists offices. (1998) 13:5007. The bibliographies of review articles and textbook chapters were also reviewed for original research articles. Cushing's syndrome in children and adolescents. Moreover, even when there is a good correlation between predicted and actual adult height, there is a wide individual variation, with almost 30% of adults differing by more than 5.0 cm from the BP predicted height (141). All authors contributed to manuscript revision and read and approved the submitted version. Am J Dis Child. Available online at: http://www.unhcr.org/publications/legal/3d4f91cf4/guidelines-policies-procedures-dealing-unaccompanied-children-seeking-asylum.html. Kawano A, Kohno H, Miyako K. A retrospective analysis of the growth pattern in patients with salt-wasting 21-hydroxylase deficiency. The Royal Children's Hospital Melbourne, Immigrant Health Service. Korean J Radiol. Effect of a gluten-free diet on bone mineral density in children with celiac disease. doi: 10.1258/ar.2012.120443, 122. Sweden Begins New Asylum Seeker Age Assessment Tests. doi: 10.1515/jpem-2015-0234, 38. (2009) 48:53843. 5 to 5.5 cm (2 to 2.2 in) Pubertal growth spurt. | Food Insecurity and the Dangers of Infant Formula Dilution, | Getting into the Roots of Childhood Atopic Dermatitis, | Opt-Out Chlamydia Screening in Adolescent Care, | The Role of the Healthcare Provider Community in Increasing Public Awareness of RSV in All Infants, | Update in Pediatric COVID-19 Vaccines, https://kidshealth.org/en/parents/xray-bone-age.html. Linklater A, Hewitt JK. Principal pros and cons related to the different methods utilized for the definition of skeletal age [82, 85, 94, 95, 97, 98, 102, 116, 121, 122, 123, 126, 129,132, 135,137, 138]. This evaluation is more detailed than a simple comparison and takes into consideration a detailed analysis of structural characteristics of different bones with the assignment of a score to each element (3, 113, 114). doi: 10.1159/000053086, 49. *Correspondence: Cosimo Giannini, cosimogiannini@hotmail.it, Debates in Clinical Management in Pediatric Endocrinology, View all The metaphyseal end of long bones usually has a sclerotic band (1719). Because the WHO growth charts are based on an international study of exclusively breastfed infants raised in optimal nutritional conditions, they are less likely to incorrectly identify breastfed infants as underweight. J Obstet Gynaecol Res. Gilsanz RO. This method has the advantage of being more reproducible, and it is not based on the subject age but on skeletal maturity of several bone elements and population-based references. doi: 10.1016/0197-0070(87)90048-9, 84. [17][20] Finally, only the wrist and hand are imaged out of a desire to minimize the amount of potentially harmful ionizing radiation delivered to a child. In some psychiatric conditions, such as anorexia and in subjects with states of psychosocial stress or abuse, the presence of delayed skeletal maturation is documented (4345). doi: 10.1111/jog.12181, 18. New technology for bone age determination includes computer-automated readings and assessments obtained from alternative imaging modalities. GreulichPyle distinguished two standard templates: 31 and 27 radiographic images, in male and female individuals, respectively, which illustrate different phases of bone maturation between 0 and 18 or 19 years, respectively. (2012) 46:7709. A small amount of spinal growth concludes an adolescent's growth. Martin MB, Li CS, Rowland CC, Howard SC, Kaste SC. In addition, 11 patients with multiple scans at different ages were assessed for change in CH with age. J Pediatr. Horm Res. This was followed by a comparison between the skeletal age estimates and the chronological ages of the patients. Few pediatric devices were approved after a clinical trial involving children. Look for a Mllerian anomaly as well. Moreover, according to recent studies, BoneXpert computer-automated bone age determination method showed a significant positive correlation with chronological age and GreulichPyle. When do boys stop growing? Recent data on pubertal milestones in United States children: the secular trend toward earlier development. J Clin Endocrinol Metab. doi: 10.1093/qjmed/hcs230, 66. Pediatr Res. (1996) 45 Suppl 2:535. Accuracy of two dental and one skeletal age estimation methods in 6-16 year old Gujarati children. (1978) 93:74955. (1960) 18:21930. Salsberry PJ, Reagan PB, Pajer K. Growth differences by age of menarche in African American and White girls. doi: 10.1006/clim.2000.4838, 35. As well, hypophyseal alterations secondary to malformation, tumor, or infiltrative pathologies may also be associated with bone age delay consequently to a secondary GH deficiency or hypothyroidism. (1970) 108:5115. Kim JR, Lee YS, Yu J. Front Pediatr. On this Wikipedia the language links are at the top of the page across from the article title. These include lifestyle factors such as diet, exercise, activity level and history of illness or injury. Tanner J, Oshman D, Bahhage F, Healy M. Tanner-Whitehouse bone age reference values for North American children. IEEE Trans Med Imaging. The emergence of the primary ossification centers of the carpal bones appear in a predictable order that can help in determining bone age. In: Preedy V, editor. Bone growth assessments can be useful when it comes to gauging growth rates, especially when it comes to understanding1: Pediatricians can look to a childs parents for some of this information, but more specialized assessments can help, particularly if there is a concern for any disorders or conditions that may affect growth, development, or bone health. (2013) 19:615. The atlas has a set of images arranged in chronological order by age for males ranging from 3 months to 19 years and for females ranging from 3 months to 18 years in varying intervals of 3 months to 1 year. Two experienced readers first derived skeletal age estimates using the GP atlas. The bone ages of hand and elbow were different at puberty, and the elbow was a more reliable location for bone-age assessment at puberty. Steps in the methodology: a Measurements of the metacarpal lengths and the M2-M5 width.b Linear regression analysis of each measured variable with chronological age.c Equations established for each model along with R 2. d Linear regression analysis of chronological age with each estimated bone age.e Intraclass correlation between the different metacarpal-based estimated bone ages and the two . Approximately 5% of children referred for evaluation of short stature have an identifiable pathologic cause.13 The most common etiologies are growth hormone deficiency, hypothyroidism, celiac disease, and Turner syndrome. A clinically oriented method based on hand-wrist films. Copyright 2015 by the American Academy of Family Physicians. (2010) 73:2208. Among these, three methods are the most representative: GreulichPyle method, TannerWhitehouse method, and Fels method. Klein KO, Newfield RS, Hassink SG. Most children will have a projected adult height within 10 cm (4 in), or two standard deviations, of their midparental height. Length should be measured using a horizontal rule in children younger than two years, and height should be measured using a wall-mounted stadiometer in children older than two years. The bone age (also called the skeletal age) is measured in years. Meet the board: Jessica L. Peck, DNP, APRN, CPNP-PC, CNE, CNL, FAANP, FAAN. 42. So the confidence interval around the chronological age estimated from bone age is 30 months (i.e. (1987) 14:35765. Clin Pediatr Endocrinol. Am J Orthod Dentofacial Orthop. Pediatrics. Tanner-Whitehouse method of assessing skeletal maturity: problems and common errors. doi: 10.1038/oby.2010.305, 51. Comparison between Greulich-Pyle and Girdany-Golden methods for estimating skeletal age of children in Pakistan. doi: 10.1359/jbmr.1998.13.3.500. (2014) 16:424. doi: 10.1186/s13075-014-0424-1, 34. [24] This technique was created to avoid errors in estimating bone age though to arise from focusing on only one area of the body. Constitutional advancement of growth in tall children is the equivalent of constitutional delay of growth and puberty in short children.1,19,20 Children with constitutional advancement of growth have accelerated growth until two to four years of age and then track parallel to the growth curve. (1989) 1:493494. 2nd ed. In a recent poll, only 1 in 5 parents believed it is unsafe for children to take medicine past its expiration date, while many did not know how to properly dispose medicine. Int J Pediatr Endocrinol. The . (2014) 22:269. (2007) 51:5003. Peters CJ, Ahmed ML, Storr HL, Davies KM, Martin LJ, Allgrove J, et al. Growth and development: congenital adrenal hyperplasia-glucocorticoids and height. 3. 109. (1996) 167:13958. This means a child tends to be shorter than average and to enter puberty later than average, while growing at a normal rate. Comparison of dental maturity in children of different ethnic origins: international maturity curves for clinicians. Particularly, in the TW3, the possibility to predict final height has been introduced. Is the Greulich and Pyle atlas applicable to all ethnicities? Likewise, some pathological clinical diseases such as ovarian tumors, Leydig cells or germ cells, as well as adrenal tumors or adrenal diseases (e.g., congenital adrenal hyperplasia) (5255) are typically associated with excessive production of pubertal hormones that cause a rapid progression of bone age, thus advanced bone maturation. The other primary skeletal component of height is the spine and skull. This information, associated with the characterization of the shape and changes of bones, represents an important factor of the biological maturation process. then every 6 months. For a correct interpretation of data, it is important to follow a correct procedure: the hand (conventionally the left hand) is positioned with the palm side resting on a rigid plane with fingers spread out to obtain an antero-posterior radiograph. Bone age (BA) is a measure of the skeletal maturity of an individual and tells us about the growth potential of a child. However, data obtained from the assessment of bone age can be widely used both in medical or nonmedical settings. The most common measurement standards used for bone age are the Greulich and Pyle Atlas2 and the Tanner-Whitehouse3 assessments.4. This means a child's height is part of his or her family's pattern of inherited tall height. The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army Service at large. Briers PJ, Hoorweg J, Stanfield JP. doi: 10.1001/jamapediatrics.2015.3526, 59. The GP and TW methods are characterized by a considerable variability. Radiation dosimetry for extremity radiographs. doi: 10.1111/j.1651-2227.1988.tb10615.x, 46. (2009) 154:2437. Pinchi V, De Luca F, Ricciardi F, Focardi M, Piredda V, Mazzeo E, et al. The Nemours Foundation. doi: 10.1055/s-2000-3766, 89. Several authors have proposed different algorithms for predicting adult height. doi: 10.1016/S0022-3476(52)80205-7, 138. Samadi M, Rashid RJ, Ghaffari S, Shoaran M. Study on bone age in pediatric patients with congenital heart disease and its relation with cyanosis and pulmonary artery pressure. doi: 10.1111/j.1651-2227.2011.02476.x, 74. doi: 10.1210/jc.82.5.1603, 86. doi: 10.1002/ibd.22979, 31. Bone age may be affected by several factors, including gender, nutrition, as well as metabolic, genetic, and social factors and either acute or chronic diseases, including endocrine dysfunction (39). doi: 10.1007/978-1-4419-1795-9_176, 124. Growth in atopic eczema. Finally, children with later than normal puberty timing, are expected to grow along a height percentile below their final adult height, but continue growing longer than their peers. IEEE Trans Med Imaging. After puberty, all carpals, metacarpals, and phalanges are completely developed, their physes are closed, and the assessment of skeletal maturity is based on the degree of epiphyseal fusion of the ulna and radius (8082).

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