HAND WRIST

RADIOGRAPH
Coojacinto, S.
Celajes, S.

Introduction as an indicator
of skeletal maturity
Chronological age is often not
sufficient for assessing the
developmental stage and somatic
maturity of the patient.
The biological age is determined from
the skeletal, dental and morphologic
age and the onset of puberty
Due to individual variations in timing,
duration and velocity of growth,
skeletal age assessment is essential

Skeletal maturity indicators provide an

objective diagnostic evaluation of
stage of maturity in an individual.

Methods available to assess the

skeletal maturity of an individual
1. Use of hand wrist x-rays
2. Evaluation of skeletal maturation
using cervical vertebrae
3. Assessment of maturity by clinical
and radiographic examination of
different stages of tooth
development

Clinical significance
To determine the amount of significant
facial cranial growth potential left and
potential vector of facial development.
To decide the onset of treatment timing
and type of effective treatment.
To evaluate the treatment prognosis.
To understand the role of genetics and
environment on the skeletal maturation
pattern.

Anatomical Landmarks Suitable

for Skeletal Maturity Assessment
Head and Neck
Skull
Cervical Vertebrae
Upper limb
Tooth
Shoulder joint-Scapula
mineralization as
Elbow
an indicator
Hand wrist and fingers
Frontal sinus
Lower limb
Femur and humerus
Hip joint
Knee
Ankle

Hand Wrist Radiographs

Skeletal age assessment is often done with the
help of hand wrist radiograph which can be
considered as the Biological clock.
Hand wrist region is made up of numerous small
bones. These bones show a predictable and
scheduled pattern of appearance, ossification
and union from birth to maturity. Hence, this is
one of the most important regions to study
growth.
Nine developmental stages are there according
to Bjrk (1972), Grave and Brown (1976). The
ossification events are localized in the area of
the phalanges, carpal bones and radius.

Biological age and Hand wrist

radiograph
Orthodontic treatment progresses more quickly
during growth spurts. Generally, children
experience a pattern of fast growth, followed
by a slow growth in late childhood and then
accelerated and peak growth in adolescence.
Because children begin this growth sequence
at different ages, chronological age is a poor
indicator of childs development. Hand-wrist
radiograph is a useful tool in identifying a
childs skeletal development.

Brief history about hand wrist

radiograph
After Roentgen demonstrate his new
radiographic history in 1895, Ronaldo, in
1896, introduced the idea of using the
comparative size and shape of the
radiographic shadows of growing bones
as indicators of rate of growth and
maturity.
In early 1900s, Pryor, Rotch and
Crampton began tabulating indicators of
maturity on sequential radiographs of the
growing hand and wrist.

 Todd compiled hand-wrist data that was further

elaborated on by Greulich and Pyle in atlas form.
In 1936, Flory indicated that beginning of
calcification of the carpal sesamoid was a good
guide to determine the period immediately before
puberty. The appearance of the adductor sesamoid
has been highly correlated to peak height velocity
and start of adolescent growth spurt.
Fishman developed a system of hand wrist
skeletal maturation indicators using 4 stages of
bone maturation at 6 anatomic sites on the hand
and wrist.
Hagg and Taranger created a method using the
hand wrist radiograph to correlate certain maturity
indicators to the pubertal growth spurt.

Anatomy of Hand-Wrist
The hand wrist
region is made up of
4 groups of bones
1. Distal ends of long
bones of forearm
2. Carpal
3. Metacarpals
4. Phalanges

Anatomy of skeleton of hand

Indications of hand-wrist
radiographs
In patients who exhibit major
discrepancy between dental and
chronologic age.
Determination of skeletal maturity
status prior to treatment of skeletal
malocclusion.
To assess the skeletal age in a patient
whose growth is affected by infections,
neoplastic or traumatic conditions.
Help to predict future skeletal
maturation rate and status.

Methods of Assessing Skeletal

Age
The comparison atlas of Greulich and
Pyle (1959)
The processes that use specific
indicators that relate skeletal
maturation to the pubertal growth
curver, such as the methods
described by
Bjrk (1972)
Fishman (1982)
Hagg and Taranger (1982)

Greulich and
Pyle (1959)

Bjrks method of assessment

Bjrk utilizes certain anatomical sites
located on the phalanges, abductor
sesamoid, carpal and radius bone, which
have predictable and consistent time of
onset of ossification.
Divided the maturation process of hand
bones into developmental stages.

Fishman (1982)
Based on the observation of
ossification events localized in the
area of the finger phalanges, carpal
bone and radius.
There is a close correlation between
sequence of hand-wrist ossification
and mandibular-growth status.
Most commonly used methods to
assess skeletal maturation.

Fishman (1982)
Leonard S. Fishman outlined four
stages of bone maturation found at
six anatomical sites located on the
thumb, 3rd finger, 5th finger and
radius.
Eleven skeletal maturity indicators
are found in these six anatomic sites.

Four stages:
1. Epiphysis equal in width to diaphysis
2. Appearance of adductor sesamoid
thumb
3. Capping of epiphysis
4. Fusion of epiphysis.

1. PP3
width
2. MP3widt
h
3. MP5widt
h
4. S
5. DP3cap
6. MP3cap
7. MP5cap
8. DP3fuse
9. PP3fuse

Hagg and Taranger (1982)

Introduced a method using the handwrist radiograph to correlate certain
maturity indicators to the pubertal
spurt and noted that the stages of
ossification of middle phalanx of third
finger of a hand (MP3) follow the
pubertal growth spurt from the onset
to the end.

 Described a method in which skeletal

development is assessed by
ossification of the ulnar sesamoid of
the metacarpophalangeal joint of the
first finger (S) and certain specified
stages of three epiphyseal bones; the
middle and distal phalanges of the 3rd
finger (MP3 and DP3) and the distal
epiphysis of the radius (R).

References:
Moyers, R., Handbook of Orthodontics, 4th ed.
Enlow, Handbook of Facial Growth, 1982
Fishman, L., Radiographic evaluation of Skeletal
maturity A clinically oriented method based on
Hand-wrist films. Vol. 52, No. 2., April 1982
Antana S, et al. Mandibular Pubertal Growth Spurt
Prediction. Part One: Method Based on the HandWrist Radiographs. Stomatologija, Baltic Dental
and Maxillofacial Journal, 7:16-20, 2005.