Skeletal Development

of the Hand and Wrist

A Radiographic Atlas and Digital
Bone Age Companion
Cree M. Gaskin, MD
Associate Professor of Radiology and Orthopaedic Surgery
Vice-Chair, Informatics
Fellowship Director, Musculoskeletal Radiology Fellowship
Director, Musculoskeletal MRI
University of Virginia Health Sciences Center
Charlottesville, Virginia
S. Lowell Kahn, MD, MBA
Interventional Radiologist
Palm Beach Radiology Professionals
JFK Medical Center
West Palm Beach, Florida
J. Christopher Bertozzi, MD
Clinical Instructor
Musculoskeletal Radiology
University of Virginia Health Sciences Center
Charlottesville, Virginia
Paul M. Bunch, MD
Musculoskeletal Radiology
University of Virginia Health Sciences Center
Charlottesville, Virginia
1
1
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Library of Congress Cataloging-in-Publication Data
Gaskin, Cree M., author.
Skeletal development of the hand and wrist : a radiographic atlas and digital bone age companion / Cree M.
Gaskin, S. Lowell Kahn, Paul M. Bunch
p. ; cm.
ISBN 978-0-19-978205-5
1. Carpal bonesRadiographyAtlases. 2. PhalangesRadiographyAtlases. 3. Skeletal
maturityAtlases. I. Kahn, S. Lowell, author. II. Bertozzi, J. Christopher, author. III. Bunch, Paul M., author.
IV. Title.
[DNLM: 1. Hand Bonesgrowth & developmentAtlases. 2. Age Determination by
SkeletonAtlases. WE 17]
QM117.G37 2011
611.718dc22
2010050983
___________________________________
This material is not intended to be, and should not be considered, a substitute for medical or other professional
advice. Treatment for the conditions described in this material is highly dependent on the individual
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9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper

To Kathy, Anna Kate, Warner, and Audrey the greatest loves of my life.
C.M.G.
To my loving wife, Carrie, and my daughters, Chloe and Ella. Thank you for your
unyielding love and support.
S.L.K.
To Joelle, Eva, and Caroline.
J.C.B.
To my parents and teachers.
P.M.B.
iv
White Matter Pathways in Early Neuroscievnce
Credits
Lead Authors: Cree M. Gaskin, MD; S. Lowell Kahn, MD, MBA
Co-Authors: J. Christopher Bertozzi, MD; Paul M. Bunch, MD
Project Consultants: Talissa Altes, MD; Joan McIlhenny, MD; Bennett Alford, MD

Acknowledgments
This atlas has been a work in progress for the last three years. It not only represents a
tremendous effort by many individuals, but a tireless commitment to quality put forth
by all of those involved. Without this level of dedication, this atlas would not exist.
A special thank you goes out to Drs. Talissa Altes, Joan McIlhenny, and Bennett
Alford of the University of Virginia for ensuring that the work adheres to the highest
standards in pediatric bone age interpretation.
Finally, wed also like to acknowledge Dr. Alex Towbin of Cincinnati Childrens Hos-
pital Medical Center, Dr. Ana Gaca of Duke University Medical Center, and Dr. George
Bissett of Texas Childrens Hospital for information regarding bone age interpretation at
their sites.
Thank you!
Cree M. Gaskin, MD
S. Lowell Kahn, MD, MBA
J. Christopher Bertozzi, MD
Paul M. Bunch, MD
v
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Table of Contents
Preface ix
Bone Age Determination 1
Tables 7
Male Standards 13
Female Standards 77
vii
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Preface
The assessment of skeletal maturity is an important part of the diagnosis and manage-
ment of pediatric growth disorders. Proper interpretation of bone age studies is impor-
tant for several reasons. In a child with growth disturbance, estimations of adult height
can be made based upon bone age radiographs. If hormonal therapy is being considered,
the time of initiation and duration of hormonal therapy depends upon the bone age.
Furthermore, certain orthopedic interventions, such as those for scoliosis and limb
length discrepancies, may be timed based upon bone age results.
Despite the magnicent technological advancements in radiology, plain radiographs
remain the exam of choice for skeletal bone age determination. Bone age studies are
ubiquitous in academic and private practice settings, and are no doubt relatively time
consuming when examining the subtle changes present within the maturing human
hand, comparing them with reference standards, and performing manual calculations to
assess whether or not a hand is of appropriate skeletal age.
The Radiographic Atlas of Skeletal Development of the Hand and Wrist, by Drs. Greulich
and Pyle, last published in 1959 as a second edition, has long been the reference of choice
for bone age interpretation for most practitioners in the United States. The book con-
tains an atlas of male and female reference standards of the left hand through the age of
18 for females and 19 for males. It also includes detailed descriptions of the subtle
changes corresponding to each image and reference charts for the appropriate standard
deviation values.
Their standards and data were based upon more than two decades of work that began
with the Brush Foundation Study of Human Growth and Development, which was
organized and led by Professor T. Wingate Todd for more than ten years. The Greulich
and Pyle standard images were the result of many years of painstaking work by many
individuals who studied hand radiographs obtained serially in thousands of children.
Beyond this, they also established age-based standard deviations for their images after
analyzing their application to the hand radiographs of hundreds of children. In part due
to the daunting task of replacing such standards and related standard deviations, this atlas
has remained in widespread use for more than fty years. Other methods for bone age
interpretation do exist, but are not in widespread use in the United States as they have
greater inter-reader variability or are signicantly more tedious.
Although the value of the Greulich and Pyle atlas itself cannot be overstated, its use
in a high-volume, PACS-based, academic or private practice setting can be cumbersome.
Rapid review of the images and text in a dark reading room, followed by the perfor-
mance of manual calculations, is somewhat tedious. As such, it is our goal to modernize
the Greulich and Pyle method for pediatric bone age interpretation for the contemporary
practice.
ix
Preface
This printed atlas contains updated images mined from many thousands of candidate
images in our PACS at the University of Virginia. Our selection process was rigorous
and took place in several phases. The images were initially clinically interpreted or
aged by academic sub-specialized pediatric radiologists. Subsequently, the images were
painstakingly compared head-to-head through several rounds of a selection process,
involving musculoskeletal radiologists, whereby we searched for images that closely
matched the developmental details evident on the Greulich and Pyle standard images
and accompanying text. Subsequently, the selected images were professionally edited in
ne detail with Photoshop to ensure that the developmental features of each bone on
each image matched the widely accepted reference standards of Greulich and Pyles
second edition. The result is an atlas of exceptionally high-quality skeletal radiographic
standards which captures both the major and ner details of the accepted standards.
On occasion, individual bones in our standards are purposefully slightly more
advanced or delayed relative to their counterparts in Greulich and Pyles atlas. These
intentional discrepancies are actually renements to aid the user in determining skeletal
age because they overcome one of the limitations of the unedited standards in Greulich
and Pyles atlas. Occasionally, individual bones in their standards are signicantly delayed
or advanced relative to the overall age of a given standard. For example, their MALE
STANDARD #11 is their 3 year 6 month (42 month) standard, yet it has a 36-month
2nd middle phalanx and a 54-month lunate. The process of reviewing their standards and
correlating with the text providing the age of each bone can be an arduous and some-
times ignored task. Failure to correlate with the text, however, can lead to errors in
assessment of skeletal age if one only compares a patients hand radiograph with the
standard images alone. Our atlas does this work for you, as we have edited our standards
so that each bone is more consistently age-appropriate. On occasion, we kept some
bones slightly advanced or delayed in order to bear necessary resemblance to the Greu-
lich and Pyle standards; however, we labeled such instances on our annotated images to
aid the user.
The Greulich and Pyle atlas contained excellent descriptive text to help distinguish
adjacent standards based upon various subtleties. One limitation though is that this tex-
tual information is somewhat tedious to apply to the images on the opposite pages. Thus,
it often goes ignored in an effort to get clinical work done. Our printed atlas contains
annotated images, opposite the bare images, that highlight important and subtle features
that can be used to distinguish standards that supercially look similar. We hope that this
format encourages use of this information so that bone age interpretation may be faster,
more accurate, and more educational.
This printed atlas is bundled with the Digital Bone Age Companion (DBAC), which is
also available for individual or institutional purchase. The Digital Bone Age Companion
(DBAC) is a freestanding Windows application with an incorporated image atlas doc-
umenting the development of the human hand for both males and females. This digital
format offers additional enhancements which further optimize bone age interpretation.
Users can easily zoom-in on subtle radiographic features, set image level and width to
their preference, and compare two or three reference standards side-by-side for those
difcult cases that supercially look like adjacent standards. Users will also be thrilled to
abandon tedious manual calculations for automated and more reliable digital results via
the exible bone age calculator. Trainees will be enabled to rapidly and reliably interpret
x
Preface
bone age studies with little attending support. Attending physicians will nd resident
check-out to be more pleasant and accurate. All users can further expedite their work-
ow by utilizing the built-in report generator, obviating the need to transpose data and
potentially avoiding dictation altogether. The digital format may also be available for
integrated use with your Radiology Information System (RIS), such as with Radiant
(the RIS for EpicCare, the electronic health record by Epic Systems). Integration further
optimizes workow by expediting the process and reducing user-introduced errors.
Given the broad application of pediatric bone aging, this atlas is not only intended
for practicing and training radiologists, but for all of those who employ bone age studies
as part of their practice. We hope that you nd this atlas as practical and academic as we
have found using it at our own institution.
Cree M. Gaskin, MD
S. Lowell Kahn, MD, MBA
xi
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1
1
Bone Age Determination
Background
The assessment of bone age is ubiquitous in academic and private radiology practices.
The importance of accurate aging cannot be overstated because of the medical implica-
tions for the pediatric patients involved. While a variety of bone aging methods have
been described, the most widely accepted and employed technique is that of Greulich
and Pyle. This is in no small part attributable to the extensive data and painstaking efforts
behind their reference standards.
Greulich and Pyles work is based upon more than two decades of radiographic
acquisition that began with the Brush Foundation Study of Human Growth and Devel-
opment, led by Professor T. Wingate Todd. Greulich and Pyles determination of the
most accurate reference standard for each age and the corresponding values for standard
deviation required the careful review of an extraordinary number of images. A criticism
of Greulich and Pyles atlas is that although the Brush Foundation sample size is large,
the data are somewhat limited for broad application because all of the children were
healthy, well-nourished Caucasian boys and girls.
As an alternative, the Stuart data obtained by Dr. Harold C. Stuart from the Depart-
ment of Maternal and Child Health at Harvards School of Public Health were acquired
from a more diverse body of children living in Boston, many of whom were from less
privileged socioeconomic groups than those in the Brush Foundation Study. Conse-
quently, these data could potentially be more broadly applicable. One can argue, how-
ever, that the more privileged children in the 1930s and 1940s reected in the Brush data
would make a better comparison for children with todays standards for health and
nutrition. In this text, we have included both the Brush data and Stuart data for com-
parison. Based upon informal polling of sites, we believe that the Brush data are much
more widely used clinically.
Another complicating factor in bone aging is that there is no universal standard for
calculation. In authoring this text, we have found that the actual methods employed vary
considerably by institution and at times within one institution. There are various styles
or techniques for determining the appropriate standard deviation from the provided
charts as well as inconsistent usage of an adjustment to the chronological age. These dif-
ferences will be detailed later. Fortunately, whether Brush or Stuart data are employed
and regardless of which one of the variant methods of calculation is utilized, the practi-
cal differences are small and unlikely to impact clinical management in the majority of
patients.
Skeletal Development of the Hand and Wrist
2
Steps to Manual Bone Age Assessment:
1.) Select a reference standard that most closely matches your patient in
order to determine the Estimated Skeletal Age: Carefully review the refer-
ence images corresponding to the same sex as your patient. By convention, these
are PA radiographs of the left hand. For the sake of speed, you should begin by
looking up the reference standard which by age is closest to the chronological age
of the patient under review. Older and younger reference standards should then be
inspected until a standard is selected which most accurately resembles the radio-
graph of the patient.
a. Tip: Use the annotations on the left-sided reference images for guidance in
choosing a standard. There is no signicance to the color scheme of the anno-
tations; the different colors are purely to facilitate visually linking the text boxes
with the arrows, circles, and other guides to the osseous ndings.
b. Tip: It is often difcult to nd a reference image which perfectly matches that
of the patient. The maturation of the hand is a heterogeneous process whereby
some bones will mature at different rates in one patient compared to another.
Nonetheless, the changes evident in the phalanges should be given more prior-
ity than those of the carpal bones since there is signicantly more variability in
carpal bone development. Therefore if one reference standard more closely
resembles your patients phalanges, while another standard more closely resem-
bles the carpal bones, the standard with the more comparable phalanges should
be given serious consideration.
c. Tip: Generally, you should choose the reference standard that best matches the
patient under review. The age of this standard is then considered the Estimated
Skeletal Age for the patient. However, when a patients radiograph falls clearly
between two reference standards, it is recommended to assign an Estimated
Skeletal Age that is intermediate between the two standards. For example, it is
acceptable to use an Estimated Skeletal Age of 8 years and 6 months for a
patient whose development falls roughly equally between the 8- and 9-year-old
standards.
2.) Determine the Patients Chronological Age: This is usually a straightforward
process since chronological age is often immediately available via patient exam
paperwork, on display in PACS from the DICOM data, or in the Radiology Infor-
mation System (RIS). However, if it is not immediately available, it should be noted
that it is necessary to use the chronological age of the patient at the time of the
study, not necessarily the current chronological age of the patient (relevant only if
there has been a signicant delay between the time of the study and the current
date). If manual calculation is needed, it is at least intuitive, reecting the date of
exam minus the date of birth.
a. Optional: Although not widely used when doing bone age calculations
manually, some radiologists prefer to adjust the patients chronological age to
compensate for differences between the chronological age of the test popula-
tion and the mean skeletal age of the test population used to determine the
standard deviations, as delineated in the Brush and Stuart data tables based upon
their reference standards. For example, reviewing the Brush data chart for boys
Bone Age Determination
3
(Table 1) shows that the mean skeletal age is 125.68 months (rounds to 126
months, or 10 years and 6 months) for the test population with a chronological
age of 10 years when using the reference standards and technique of Greulich
and Pyle. For a patient with a chronological age of 10 years, some radiologists
add 6 months to the chronological age of the patient to make further bone
age calculations based upon this Adjusted Chronological Age, rather than using
the actual chronological age. Some radiologists do not feel that this is necessary
and they simply use the patients chronological age. Some believe it is a reason-
able step, but still may not practice it clinically as it is relatively tedious and often
does not impact the nal result of normal vs. delayed vs. advanced
development. For those who want to do this optional step, we have shortened
the process by calculating these modiers and adding them to our tables
(see Optional Adjustment to Chronological Age in Tables 1-4).
Equations for optional adjustment to chronological age:
CA = Patients Chronological Age
ACA = Adjusted Chronological Age
Modier = Mean skeletal age of test population Chronological
age of test population = Optional Adjustment to Chronologi-
cal Age in Tables 1-4
ACA = CA + Modier (modier can be positive or negative)
Example of optional calculation of Adjusted Chronological Age:
Consider a 10-year and 1-month old boy. In Table 1, the optional modier
for a 10-year old boy is 5.68 months which rounds to 6 months.
ACA = CA + modier = 10 years and 1 month plus 6 months = 10 years
and 7 months
3.) Determine the appropriate standard deviation: This is based upon the
patients chronological age, not the age of the selected reference standard from the
atlas (nor the Adjusted Chronological Age should you choose to do that optional
step). The standard deviation is obtained from either the Brush or Stuart data tables
(Tables 1-4). As mentioned earlier, use of the Brush data is more conventional and
it is what we use at our institution; however, some may prefer the Stuart data. Most
patients are not conveniently the exact same chronological age as the groups offered
in the charts. So, one is faced with choosing a standard deviation value from a vari-
ety of approaches. Some radiologists round the patients chronological age down to
the closest available chronological age in the table and then choose a standard
deviation value. Other radiologists round to the nearest chronological age avail-
able in the table and then choose a standard deviation value. And nally, some
radiologists interpolate a standard deviation value between the two closest chron-
ological ages available in the table. From informal polling, we believe that all of the
above techniques are in wide clinical use. Fortunately, these different options only
create small numerical differences; thus they are unlikely to have a signicant
impact on the overall determination of normal vs. delayed vs. advanced develop-
ment. We do not advocate for one approach over another as this was not dened in
the Greulich and Pyle atlas; however, we do recommend consistency in methodol-
ogy at a given site, where serial bone age exams could be performed on one patient
by different readers.
Skeletal Development of the Hand and Wrist
4
Example: Determine the standard deviation for a 9-year and 9-month-old girl
using the Brush data (Table 2). If you round the patients age down to 9 years, the
table shows a standard deviation of 10.74 months. If you round the patients age to
the closest age available in the chart (10 years), then the standard deviation is 11.73
months. If you use the patients chronological age of 9 years and 9 months and
interpolate the standard deviation between the values for the 9-year-old and the
10-year-old, you get 11.48 months.
4.) Interpretation of results: After the standard deviation value is determined from
the Brush or Stuart data tables, this value is multiplied by two. This doubled value
is then added to and subtracted from the chronological age of the patient (or the
Adjusted Chronological Age as discussed in 2a. above). This denes a range of nor-
mal skeletal ages that would be expected to encompass the skeletal development of
approximately 95% of patients at the patients chronological age (and sex). Those
patients whose Estimated Skeletal Age falls within this range are considered to have
normal skeletal development. Those patients whose Estimated Bone Age exceeds
their chronological age (or Adjusted Chronological Age) by more than two stan-
dard deviations are considered to have advanced skeletal development, while
those patients whose Estimated Bone Age falls short of their chronological age (or
Adjusted Chronological Age) by more than two standard deviations are considered
to have delayed skeletal development.
Bone Age Equations:
ESA = Estimated Bone Age or Estimated Skeletal Age
CA = Patients Chronological Age
ACA = Adjusted Chronological Age (see 2a. above)
SD = Standard Deviation
Basic technique:
Normal skeletal development: CA (2 x SD) < ESA < CA + (2 x SD)
Advanced skeletal development: ESA > CA + (2 x SD)
Delayed skeletal development: ESA < CA (2 x SD)
Modied (longer) technique (includes step 2a. above):
ACA = CA + Modier (modier can be positive or negative)
Modier = Mean skeletal age of test population Chronological age of test popu-
lation (see Tables 1-4)
Normal skeletal development: ACA (2 x SD) < ESA < ACA + (2 x SD)
Advanced skeletal development: ESA > ACA + (2 x SD)
Delayed skeletal development: ESA < ACA (2 x SD)
5.) This entire process can be simplied and enhanced by using the Digital
Bone Age Companion software by Oxford University Press, which is
available separately or bundled with this book. The Digital Bone Age Com-
panion is a freestanding Windows application which further optimizes the bone
age interpretation process. Users can easily zoom in on subtle radiographic features,
set image level and width to their preference, and compare two or three reference
standards side-by-side for those difcult cases that supercially look like adjacent
standards (no more ipping pages back-and-forth!). Users will also be thrilled to
Bone Age Determination
5
abandon tedious manual calculations for automated and more reliable digital results
via the exible bone age calculator. Trainees will be enabled to rapidly and reliably
interpret bone age studies with little attending support. Attending physicians will
nd resident check-out to be more pleasant and accurate. All users can further
expedite their workow by utilizing the built-in report generator, obviating the
need to transpose data and potentially avoiding dictation altogether.
6.) Bone age practice examples:
a. Using the basic technique, determine the overall status of skeletal maturity
(normal vs. delayed vs. advanced) of a 14-year-old boy whose hand and wrist
radiograph matches that of the 13-Year Male Standard. Use the male data from
the Brush Foundation Study (Table 1) to look up the standard deviation for a
14-year-old boy, yielding 10.72 months. Two times the standard deviation equals
21.4 months. The normal range of skeletal age is chronological age +/- 2 stan-
dard deviations. For a 14-year-old male, this is 168 months +/- 21.4 months,
yielding a range of normal for the skeletal age of 146.6 to 189.4 months. The
Estimated Skeletal Age for this patient is the age of the chosen 13-Year Male
Standard or 156 months. Since the Estimated Skeletal Age (156 months) of the
patient falls in the range of normal (146.6 to 189.4 months) for his chrono-
logical age, he is considered to have normal skeletal development and this is
his bone age result.
b. Using the basic technique, determine the overall status of skeletal maturity of a
10-year and 9-month-old girl whose hand and wrist radiograph falls evenly
between the 13-Year and 6-Month Female Standard and the 14-Year Female
Standard. Her Estimated Skeletal Age is halfway between the two standards
(13 years and 9 months or 165 months). Use the female data from the Brush
Foundation Study (Table 2) to look up the standard deviation. If you round the
patients age down to 10 years, then the standard deviation is 11.73 months. If
you round to the nearest age of 11 years, then the standard deviation is 11.94
months. If you interpolate the standard deviation between these values, you get
11.89 months. Whichever technique you choose for looking up the standard
deviation, the result is often very similar. The standard deviation by whichever
technique is roughly 11.9 months. The normal range of skeletal ages at the
patients chronological age is the chronological age (129 months) +/- 2 stan-
dard deviations (or +/-23.8 months), which yields 105 to 153 months. Her
Estimated Skeletal Age of 165 months is greater than the range of normal at her
age (that is, greater than 2 standard deviations above normal), so she is consid-
ered to have advanced skeletal maturity. Her Estimated Skeletal Age is 3.0
standard deviations above the mean.
c. Using the modied (longer) technique, determine the overall status of skeletal
maturity of a 16-year-old boy whose hand and wrist radiograph closely resem-
bles that of the 13-Year Male Standard. The standard deviation in Table 1 is
12.86 months; double this and you have 25.72 months. The Estimated Skeletal
Age is 13 years or 156 months. A 16-year-old is 192 months old. The Adjust-
ment to Chronological Age for this age group is 3.32 months (from Table 1), so
the Adjusted Chronological Age for bone age calculation is 192 months + 3.32
months = 195.32 months. By the modied technique, the range of normal at
Skeletal Development of the Hand and Wrist
6
this patients age is the Adjusted Chronological Age of 195.32 months +/- 2
standard deviations (or +/- 25.72 months), yielding a normal skeletal age range
of 169.6 to 221.0 months. Since his Estimated Skeletal Age of 156 months is
lower than the bottom of the normal range, he is considered to have delayed
skeletal maturity. His Estimated Skeletal Age is 3.1 standard deviations below
the mean.

7
2
Tables
Skeletal Development of the Hand and Wrist
8
Table 1 :
Brush data Boys: The variability of skeletal age of boys in the Brush Foundation Study
Chronological
Age
Number of Hand
Radiographs
Mean Skeletal Age
(Months)
Optional Adjustment to
Chronological Age
(months)
Standard Deviation
for Skeletal Age
(Months)
3 months 121 3.01 0.01 0.69
6 months 129 6.09 0.09 1.13
9 months 137 9.56 0.56 1.43
12 months 130 12.74 0.74 1.97
18 months 106 19.36 1.36 3.52
2 years 105 25.97 1.97 3.92
2.5 years 107 32.40 2.40 4.52
3 years 127 38.21 2.21 5.08
3.5 years 138 43.89 1.89 5.40
4 years 170 49.04 1.04 6.66
4.5 years 176 56.00 2.00 8.36
5 years 191 62.43 2.43 8.79
6 years 186 75.46 3.46 9.17
7 years 182 88.20 4.20 8.91
8 years 168 101.38 5.38 9.10
9 years 160 113.90 5.90 9.00
10 years 177 125.68 5.68 9.79
11 years 154 137.32 5.32 10.09
12 years 165 148.82 4.82 10.38
13 years 175 158.39 2.39 10.44
14 years 163 170.02 2.02 10.72
15 years 124 182.72 2.72 11.32
16 years 99 195.32 3.32 12.86
17 years 68 206.21 2.21 13.05
Modied from: Greulich WW, Pyle SI. Radiographic Atlas of Skeletal Development of the Hand and Wrist, 2nd ed. Stanford, CA: Stanford
University Press and London, UK: Oxford University Press, 1959.
Tables
9
Table 2 :
Brush data Girls: The variability of skeletal age of girls in the Brush Foundation Study
Chronological
Age
Number of Hand
Radiographs
Mean Skeletal Age
(months)
Optional Adjustment to
Chronological Age
(months)
Standard Deviation
for Skeletal Age
(months)
3 months 108 3.02 0.02 0.72
6 months 121 6.04 0.04 1.16
9 months 122 9.05 0.05 1.36
12 months 117 12.04 0.04 1.77
18 months 93 18.22 0.22 3.49
2 years 101 24.16 0.16 4.64
2.5 years 98 30.96 0.96 5.37
3 years 133 36.63 0.63 5.97
3.5 years 131 43.50 1.5 7.48
4 years 154 50.14 2.14 8.98
4.5 years 152 60.06 6.06 10.73
5 years 167 66.21 6.21 11.65
6 years 191 78.50 6.5 10.23
7 years 200 89.30 5.3 9.64
8 years 201 100.66 4.66 10.23
9 years 195 113.86 5.86 10.74
10 years 206 125.66 5.66 11.73
11 years 203 137.87 5.87 11.94
12 years 198 149.62 5.62 10.24
13 years 179 162.28 6.28 10.67
14 years 170 174.25 6.25 11.30
15 years 117 183.62 3.62 9.23
16 years 64 189.44 -2.56 7.31
Modied from: Greulich WW, Pyle SI. Radiographic Atlas of Skeletal Development of the Hand and Wrist, 2nd ed. Stanford, CA: Stanford Uni-
versity Press and London, UK: Oxford University Press, 1959.
Skeletal Development of the Hand and Wrist
10
Table 3 :
Stuart dataBoys (Less commonly used than the Brush Foundation Study data); means and standard
deviations for skeletal age of the hand and wrist
Chronological
Age
Number of Hand
Radiographs
Mean Skeletal
Age (months)
Optional Adjustment to
Chronological Age
(months)
Standard Deviation
for Skeletal Age
(months)
12 months 66 12.7 0.7 2.1
18 months 67 17.5 -0.5 2.7
2 years 67 22.6 -1.4 4.0
2.5 years 67 28.1 -1.9 5.4
3 years 67 33.8 -2.2 6.0
3.5 years 67 39.5 -2.5 6.6
4 years 65 44.8 -3.2 7.0
4.5 years 64 50.3 -3.7 7.8
5 years 64 56.2 -3.8 8.4
5.5 years 64 62.4 -3.6 9.1
6 years 66 68.4 -3.6 9.3
7 years 66 80.6 -3.4 10.1
8 years 63 92.5 -3.5 10.8
9 years 63 104.9 -3.1 11.0
10 years 63 118.0 -2 11.4
11 years 65 132.1 0.1 10.5
12 years 64 144.5 0.5 10.4
13 years 66 156.4 0.4 11.1
14 years 65 168.5 0.5 12.0
15 years 65 180.7 0.7 14.2
16 years 65 193.0 1 15.1
17 years 60 206.0 2 15.4
Modied from: Greulich WW, Pyle SI. Radiographic Atlas of Skeletal Development of the Hand and Wrist, 2nd ed. Stanford, CA: Stanford
University Press and London, UK: Oxford University Press, 1959.
Tables
11
Table 4 :
Stuart dataGirls (Less commonly used than the Brush Foundation Study data); means and standard
deviations for skeletal age of the hand and wrist
Chronological
Age
Number of Hand
Radiographs
Mean Skeletal
Age (months)
Optional Adjustment to
Chronological Age
(months)
Standard Deviation
for Skeletal Age
(months)
12 months 65 12.7 0.7 2.7
18 months 66 18.4 0.4 3.4
2 years 66 23.7 -0.3 4.0
2.5 years 65 29.0 -1 4.8
3 years 66 34.5 -1.5 5.6
3.5 years 66 40.6 -1.4 6.5
4 years 67 46.4 -1.6 7.2
4.5 years 67 52.3 -1.7 8.0
5 years 67 58.1 -1.9 8.6
5.5 years 67 63.9 -2.1 8.9
6 years 67 70.4 -1.6 9.0
7 years 67 82.0 -2 8.3
8 years 67 94.0 -2 8.8
9 years 67 105.9 -2.1 9.3
10 years 66 119.0 -1 10.8
11 years 66 132.9 0.9 12.3
12 years 66 147.2 3.2 14.0
13 years 66 160.3 4.3 14.6
14 years 63 172.4 4.4 12.6
15 years 61 184.3 4.3 11.2
Modied from: Greulich WW, Pyle SI. Radiographic Atlas of Skeletal Development of the Hand and Wrist, 2nd ed. Stanford, CA: Stanford
University Press and London, UK: Oxford University Press, 1959.
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13
3
Male Standards
Skeletal Development of the Hand and Wrist
14
Male Skeletal Age: Newborn (term)
The typical degree
of radial flare for a
full-term newborn
The proximal
and middle
phalanges
are rounded
distally, but
wider and
flattened
proximally
The 2
nd
5
th
metacarpal
shafts are
constricted
in the
middle
The metacarpal
shafts radiate
out from the
carpus when
the newborn is
full-term
Male Standards
15
Male Skeletal Age: Newborn (term)
Skeletal Development of the Hand and Wrist
16
Male Skeletal Age: 3 Months
Flaring of the
distal radius
and ulna has
increased
mildly
The capitate
and hamate
ossification
centers are
now present
The
phalanges
have
increased in
length more
than width
The central
portions of
the
phalangeal
shafts are
now mildly
constricted
Male Standards
17
Male Skeletal Age: 3 Months
Skeletal Development of the Hand and Wrist
18
Male Skeletal Age: 6 Months
The
metacarpals
have distinct
individual
differences in
morphology
The capitate and
hamate have
enlarged but,
both remain
rounded. The
long axis of the
capitate is now
established. Pronounced
flaring of the
ends of the
distal radius
and ulna
Male Standards
19
Male Skeletal Age: 6 Months
Skeletal Development of the Hand and Wrist
20
Male Skeletal Age: 9 Months
2
nd
5
th
metacarpal bases and distal 1
st
metacarpal
now rounded and broader relative to their constricted
shafts
Mild flattening
of the hamate
surface of the
capitate
Male Standards
21
Male Skeletal Age: 9 Months
Skeletal Development of the Hand and Wrist
22
Male Skeletal Age: 1 Year
Mild constriction
or slight
flattening of the
radial and ulnar
aspects of the
distal tips of the
3
rd
and 4
th
proximal
phalanges
The capitate
and hamate
have enlarged
and grown
closer together
Further
flattening of
the hamate
surface of
the capitate
Male Standards
23
Male Skeletal Age: 1 Year
Skeletal Development of the Hand and Wrist
24
Male Skeletal Age: 1 Year and 3 Months
The sides of
the distal
ends of the
3
rd
and 4
th
proximal
phalanges are
now
somewhat
flattened
The portion of the
2
nd
metacarpal
that will articulate
with the capitate
has begun to
flatten
The capitate
surface of
the hamate
has begun to
flatten
Progressive
flattening of
the hamate
surface of
the capitate
The trapezoid margin
of the capitate may be
convex, flat, or
slightly concave
A small ossification
center is now visible
at the distal radial
epiphysis
Male Standards
25
Male Skeletal Age: 1 Year and 3 Months
Skeletal Development of the Hand and Wrist
26
Male Skeletal Age: 1 Year and 6 Months
Ossification centers are
now present at the
heads of the 2
nd
4
th
metacarpals, the bases
of the 2
nd
4
th
proximal
phalanges, and the
distal phalanx of the
thumb
(Not shown: the ulnar
aspect may be pointed
relative to a thicker
radial aspect)
Mild enlargement of the
distal radial epiphysis
Male Standards
27
Male Skeletal Age: 1 Year and 6 Months
Skeletal Development of the Hand and Wrist
28
Male Skeletal Age: 2 Years
Ossification has
now begun in
the following
epiphyses:
middle & distal
phalanges of
3
rd
and 4
th
digits
5
th
proximal
phalanx
5
th
metacarpal
head
The epiphyses of the
proximal phalanges of
the 2
nd
4
th
digits and
the distal phalanx of the
thumb are now disc
shaped
The capitate
and hamate
have increased
further in size
Male Standards
29
Male Skeletal Age: 2 Years
Skeletal Development of the Hand and Wrist
30
Male Skeletal Age: 2 Years and 8 Months
The epiphyses of the
proximal phalanges of the
2
nd
5
th
fingers are at least
as wide as their shafts
Ossification has
now begun in
the following
epiphyses:
middle phalanx
of the 2
nd
digit
1
st
proximal
phalanx
1
st
metacarpal
The epiphysis of the
radius has become
wedge-shaped due to
relative thickening of
its radial aspect
Elongation or
flattening of
this epiphysis
The
Ossification of
the triquetrum
has begun
(start time is
quite variable)
Male Standards
31
Male Skeletal Age: 2 Years and 8 Months
Skeletal Development of the Hand and Wrist
32
Male Skeletal Age: 3 Years
Phalangeal
ossification
centers are
slightly
larger and
more disc
shaped
Lunate
ossification
has begun,
although
precociously
Volar (white line)
and dorsal (more
distal margin)
surfaces of the
radial epiphysis
can now be
distinguished
Metacarpal
ossification
centers are
slightly larger
Male Standards
33
Male Skeletal Age: 3 Years
Skeletal Development of the Hand and Wrist
34
Male Skeletal Age: 3 Years and 6 Months
The
epiphyses of
the 2
nd
and
5
th
distal
phalanges
are now
visible
The epiphyses of
the 3
rd
and 4
th
distal phalanges
are now disc
shaped
Increased
ossification
of the
lunate and
triquetrum
Flattening of the
base of the second
metacarpal where it
will articulate with
the trapezoid
Male Standards
35
Male Skeletal Age: 3 Years and 6 Months
Skeletal Development of the Hand and Wrist
36
Male Skeletal Age: 4 Years
Ossification
centers have
appeared in all
phalangeal
epiphyses,
including that of
the 5
th
middle
phalanx
Ossification of the
trapezium has
appeared somewhat
precociously. It is
not required for this
bone age
The volar (white line)
and dorsal (more
distal margin)
surfaces of the radial
epiphysis can be
distinguished
The epiphyses of
the 2
nd
and 3
rd
proximal
phalanges are
mildly wedge
shaped, tapering
toward their
ulnar aspects
Male Standards
37
Male Skeletal Age: 4 Years
Skeletal Development of the Hand and Wrist
38
Male Skeletal Age: 4 Years and 6 Months
The middle phalangeal epiphyses are
more than as wide as their shafts
The articular
surfaces
of the
2
nd
and 3
rd
proximal
phalanges
are slightly
concave as
they shape
to the
metacarpal
heads
The epiphyses of the
2
nd
5
th
metacarpals
are flattened at their
ulnar aspects and
rounded distally
A small round
ossification center
is present in the
trapezium
Male Standards
39
Male Skeletal Age: 4 Years and 6 Months
Skeletal Development of the Hand and Wrist
40
Male Skeletal Age: 5 Years
The epiphysis of the
5
th
distal phalanx is
at least 2/3 as wide
as its metaphysis
All 5 apparent
MCP joint
spaces have
become
progressively
smaller as the
metacarpal and
phalangeal
ossification
centers have
enlarged
The trapezoidal
facet of the 2
nd
metacarpal is
slightly
concave
The 4
th
and 5
th
metacarpal bases
now partially
overlap
The lunate and
hamate facets of
the triquetrum are
now distinct
The 1
st
metacarpal
epiphysis is more
than the width of
the metaphysis
The non-articular
surface of the
triquetrum
remains convex
Male Standards
41
Male Skeletal Age: 5 Years
Skeletal Development of the Hand and Wrist
42
Male Skeletal Age: 6 Years
The articular
margins of the
epiphyses of the
4
th
and 5
th
proximal
phalanges are
slightly concave
The epiphyses
of the proximal
phalanges are
not yet as wide
as their shafts
The 2
nd
metacarpal is
more clearly concave
at its articular margin
with the trapezoid
The trapezium has
enlarged slightly
and its 1
st
metacarpal surface
has begun to flatten
The lunate,
capitate, hamate,
and triquetrum
have enlarged and
their surfaces
have differentiated
further
The scaphoid and
trapezoid ossification
centers have appeared
This early
ossification
of the ulnar
epiphysis is
mildly
advanced
for this age
Early enlargement of the part of
the radial epiphysis from which
the styloid process will develop
Male Standards
43
Male Skeletal Age: 6 Years
Skeletal Development of the Hand and Wrist
44
Male Skeletal Age: 7 Years
The proximal
epiphysis of
the 5
th
middle
phalanx is
over the
width of the
shaft
Reciprocal
convexity and
concavity of
the hamate
and capitate
respectively
Slight flattening of
the surface of the
trapezoid adjacent to
the capitate
Flattening of the
metacarpal margin
of the hamate
The trapezium
and trapezoid
now overlap if
properly
positioned
The proximal
margin of the 1
st
metacarpal has
flattened
The radial epiphysis
has increased in width
and its future styloid
portion has thickened
Enlarged
ulnar
epiphysis
Male Standards
45
Male Skeletal Age: 7 Years
Skeletal Development of the Hand and Wrist
46
Male Skeletal Age: 8 Years
The
epiphyses
of the distal
phalanges
are as wide
as their
shafts
All middle
phalangeal
epiphyses as well
as the 2
nd
and 3
rd
distal phalangeal
epiphyses are
thicker centrally
as they contour
to the trochlear
surfaces of their
respective
proximal
phalanges
The ulnar margin of the
2
nd
metacarpal is now
more pronounced
where it will articulate
with the capitate
The 2
nd
metacarpal
concavity adjacent
to the trapezoid is
now pronounced
The scaphoid
has elongated
with less
convexity of its
capitate surface
White lines are now
evident at the
metacarpal surfaces
of the hamate,
capitate, and
trapezoid, denoting
their volar surfaces;
these become more
pronounced with
later standards
The 1
st
metacarpal
epiphysis reaches the
volar-ulnar margin of
its shaft before the
dorsal-radial margin
Male Standards
47
Male Skeletal Age: 8 Years
Skeletal Development of the Hand and Wrist
48
Male Skeletal Age: 9 Years
The distal ends of the 2
nd
and 3
rd
proximal phalanges
have become slightly
concave at their trochlear
surfaces
The ulnar
distal margin
of the hamate
is developing a
projection to
articulate with
the 5
th
metacarpal
The ulnar
epiphysis
has
enlarged
and an
early
styloid
process is
evident
The trapezium is
developing a process
projecting toward the
2
nd
metacarpal
Two distinct
metacarpal
surfaces of the
capitate have
begun to
differentiate
Male Standards
49
Male Skeletal Age: 9 Years
Skeletal Development of the Hand and Wrist
50
Male Skeletal Age: 10 Years
The epiphyses of the 2
nd
5
th
distal phalanges are
wider than their shafts
The epiphyses of
all middle
phalanges are
thicker centrally,
with angulated
articular surfaces
and flattened
distal margins
The epiphyses
of the 2
nd
5
th
proximal
phalanges are
not quite as
wide as their
metaphyses
Flattening of the
surface of the
trapezoid adjacent to
the scaphoid
The 1
st
metacarpal
epiphysis has slight
concavity at its
articular surface
The 1
st
metacarpal
epiphysis
has not fully
widened to
reach the
radial margin
of its
metaphysis
The volar
margin of the
scaphoid is
noted as a
heavy white line
Vague
ossification
of the
pisiform is
now evident
over the
triquetrum
Slight concavity of the
trapezium at its
articulation with the 1
st
metacarpal; flattening of
its scaphoid surface
Slight
Male Standards
51
Male Skeletal Age: 10 Years
Skeletal Development of the Hand and Wrist
52
Male Skeletal Age: 11 Years
Overall
continued
enlargement
and
progressive
reciprocal
shaping of the
carpal bones
The epiphyses of
the 2
nd
5
th
distal phalanges
have started to
contour to the
trochlear
surfaces of the
middle
phalanges
The distal
scaphoid
has flattened
and its
capitate
surface is
distinctly
concave
The volar and dorsal
surfaces of the
hamate are now
discernible at the
articulation with the
4
th
metacarpal base
The pisiform is
better defined
The ulnar
epiphysis
has matured
The scaphoid and radial
facets of the lunate are
becoming defined
The epiphysis of the
2
nd
proximal phalanx
is now as wide as its
metaphysis
The ulnar volar
margin of the
epiphysis of the 1
st
metacarpal now
extends beyond
the margin of the
metaphysis
Male Standards
53
Male Skeletal Age: 11 Years
Skeletal Development of the Hand and Wrist
54
Male Skeletal Age: 11 Years and 6 Months
Overall, the carpal
bones have enlarged,
the spaces between
them have decreased,
and their reciprocal
shaping has progressed
The capitate
and the
scaphoid
now mildly
overlap
In the preceding
standard, the
lunates distal
dorsal surface
appears as a thick
white line. In the
current standard,
this is expanded
centrally, forming
a slight, blunt
protuberance
toward the
capitate
The styloid
processes of the
ulnar and radial
epiphyses are now
more distinct
Male Standards
55
Male Skeletal Age: 11 Years and 6 Months
Skeletal Development of the Hand and Wrist
56
Male Skeletal Age: 12 Years and 6 Months
The epiphyses of
the 2
nd
and 3
rd
middle phalanges
and the 3
rd
5
th
proximal
phalanges are
now as wide as
their metaphyses
The outline
of the hook
of the
hamate is
now visible
Overall, the carpals
have enlarged and
their articular
surfaces have
become more
distinct. This is
most notable at the
CMC joints.
Male Standards
57
Male Skeletal Age: 12 Years and 6 Months
Skeletal Development of the Hand and Wrist
58
Male Skeletal Age: 13 Years
The tips of the epiphyses of the 2
nd
5
th
distal phalanges are bent slightly
distally and the trochlear (distal) portions of the adjacent middle phalanges
are slightly concave
The epiphyses of the
2
nd
5
th
proximal
phalanges have
distally directed tips
at their radial margins
as they begin to cap
their shafts
The
epiphysis
of the 5
th
middle
phalanx is
now as
wide as its
metaphysis
Ossification is now
visible in the
sesamoid of the
adductor pollicis
The epiphyses of the
2
nd
5
th
metacarpals are
now as wide as their
corresponding metaphyses
Male Standards
59
Male Skeletal Age: 13 Years
Skeletal Development of the Hand and Wrist
60
Male Skeletal Age: 13 Years and 6 Months
All metacarpal
epiphyses are
clearly as wide as
their shafts; these
epiphyses and
their shafts
closely conform
to each other at
their shared
growth plates
The epiphyses of the
proximal and middle
phalanges have all
begun to cap their
shafts (that is, they
have slight distally
directed tips at their
radial and ulnar
margins)
Enlargement of the
ossification center
of the sesamoid of
the adductor
pollicis
The flexor
pollicis
brevis
sesamoid is
now faintly
seen lateral
to the
adductor
sesamoid
The
complete
outline of
the hook of
the hamate
is distinct
by this age
The radial epiphysis has
adjusted further to match
its metaphysis; this is
most evident at its lateral
margin, as it prepares to
cap its shaft
Male Standards
61
Male Skeletal Age: 13 Years and 6 Months
Skeletal Development of the Hand and Wrist
62
Male Skeletal Age: 14 Years
All epiphyses of the 2
nd
5
th
digits, including
those of the distal
phalanges, have begun
to cap their shafts. In the
proximal phalanges,
capping is more evident
on the radial side
The cartilaginous
growth plates of the
metacarpals are now
uniformly narrow.
Some portions of the
osseous margins
around them have
become less distinct
The radial
epiphysis has
begun to cap its
shaft (that is, its
margins point
proximally)
Male Standards
63
Male Skeletal Age: 14 Years
Skeletal Development of the Hand and Wrist
64
Male Skeletal Age: 15 Years
Fusion has begun at the epiphyses of all distal phalanges
The cartilaginous
growth plates of
the radius, ulna,
metacarpals, and
phalanges have
reduced in
thickness
compared with
the previous
standard
Fusion of the
dorsal/radial
1/3 of the 1
st
metacarpal
epiphysis
The radial epiphysis
has capped its shaft
(that is, its margins
point proximally)
Male Standards
65
Male Skeletal Age: 15 Years
Skeletal Development of the Hand and Wrist
66
Male Skeletal Age: 15 Years and 6 Months
This standard
represents the
degree of skeletal
maturity reached by
most boys at
puberty. It is
comparable to the
13-Year 6-Month
Female Standard,
which represents
the degree of
skeletal maturity
reached by most
girls at menarche
Fusion is complete in all distal phalanges
Fusion is about to
begin in the distal
aspects of the 2
nd
5
th
metacarpals
The 1
st
metacarpal
epiphysis has fused
with its shaft
Male Standards
67
Male Skeletal Age: 15 Years and 6 Months
Skeletal Development of the Hand and Wrist
68
Male Skeletal Age: 16 Years
Fusion is advanced in all of the proximal phalanges
as well as in the 2
nd
and 5
th
middle phalanges. It
has begun in the 3
rd
and 4
th
middle phalanges
The epiphyses of
the 2
nd
5
th
metacarpals have
begun to fuse
If accessory
sesamoid
bones are
going to
develop, they
are usually
evident by this
stage;
however, they
are variable
and may occur
sooner
Accessory sesamoids are
noted volar to the distal
end of the 1
st
proximal
phalanx as well as the
heads of the 2
nd
and 5
th
metacarpals. These are
variable; more, less, or
even none may be
present
Male Standards
69
Male Skeletal Age: 16 Years
Skeletal Development of the Hand and Wrist
70
Male Skeletal Age: 17 Years
All phalangeal
epiphyses have
fused with their
shafts. The 3
rd
and 4
th
middle
phalangeal
epiphyses are
often the last of
these to fuse
The thickness of the radial
growth plate has reduced
in preparation for fusion
Fusion has
begun at the
ulnar growth
plate
Fusion of the
2
nd
5
th
metacarpal
epiphyses has
completed
Male Standards
71
Male Skeletal Age: 17 Years
Skeletal Development of the Hand and Wrist
72
Male Skeletal Age: 18 Years
Vertical white lines on the 2
nd
5
th
metacarpal heads outline
portions of their volar surfaces. Prior to fusion, these lines are
interrupted by the growth plates as in the 13-Year, 6-Month Male
Standard. These lines become continuous with the shaft as
fusion occurs. This is usually more advanced on the ulnar side.
All of the epiphyses
except that of the
radius have fully
completed fusion with
their respective
shafts. This process
is nearly complete in
the radius.
Male Standards
73
Male Skeletal Age: 18 Years
Skeletal Development of the Hand and Wrist
74
Male Skeletal Age: 19 Years
The epiphyseal
line of the radius
is now only
faintly seen. It
may disappear
completely or
persist into
adulthood.
The radial epiphysis
is now completely
fused with its shaft,
completing skeletal
maturation of the
hand and wrist.
Male Standards
75
Male Skeletal Age: 19 Years
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77
4
Female Standards
Skeletal Development of the Hand and Wrist
78
Female Skeletal Age: Newborn (term)
The typical
degree of radial
and ulnar flare
seen in a full-term
baby girl
The metacarpal shafts typically radiate out from
the carpus in a full-term infant, while they may be
more parallel if the infant is premature
The proximal
and middle
phalanges
are rounded
distally, but
wider and
flattened
proximally
The shafts of
the 2
nd
5
th
metacarpals
are slightly
constricted in
the middle
Female Standards
79
Female Skeletal Age: Newborn (term)
Skeletal Development of the Hand and Wrist
80
Female Skeletal Age: 3 Months
Flaring of the
distal radius and
ulna has
increased mildly
and there is a
typical beak-like
projection from
the radial side of
the distal ulna
The capitate
and hamate
ossification
centers are
now present
The
phalanges
have
increased in
length more
than width
The 2
nd
5
th
metacarpal
bases have
become
more
rounded
Female Standards
81
Female Skeletal Age: 3 Months
Skeletal Development of the Hand and Wrist
82
Female Skeletal Age: 6 Months
Interval
enlargement
of the capitate,
establishment
of its long
axis, and
flattening of
its hamate
surface
Interval
enlargement
of the
ossification
center of the
hamate
The bases of
the 2
nd
5
th
metacarpals
are distinctly
rounded
The metacarpals
have distinct
individual
differences in
morphology
Female Standards
83
Female Skeletal Age: 6 Months
Skeletal Development of the Hand and Wrist
84
Female Skeletal Age: 9 Months
The capitate
has enlarged
and
developed
more so
than the
hamate
Relative
enlargement
of the base of
the 2
nd
metacarpal
Female Standards
85
Female Skeletal Age: 9 Months
Skeletal Development of the Hand and Wrist
86
Female Skeletal Age: 1 Year
The proximal
aspect of the
hamate is now
narrower than its
distal aspect
An ossification center
is now evident in the
radial epiphysis
The capitate
articular
surface of the
2
nd
metacarpal
has flattened
The epiphyses of the 2
nd
4
th
proximal phalanges
now have discrete
ossification centers
The epiphyses
of the 2
nd
and 3
rd
metacarpals
have early
ossification
Female Standards
87
Female Skeletal Age: 1 Year
Skeletal Development of the Hand and Wrist
88
Female Skeletal Age: 1 Year and 3 Months
Ossification
has begun in
the epiphysis
of the 4
th
metacarpal
Ossification
has begun in
the epiphysis
of the distal
phalanx of
the thumb
The ossification centers of the
2
nd
4
th
proximal phalanges as
well as those of the 2
nd
and 3
rd
metacarpals are now slightly
larger and more discrete
Interval
enlargement
of the
ossification
center of the
distal radius
Female Standards
89
Female Skeletal Age: 1 Year and 3 Months
Skeletal Development of the Hand and Wrist
90
Female Skeletal Age: 1 Year and 6 Months
Ossification
has started in
the epiphyses
of the 5
th
metacarpal and
5
th
proximal
phalanx
The epiphyses of the
2
nd
5
th
proximal
phalanges are disc
shaped and have
smooth margins
Ossification has started in the epiphyses of the 1
st
distal and 2
nd
4
th
middle phalanges
Female Standards
91
Female Skeletal Age: 1 Year and 6 Months
Skeletal Development of the Hand and Wrist
92
Female Skeletal Age: 2 Years
The radial epiphysis
has a pointed ulnar
aspect and a
rounded lateral side
Narrowing of the
proximal aspect
of the hamate
with flattening of
its capitate and
triquetral
surfaces
Early
ossification
of the
triquetrum
New
ossification
of the
epiphyses of
the 1
st
metacarpal
and 1
st
proximal
phalanx
The 2
nd
5
th
metacarpal
epiphyses are
rounded and
have smooth
margins
New ossification of
the epiphyses of
the 3
rd
5
th
distal
phalanges
The
epiphyses of
the 2
nd
5
th
proximal
phalanges
are more
than the
width of
their
metaphyses
Female Standards
93
Female Skeletal Age: 2 Years
Skeletal Development of the Hand and Wrist
94
Female Skeletal Age: 2 Years and 6 Months
The dorsal (top arrow)
and volar (bottom
arrow) surfaces of the
distal margin of the
radial epiphysis can be
distinguished
Ossification
of the
triquetrum
has enlarged
Flattening of
the trapezoid
surface of
the base of
the 2
nd
metacarpal
The proximal
surfaces of
the epiphyses
of the 3
rd
5
th
metacarpals
have begun
to conform to
their shafts
The disc-shaped
epiphysis of the
1
st
proximal
phalanx is now
more than the
width of its shaft
Ossification of the
epiphyses is now
distinct at the 2
nd
distal phalanx and the
5
th
middle phalanx
Female Standards
95
Female Skeletal Age: 2 Years and 6 Months
Skeletal Development of the Hand and Wrist
96
Female Skeletal Age: 3 Years
Ossification
of the lunate
has begun
The ossification centers
of the triquetrum and
radius have enlarged
The 2
nd
4
th
middle phalangeal epiphyses are
more than as wide as their adjacent shafts
The epiphyses
of the 2
nd
5
th
proximal
phalanges have
thickened
slightly
Most of the distal volar
margin (heavy white line) of
the radial epiphysis is seen
Female Standards
97
Female Skeletal Age: 3 Years
Skeletal Development of the Hand and Wrist
98
Female Skeletal Age: 3 Years and 6 Months
Interval
progression of
ossification of
the lunate and
triquetrum
This early ossification of
the trapezium is mildly
precocious for this age
Some degree of
reciprocal
shaping should
be present by
this stage at
adjacent
surfaces of the
capitate and
hamate
Slight concavity
has developed at
the articular
surfaces of the
epiphyses of the
2
nd
and 3
rd
proximal
phalanges as
they shape to
the adjacent
metacarpals
Interval progression
of ossification of the
radial epiphysis
The ulnar, distal, and radial
margins of the epiphyses of
the 2
nd
and 3
rd
metacarpals are
just becoming dissimilar in
shape as the joint surfaces
begin to differentiate
Female Standards
99
Female Skeletal Age: 3 Years and 6 Months
Skeletal Development of the Hand and Wrist
100
Female Skeletal Age: 4 Years and 2 Months
The articular surfaces
of the epiphyses of the
4
th
and 5
th
proximal
phalanges have
become slightly
concave as they shape
to the metacarpal
heads
The scaphoid
and trapezoid
ossification
centers have
formed
The ossification
center of the
trapezium has
enlarged and
become more
discrete
Early flattening of the
radial and capitate
surfaces of the lunate
Increased
ossification
of the
lunate and
triquetrum
Female Standards
101
Female Skeletal Age: 4 Years and 2 Months
Skeletal Development of the Hand and Wrist
102
Female Skeletal Age: 5 Years
Differentiation of the
ulnar, distal, and radial
margins of the 4
th
and 5
th
metacarpal epiphyses
The triquetrum
has elongated
with early
flattening of
its hamate
surface
Early
enlargement
of the radial
epiphysis at
the site of its
future styloid
process
The trapezoid
ossification
center is
rounded and
has a smooth
margin
Enlarged
scaphoid is
now ovoid
Early
flattening of
the 1
st
metacarpal
surface of the
trapezium
The epiphyses
of the 3
rd
5
th
distal phalanges
are as wide as
their shafts
The epiphyses of the 2
nd
4
th
middle phalanges are shaping to
the adjacent trochlear surfaces
Beginning of distinction
between the volar
(curved white marking)
and dorsal margins of
the capitate articular
surface of the lunate
Female Standards
103
Female Skeletal Age: 5 Years
Skeletal Development of the Hand and Wrist
104
Female Skeletal Age: 5 Years and 9 Months
Further
enlargement of
the lateral side
of the radial
epiphysis
The capitate
and hamate
now overlap
The space
between the
trapezium
and trapezoid
has reduced
The carpal
ossification
centers
have
increased
in size
Female Standards
105
Female Skeletal Age: 5 Years and 9 Months
Skeletal Development of the Hand and Wrist
106
Female Skeletal Age: 6 Years and 10 Months
The styloid process
has begun to form
Start of ulnar
epiphyseal
ossification
Slight concavity of
the capitate surface
of the scaphoid
Flattening of
the scaphoid
surface of the
trapezium
has begun
Flattening of
the capitate
surface of the
trapezoid has
begun
Slight concavity has formed at
the base of the 2
nd
metacarpal
Shaping of the
epiphysis of
the 5
th
middle
phalanx to the
adjacent
trochlear
surface
Elongation of the
triquetrum,
relative narrowing
of its distal
portion, and
flattening of its
lunate surface
The epiphysis of
the 1
st
proximal
phalanx reaches
the volar-ulnar
margin of its
metaphysis
before reaching
its dorsal-radial
margin
Female Standards
107
Female Skeletal Age: 6 Years and 10 Months
Skeletal Development of the Hand and Wrist
108
Female Skeletal Age: 7 Years and 10 Months
Increased size of
the ulnar epiphysis
Distinct
flattening of
the lunate
surface of the
triquetrum
The volar and dorsal edges of the
capitate surface of the scaphoid
are becoming distinguishable
The trapezium has a
rounded process between
the 1
st
and 2
nd
metacarpals
The trapezium and
trapezoid overlap;
the volar and
dorsal margins of
the trapezoid are
seen and its
scaphoid surface
has flattened
The 2
nd
metacarpal
base is concave
and its capitate
surface has
elongated
The 1
st
proximal
phalangeal
epiphysis
extends
beyond its
shaft at the
ulnar-volar
margin and is
now even
with the shaft
at the dorsal
margin
Slight concavity at
the trochlear
surfaces of the 2
nd
and 3
rd
proximal
phalanges
The 2
nd
5
th
distal phalangeal epiphyses are shaping
to the trochlear surfaces of the middle phalanges
The 1
st
metacarpal
surface of the
trapezium is concave
Female Standards
109
Female Skeletal Age: 7 Years and 10 Months
Skeletal Development of the Hand and Wrist
110
Female Skeletal Age: 8 Years and 10 Months
Hamate: the
volar and dorsal
margins of the
radial half of its
metacarpal
surface can be
distinguished;
its 5
th
metacarpal
articular surface
has elongated
Scaphoid distal margin
has begun to flatten and
its capitate margin has
enlarged
The metacarpal
surfaces of the
capitate have
begun to form
Beginning of
pisiform
ossification
Epiphyses of the
2
nd
5
th
metacarpals: the
volar aspects of
their radial and
ulnar borders
are visible as
faint white lines
The epiphyses of the
2
nd
4
th
proximal and
middle phalanges are
as wide as their
respective metaphyses
Widened ulnar
epiphysis with
distinct styloid
and concavity of
the distal margin
The proximal
margins of the
2
nd
5
th
metacarpal
epiphyses
have shaped
further to their
respective
shafts
Female Standards
111
Female Skeletal Age: 8 Years and 10 Months
Skeletal Development of the Hand and Wrist
112
Female Skeletal Age: 10 Years
The radial and scaphoid
surfaces of the lunate are
delineated
An indentation is
evident in the
articular surface of
the epiphysis of
the 1
st
metacarpal
The hook (or
hamulus) of the
hamate is faintly
evident
The triquetrum
is shaping to
the hamate
and its volar
margin is
evident (white
linear marking)
Shallow
indentations
are noted in
the trochlear
articular
surfaces of the
2
nd
4
th
proximal
phalanges
The radial aspect of the
epiphysis of the 3
rd
distal
phalanx has begun to cap
its shaft, meaning that it has
a slight distally directed tip
The epiphyses of the
5
th
proximal and
middle phalanges are
now as wide as their
adjacent metaphyses
The ulnar
epiphysis
has widened
The pisiform
has enlarged
Female Standards
113
Female Skeletal Age: 10 Years
Skeletal Development of the Hand and Wrist
114
Female Skeletal Age: 11 Years
The radial and ulnar
epiphyses are shaping
further to their shafts
The hook of
the hamate
is triangular
in shape
Further
reciprocal
shaping at
the capitate
and scaphoid
articulation
Further reciprocal shaping of the
trapezoid and the 2
nd
metacarpal;
the long axis of the trapezoid is
now transverse
The medial aspect of
the trapezium projects
toward the base of the
2
nd
metacarpal
The 1
st
metacarpal
epiphysis
now
conforms
more
closely to
its shaft
and the
trapezium
The adductor
pollicis and
flexor pollicis
brevis
sesamoids
have ossified
The 2
nd
5
th
metacarpal
epiphyses
are as wide
as their
shafts
All phalangeal
epiphyses now
cap their shafts
Female Standards
115
Female Skeletal Age: 11 Years
Skeletal Development of the Hand and Wrist
116
Female Skeletal Age: 12 Years
The radial
epiphysis now
caps the shaft
and its ulnar
surface has
flattened
The developing
scaphoid tubercle
is faintly evident
(this is variable)
All carpal
articular
surfaces are
well defined
by this point
All cartilaginous growth plates have reached their
final thickness prior to beginning epiphysial
diaphysial fusion
The ulnar
styloid
process
has
enlarged
Female Standards
117
Female Skeletal Age: 12 Years
Skeletal Development of the Hand and Wrist
118
Female Skeletal Age: 13 Years
The carpals
have all
reached
adult form
The epiphysis
of the 1
st
metacarpal now
caps its shaft
Fusion of the epiphysis
and the diaphysis has
begun in the distal
phalanx of the thumb
The 2
nd
metacarpal
base has completed
capping the trapezoid
Any accessory
sesamoid
bones which
will develop
are usually
evident by this
stage
The thickness
of all growth
plates has
been notably
reduced; this
is less evident
in the radius
and ulna
Female Standards
119
Female Skeletal Age: 13 Years
Skeletal Development of the Hand and Wrist
120
Female Skeletal Age: 13 Years and 6 Months
Epiphyseal fusion has
begun in the 3
rd
5
th
proximal phalanges
Epiphyseal fusion
has begun in the
1
st
metacarpal
The epiphyses of all distal phalanges have fused
This standard represents
typical skeletal development
near menarche; it is similar to
the 15-Year, 6-Month Male
Standard, which corresponds
with male puberty
Female Standards
121
Female Skeletal Age: 13 Years and 6 Months
Skeletal Development of the Hand and Wrist
122
Female Skeletal Age: 14 Years
Fusion is well
under way in the
2
nd
5
th
metacarpals
Fusion is
complete at the 1
st
metacarpal and
the 1
st
proximal
phalanx
Fusion is advanced in
the 3
rd
5
th
middle
phalanges
The radial and ulnar
cartilaginous growth plates
have reduced in thickness
Epiphyseal
fusion is near
complete in
the 2
nd
middle
phalanx
Fusion is
complete in
the 5
th
proximal
phalanx
Fusion is near complete in
the 2
nd
4
th
proximal
phalanges
Female Standards
123
Female Skeletal Age: 14 Years
Skeletal Development of the Hand and Wrist
124
Female Skeletal Age: 15 Years
Fusion is
complete in
the 2
nd
5
th
metacarpals
Fusion is nearly complete
in the middle phalanges
Radial and ulnar
epiphyseal fusion
has begun; the ulna
is more progressed
than the radius
Fusion completes first in the
distal phalanges, followed by
the proximal phalanges, and
lastly in the middle phalanges
Epiphyseal
fusion is
complete in all
proximal
phalanges and
the lines of
fusion are nearly
obliterated
Female Standards
125
Female Skeletal Age: 15 Years
Skeletal Development of the Hand and Wrist
126
Female Skeletal Age: 16 Years
The radial
epiphysis has
fused except
along the
periphery
The ulnar
epiphysis is
fused except
near the base
of the styloid
process
Female Standards
127
Female Skeletal Age: 16 Years
Skeletal Development of the Hand and Wrist
128
Female Skeletal Age: 17 Years
Epiphyseal fusion
is complete in the
radius and ulna
Epiphyseal
lines are almost
completely
obliterated in
the middle
phalanges
Trabecular lines
traversing
former physes
indicate fusion
has been
complete for
months
Thin terminal
lines persist at
the former
physes of the
distal radius,
1
st
metacarpal,
and a few
phalanges
Female Standards
129
Female Skeletal Age: 17 Years
Skeletal Development of the Hand and Wrist
130
Female Skeletal Age: 18 Years
This hand is
indistinguishable
from that of a
young adult
Traces of some epiphyseal
lines of fusion can persist
throughout life, especially
in the radius and the 1
st
metacarpal
Female Standards
131
Female Skeletal Age: 18 Years