Original communication
The applicability of Greulich and Pyle atlas to assess skeletal age for four ethnic groups

https://doi.org/10.1016/j.jflm.2013.11.011Get rights and content

Abstract

Background

Recently, determination of skeletal age, defined as the assessment of bone age, has rapidly become an important task between forensic experts and radiologists. The Greulich–Pyle (GP) atlas is one of the most frequently used methods for the assessment of skeletal age around the world. After presentation of the GP approach for the estimation of the bone age, much research has been conducted to examine the usability of this method in various geographic or ethnic categories. This study investigates on a small-scale and compares the reliability of the GP atlas for assessment of the bone age for four ethnic groups – Asian, African/American, Caucasian and Hispanic – for a different range of ages.

Materials and methods

Plain radiographs of 184 left hands and wrists for males from the healthy sample between 1 to 18 years of age for four ethnic groups were taken. The skeletal age (SA) was estimated by a radiologist using the GP atlas. The blind method was utilized. The mean (SA) results were compared with mean chronological ages (CA) for the separate ethnic groups. SPSS was used to conduct the analysis and the paired t-test was applied to show the difference between the mean CA and mean SA achieved from the GP atlas.

Results

The results from the GP atlas were compared to the CA of the samples. In Asian subjects the mean difference was 0.873 years. The GP atlas showed delayed bone age at 2–7 ages (from 0.2 to 2.3 year) and then advanced bone age for age 8. In the African/American subjects the difference between CA and SA was statistically significant (P-value = 0.048). The mean difference in the Caucasian and Hispanic subjects reflects no considerable distinction with a standard deviation (SD) of 0.3088 and 0.3766, respectively, (P-value >0.05 for both groups).

Conclusion

According to the present study, it is concluded that although the GP atlas is reliable for Caucasian and Hispanic ethnic groups it is not applicable for other ethnic groups for different ranges of age, especially in the sample of the male African/American group from 8 years to 15 years and Asian during childhood. Although it is not clear whether the other references are more useful than this standard, we believe that some enhancement is vital for the GP atlas to obtain more consistent results.

Introduction

Assessment of bone age or skeletal maturity is not only used in forensic science, but it is also utilized in the clinical environment in radiology and paediatrics.1, 2 Usually, bone age is determined by comparing the left-hand radiograph of children with a standard reference sample as an atlas. Bone age assessment (BAA) has become an interesting academic topic due to the increase in illegal border immigration in developing countries. These days, most countries have been faced with a rise in the amount of foreigners who do not have a valid ID to prove their age.3 Skeletal age (SA) is an excellent indicator for determination of the growth status, health monitoring, metabolic and genetic disorders, as well as diagnosis of precocious puberty, endocrinology diseases, nutritional disorders and orthopaedic problems in children.4

Tanner, and Greulich and Pyle (GP) are two famous methods for assessment of the skeletal age.5 While using the Tanner atlas is more complex, the GP atlas is less time consuming and less prone to errors. Hence, the GP method has become the most preferred method for estimation of the bone age among the experts and radiologists.6, 7 The primary version of the GP atlas was introduced in the 1950s, and involved the hand skeletal of the Caucasian population in the 1930s. The data were collected from 1000 radiographs of people living in Cleveland, aged between 0 and 18 years. The second edition was published in 1959 and the last version was re-edited in 1988.

Although skeletal development is the most common indicator of bone age, there is considerable literature that bone age is affected by different criteria, such as gender, ethnicity, socio-economic citation, nutritional and geographical location.8, 9, 10, 11 In this research, we investigate the comparison of the applicability of the GP atlas for assessment of the skeletal age (SA) in the sample of four different ethnic groups – Asian, African/American, Caucasian and Hispanic. For the purpose of this study, we have chosen to limit the scope to only male subjects to remove the variability involved in assessing both genders in the four ethnic groups.

Section snippets

Materials and methods

From 1400 radiographs that were collected from the Children's Hospital Los Angeles, 184 radiographs of the left hand and wrist were randomly selected. These images were obtained by the Image Processing and Informatics (IPI) Laboratory to conduct an automatic computer-aided-diagnosis (CAD) method for bone age assessment. The radiographs were collected over ten years for both the male and female categories from new born to 18 years for the Asian, African American, Caucasian and Hispanic

Results

The data selected from the 184 male samples were classified based on the ethnicity and age. The data were analysed with SPSS 21 software. The difference between chronological age (CA) and skeletal age (SA), (CA_SA) was calculated. The mean value and standard deviation (SD) of chronological age (CA), skeletal age (SA) and their difference (CA_SA) was noted based on the ethnicity for each age group. A paired t-test was performed and the p-value obtained to show the significant age for each group.

Discussion

Skeletal maturity is accepted as an important indicator to show human development or growth status. The Greulich and Pyle atlas has proved to be a reliable standard worldwide. Scientists are interested in investigating the skeletal age of children according to different conditions – social, economic, nutritional, sex and racial. Bone age is assessed by comparison of the left X-ray image of the unknown subject with a standard reference. The objective of this study was to attempt to examine the

Conclusion

This research investigated whether the Greulich–Pyle (G–P) method is applicable for determination of the skeletal maturity in four different ethnic groups of certain age groups. It could be determined from the results that:

  • (1)

    In the case of Asian males there is a retardation of bone age for age group 2 year to 7 years.

  • (2)

    In the case of African/American males the GP atlas is not reliable for assessment of the age group of 8 years–15 years.

  • (3)

    In the case of Caucasian and Hispanic males, the GP atlas is

Ethical approval

None declared.

Funding

No grants or financial support has been obtained for this manuscript.

Conflict of interest

I declare no conflict of interest for this manuscript as the responsible author.

Acknowledgement

This study was supported by the Grant number FL012/2011, from the University of Malaya (UM), Malaysia.

References (19)

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