This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). Statistics have been compiled to indicate the percentage of height growth remaining at a given bone age. 106. Stanhope R, Albanese A, Azcona C. Growth hormone treatment of russell-silver syndrome. Bayley N, Pinneau S. Tables for predicting adult height from skeletal age. Several smartphone applications have been developed to facilitate the use of vertebral methods such as Easy Age. doi: 10.1016/j.ghir.2017.10.005. (2012) 102:1742. 9:21. doi: 10.3389/fped.2021.580314. (2015) 42:3027. Bone age may be used either in normal variants of delayed growth patterns with delayed puberty and accelerated growth patterns with early puberty, where it may be more consistent with height age and adult height prediction may be more consistent with genetics. In addition, biology and genetics can play a part . Available online at: http://www.ice.gov/doclib/foia/dro_policy_memos/agedeterminationproceduresforcustodydecisionsaug202004.pdf. Pediatr Endocrinol Rev. Intestinal inflammatory chronic conditions. After dividing the population into two different age groups: children < 11 years and adolescents 11 years, children showed an average delay in bone age of 3.4 months and adolescents of 2.4 months. Short stature is defined as a height more than two standard deviations below the mean for age, or less than the 3rd percentile. X-rays should be perpendicular to the rigid plane and usually be performed with a tube of 4560 kVp potential. Peak height velocity (PHV) occurs at the average age of 11 years for girls and at the average age of 13 years for boys. Constitutional Delay of Growth and Puberty. (1952) 40:42341. It's usually done by taking a single X-ray of the left wrist, hand, and fingers. (2013) 58:1149. 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. The other primary skeletal component of height is the spine and skull. No use, distribution or reproduction is permitted which does not comply with these terms. [5][2][3][1] Drs. doi: 10.1080/03014460500087725, 119. This means a child tends to be shorter than average and to enter puberty later than average, while growing at a normal rate. The normal range is represented by 2 standard deviations (SD) above and below the mean (white area on this chart). The Fels method was developed by Roche through a longitudinal study, based on a total of 13,823 serial X-rays of the left hand and wrist. Bone age delay is also associated with genetic syndromes such as trisomy 21, Turner syndrome, and RussellSilver syndrome (10, 4648). Table 3. . Age Determination Procedures for Custody Decisions. Medical, statistical, ethical and human rights considerations in the assessment of age in children and young people subject to immigration control. In Italy, a multidisciplinary approach is suggested to evaluate bone age using the GreulichPyle TW3 methods for a complete characterization of chronological age of the refugee. Vaska AI, Benson J, Eliott JA, Williams J. According to a recent study, the BP method predicts lower adult heights than the RWT method (139). [36], Bone maturation is delayed with the variation of normal development termed constitutional delay of growth and puberty, but delay also accompanies growth failure due to growth hormone deficiency and hypothyroidism.[37][38]. [16][22] The TW methods consist of evaluating individual bones and assigning a letter grade to each bone based on its degree of maturation. [5][17] The reason for imaging only the left hand and wrist are that a hand is easily x-rayed with minimal radiation[18] and shows many bones in a single view. For specific medical advice, diagnoses, and treatment, consult your doctor. Pediatr Endocrinol Rev. doi: 10.1159/000101336, 25. (2001) 50:6248. However, data obtained from the assessment of bone age can be widely used both in medical or nonmedical settings. Contemporary Pediatrics Resident Writer Program, 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, | Obstetrics-Gynecology & Women's Health. Br J Sports Med. (2009) 33:10914. The effect of chronic childhood malnutrition on pubertal growth and development. CT Analysis Demonstrates That Cochlear Height Does Not Change with Age A projected height that differs from the midparental height by more than 10 cm suggests a possible pathologic condition. Evaluation of skeletal maturity is a common procedure frequently performed in clinical practice. [1 2 3]The two major methods of BA assessment used commonly are i . (1997) 82:16037. Although the Khamis-Roche method is considered an accurate predictor, it is not as accurate as methods using the bone age. Included criteria were age below 18 years, height more than 2 SD below the mean for age (< 3rd percentile), growth failure (< 4 cm/year), small for mid-parental height, and adequate. Horm Res. Alshamrani K, Messina F, Offiah AC. For these reasons, BoneExpert is considered a valid method. Comprehensive Pediatric Nephrology. 6. The bones on the X-ray image are compared with X-ray images in a standard atlas of bone development. Office of the United Nations High Commissioner for Refugees. Khan KM, Miller BS, Hoggard E, Somani A, Sarafoglou K. Application of ultrasound for bone age estimation in clinical practice. This lack of precision impacts on the value of bone age as evidence . In these normal boys, the chronological age at onset of puberty was 11.4 0.8 years (mean S.D.). chronological age and bone age in both genders (Females r=0.778; p-value < 0.001, Males r=0.816; p-value < 0.001). Reliability of the methods applied to assess age minority in living subjects around 18 years old. 109. doi: 10.1007/s00247-019-04435-z. Cox LA. 114. Clinical review: An automated method for determination of bone age. In a study conducted by King and collaborators in which bone aging was performed by three different operators using either GP or TW method, there was a significant intraindividual variability with values equal to 0.96 and 0.74 years, respectively (94). If the image is blurred, the X-ray technician might take another one. Available online at: http://www.unhcr.org/publications/legal/3d4f91cf4/guidelines-policies-procedures-dealing-unaccompanied-children-seeking-asylum.html. Ontell FK, Ivanovic M, Ablin DS, Barlow TW. doi: 10.1097/MPG.0b013e31818cb4b6, 32. (2009). Over the years, many standardized methods have been developed to evaluate a skeletal maturity score for hand and wrist X-rays. Bone Age and Maturity in Association with Anthropometric Measurements Idiopathic short stature is defined as a height less than two standard deviations below the mean for age without a known etiology. External validation of deep learning-based bone-age software: a Br J Radiol. The issue here is the size of the standard deviation (SD) of the difference between bone age and chronological age, which is 15 months or more. - average male height Boys come into puberty later than girls. (1994) 67:84851. In addition, subjects with long-lasting and untreated growth hormone (GH) deficiency have a delay in bone maturation. Int J Androl. Usually, the first ossification center to appear is in the context of capitate and hamate at the second month in female individuals and around the fourth month in male individuals and remain the only useful observable features for the next 6 months. They add length and width to the bone. [3] If a patient's x-ray is found to be very close in appearance to two contiguous images in the atlas, then an average of the chronological ages in the atlas may be used as the patient's bone age, although some evaluators choose to interpolate the closest age while others report a range of possible bone ages. Aynsley-Green A, Cole TJ, Crawley H, Lessof N, Boag LR, Wallace RM. According to our experience in the field, the best approach might be the Greulich-Pyle (GP) method. Applicability of Greulich and Pyle skeletal age standards to Indian children. Kulin HE, Bwibo N, Mutie D, Santner SJ. As well, height prediction methods might be affected by ethnicity-related differences, thus either underestimating or overestimating adult height, with wide variations in accuracy. Bone age is the degree of maturation of a child's skeleton ().The assessment of bone age and its comparison with chronological age are particularly useful in pediatric endocrinology for estimations of an individual's final height and to study other growth problems in clinical pediatrics (2,3). 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). The Pediatric Endocrine Society website was searched for consensus statements and clinical guidelines. Bergeron MF, Bahr R, Bartsch P, Bourdon L, Calbet JA, Carlsen KH, et al. In particular, bone age is more advanced in female than in male individuals with the same chronological age. doi: 10.1002/ibd.22979, 31. Woods CP, Argese N, Chapman M, Boot C, Webster R, Dabhi V, et al. Revised for use with the Greulich-Pyle hands standards. FCa, CG, AM, and FCh have contributed to the conception and the design of the manuscript. Nurs Res. MATERIALS AND METHODS: We measured CH on coronal CT scans of the temporal bone of 422 ears scanned from 2001 to 2007 in 211 patients, 1 month to 23 years of age. Ostojic SM. These look white on the X-ray image. (2009) 94:223944. doi: 10.1097/00004032-199811000-00005, 87. (1995) 154:627. doi: 10.1007/BF02079065, 142. [26] This method is called the Cervical vertebral maturation method. In children, bone age serves as a measure of physiological maturity and aids in the diagnosis of growth abnormalities, endocrine disorders, and other medical conditions. Pathologic causes of short stature include chronic diseases; growth hormone deficiency; and genetic disorders, such as Turner syndrome. Softer body tissues, such as the skin and muscles, allow the X-ray beams to pass through them. This was followed by a comparison between the skeletal age estimates and the chronological ages of the patients. (2014) 164:8016. In fact, the bone maturation process lasts longer in male than in female individuals (8385), and the moment of closure of the epiphyseal region occurs is roughly 2 years earlier in girls than in boys. A newborn's size and growth are a result of the intrauterine environment, and growth hormone does not play a major role. Assessment of skeletal age at the wrist in children with a new ultrasound device. Thorne MC. (1997). Projected height can be estimated by projecting the current growth curve to adulthood in children with normal bone age, or by using a bone age atlas in those with delayed bone age. (2009) 58:38290. Front Pediatr. A total 156 samples were selected convenient sampling to make comparison of bone age and chronological age between thalassaemic children (age 9-15years) and age sex matched normal control. Dysmorphic characteristics suggest a genetic disorder, whereas midline defects suggest an abnormality of the growth hormone axis. Children with normal variants of height tend to have a normal growth velocity (5 cm [2 in] per year for children between five years of age and puberty) after catch-up or catch-down growth. This means a child's height is part of his or her family's pattern of inherited tall height. Magiakou MA, Mastorakos G, Oldfield EH, Gomez MT, Doppman JL, Cutler GB, et al. Furthermore, the GP method has not been updated from its initial publication, representing important limits of applications especially in some ethnic groups such as African or Hispanic female subjects and in Asian and Hispanic male subjects during late infancy and adolescence (95, 96). The . On this Wikipedia the language links are at the top of the page across from the article title. New growth references for assessment of stature and skeletal maturation in Australians. J Pediatr. The emergence of the primary ossification centers of the carpal bones appear in a predictable order that can help in determining bone age. Table 1. Although several bones have been studied to better define bone age, the hand and wrist X-rays are the most used images. The test also can help doctors monitor progress and guide treatment of kids with conditions that affect growth, including: If you have questions about the bone age X-ray or what the results mean, talk to your doctor. United Nations Treaty Collection. 4. Cameron N. Can maturity indicators be used to estimate chronological age in children? doi: 10.1006/clim.2000.4838, 35. doi: 10.1016/j.legalmed.2011.01.004, 123. (1997) 24:13116. In terms of height growth and height growth related to bone age, average females stop growing taller two years earlier than average males. The effects of long-term medication on growth in children and adolescents with ADHD: an observational study of a large cohort of real-life patients. The TannerWhitehouse method was developed in 1,930 using data obtained in European children (3, 113). J Paediatr Child Health. Peters CJ, Ahmed ML, Storr HL, Davies KM, Martin LJ, Allgrove J, et al. 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]. doi: 10.1038/oby.2010.305, 51. In clinical trials, the most common adverse reactions involved the implant site and included discomfort, bruising, soreness, pain . J Pediatr. Puberty usually occurs early, leading to a near-normal height.19, Obese children are tall for their age.19 However, these children often have an early onset of puberty and therefore a near-normal final height.20, Intervention is usually not needed in children with tall stature. Martin MB, Li CS, Rowland CC, Howard SC, Kaste SC. Hand and wrist X-rays are considered as an important indicator of children's biological age. Nemours Children's Health and KidsHealth are registered trademarks of The Nemours Foundation. Table 6 includes the differential diagnosis of tall stature. There is a chart for males and another for females with possible bone ages ranging from 1 month to 5 years. doi: 10.1159/000185511, 141. Growth at Adolescence. doi: 10.1055/s-2000-3766, 89. De Moraes ME, Tanaka JL, de Moraes LC, Filho EM, de Melo Castilho JC. Haffner D, Nissel R. Growth and puberty in chronic kidney disease. Meet the Board: Vivian P. Hernandez-Trujillo, MD, FAAP, FAAAAI, FACAAI. Extensive clinical experience: nonclassical 21-hydroxylase deficiency. Pituitary. doi: 10.1530/EJE-15-0608, 60. Precocious puberty and statural growth - Oxford Academic Chronological age and bone age were 8.12 4.1 and 8.4 4.4 years, respectively, for girls and 9.0 3.9 and 9.1 4.2 years, respectively, for boys. In the case of too much growth hormone, a child may have a bone age that is older than their chronological age suggesting that they are growing abnormally fast. 3rd ed. Assessment of the carpals, metacarpals, and phalanges are used to find the closest match in the atlas; the chronological age of the patient in the atlas becomes the bone age assigned to the patient under review. ( p =0.67). The image in the reference atlas that most closely resembles the patient's x-ray is then used to assign a bone age to the patient. This may be inherited. Then the remaining centers appear, including Triquetrum at 2 years in females and 3 years in males, Lunate at 3 years in females and 4 years in males, Trapezium at 3 years in females and 4 years in males, Trapezoid at 4 years in females and 6 years in males, Scaphoid at 4 years in females and 6 years in males, Pisiform at 9 years in females and 12 years in males [77]. The inability to be applied in children younger than 6 years or to perfectly match (equal to 100%) the images or to weigh the differences between bone structures (short and long) represents the main disadvantages of the procedure. 9 Articles, This article is part of the Research Topic, Standardization of Hand and Wrist Radiography, Assessment Methods for Evaluating Bone Age, Computerized Automatic Systems for Reading Bone Age: Potentials and Limits, Relevance of the Variability Related to the Operator and Between the Operators, https://treaties.un.org/Pages/ViewDetails.aspx?src=IND&mtdsg_no=IV-1&chapter=4&clang=_en, http://www.ice.gov/doclib/foia/dro_policy_memos/agedeterminationproceduresforcustodydecisionsaug202004.pdf, http://www.unhcr.org/publications/legal/3d4f91cf4/guidelines-policies-procedures-dealing-unaccompanied-children-seeking-asylum.html, https://www.rch.org.au/immigranthealth/clinical/Birth_date_issues/, www.thelocal.se/20170307/sweden-begins-newasylum-seeker-age-assessment-tests, Creative Commons Attribution License (CC BY), Department of Pediatrics, University of Chieti-Pescara, Chieti, Italy. Gilsanz RO. 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). Condo R, Costacurta M, Maturo P, Docimo R. The dental age in the child with coeliac disease. J Pediatr Endocrinol. Evaluation may also be needed in a child who has a normal height, but a projected height more than two standard deviations from the midparental height. Look for a Mllerian anomaly as well. Accessed November 22, 2021. https://kidshealth.org/en/parents/xray-bone-age.html, 2. 2nd ed. doi: 10.1097/YIC.0000000000000109, 44. (1978) 93:74955. Herman TE, Crawford JD, Cleveland RH, Kushner DC. The choice of the left hand depends on the fact that, at the time of sampling, the left hand was the less frequently impaired (at that time, many boys used to work in factories, and they could have suffered accidents at work). 107. doi: 10.1016/j.forsciint.2004.08.018, 80. Jung H. The radiation risks from x-ray studies for age assessment in criminal proceedings. Doctors assign a childs bone age based on which standard X-ray images in the atlas most closely match how the child's bones look on the X-ray. [3] Large differences between a person's bone age and their chronological age may indicate a growth disorder. (2006) 22:4758. Birth Date Issues. At birth, only the metaphyses of the "long bones" are present. 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. Puberty is a time for rapid growth and development for nearly every system in the bodynot just the reproductive system. doi: 10.1088/0952-4746/23/1/302, 88. doi: 10.1002/mpo.2950210104, 40. Lin NH, Ranjitkar S, Macdonald R, Hughes T, Taylor JA, Townsend GC. (2012) 101:47. In this study of prepubertal children with and without obesity and/or PA, obesity was highly associated with BA advancement. Acta Paediatr. Several authors have proposed different algorithms for predicting adult height. In order to improve the accuracy and reproducibility of this method, changes and improvements have been made over the years. (2010) 60:5525. Factors influencing skeletal maturation at diagnosis of paediatric Cushing's disease. Bone age is distinct from an individual's biological or chronological age, which is the amount of time that has elapsed since birth. [1][2][21], The Tanner-Whitehouse (TW) technique of estimating bone is a "single-bone method" based on an x-ray image of a patient's left hand and wrist. [30][31][32][33][34], There are exceptions with people who have an advanced bone age (bone age is older than chronological age) due to being an early bloomer (someone starting puberty and hitting PHV earlier than average), being an early bloomer with precocious puberty, or having another condition. Int J Pediatr Endocrinol. A distance of 76 cm from the box tube is recommend. X-ray exam: bone age study. Anink J, Nusman CM, van Suijlekom-Smit LW, van Rijn RR, Maas M, van Rossum MA. Figure 1. Bone age is measured in years, most often using the Greulich-Pyle scale. Katherine Kutney, MD, a pediatric endocrinologist at Rainbow Babies and Childrens Hospital in Cleveland, Ohio, said bone age assessments are typically done with an x-ray of the left hand. A bone age study helps doctors estimate the maturity of a child's skeletal system. Speiser PW. doi: 10.1520/JFS2005020. doi: 10.1210/jc.2006-1645, 13. (2015) 173:63342. This method is very simple and fast, needing roughly 1.4 min for the evaluation (10, 107), thus explaining why it is preferred by 76% of pediatric endocrinologists and radiologists (10). (1993) 147:132933. 111. Tanner J, Oshman D, Bahhage F, Healy M. Tanner-Whitehouse bone age reference values for North American children. (2007) 68:2315. Introduction. Among the different procedures proposed, BonAge system represents an ultrasound machine that includes a probe connected to a main unit. (1989) 1:17583. The injections are generally well tolerated, but rare adverse reactions have been reported. When the bone age reaches 16 years in females and 18 years in males, growth in height is over, and they have reached their full adult height. [1][2], Bone age acts as a surrogate for physiological development because growth and maturation of the skeletal system depend on the presence of hormones like growth hormone, sex steroids (e.g., estrogen and testosterone), and thyroxine. (2009) 39:5917. A number of factors can help determine your body age. Common normal variants of short stature are familial short stature, constitutional delay of growth and puberty, and idiopathic short stature. To note, a proper assessment of bone age must always take into account differences between ethnic groups, sex, and any present pathological conditions. Acta Paediatr Scand. The middle finger axis should be in line with the forearm axis, and the center of the X-ray tube should be over the distal end of the third metacarpus. In particular, estrogens and oral contraceptives or creams containing testosterone or estrogens can cause an early closure of the growth plate. Assessment of bone age is also important for the correct diagnosis, particularly with the aim of detecting the causes of bone age alteration including mainly endocrine and nutritional causes and chronic nonendocrine disorders and syndromes. doi: 10.1136/bjsports-2015-094623, 67. Bone age assessments: What they can tell you about growth 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: 10.1093/ajcn/36.3.527, 27. doi: 10.1136/bcr-2015-212216, 58. As sex steroid levels rise during puberty, bone maturation accelerates. The evaluation of potential pathologic causes of short or tall stature should be guided by the history and physical examination findings.13, The first step in the evaluation of a child with suspected short or tall stature is to obtain accurate measurements and plot them on the appropriate growth chart. Between 1931 and 1942, Greulich and Pyle evaluated the hand and wrist radiographs obtained from about 1,000 white people of Cleveland (Ohio, USA) belonging to mediumhigh social classes (9, 10, 106). Interleukin-6 release by cultured peripheral blood mononuclear cells inversely correlates with height velocity, bone age, insulin-like growth factor-I, and insulin-like growth factor binding protein-3 serum levels in children with perinatal HIV-1 infection. In addition, 11 patients with multiple scans at different ages were assessed for change in CH with age. Computer-assisted phalangeal analysis in skeletal age assessment. Kawano A, Kohno H, Miyako K. A retrospective analysis of the growth pattern in patients with salt-wasting 21-hydroxylase deficiency. J Obstet Gynaecol Res. Int J Legal Med. 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. 5. 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. Malina RM, Rogol AD, Cumming SP, Coelho e Silva MJ, Figueiredo AJ. chronological and bone age for each sex and age group, the equality of the mean for each age was compared (Student's t-test for paired Bone age assessments can provide pediatricians with a rough estimate of when a child will enter puberty, Kutney stated. Issues and advances in adolescent growth and development. Multiple regression equations for predicting the adult height of boys and girls from height and bone age at ages 4 and upwards are presented. (2005) 35:42933. Although this method is very accurate and allows doctors to estimate children's bone age even when they are <1 year old, the Fels method is too complex, thus minimizing its daily use. This content is owned by the AAFP. But perfectly healthy kids also can have bone ages that differ from their actual ages. (2000) 94:2128. In fact, bone age can provide important information for athletes in order to distribute physical, human, and monetary resources properly (6567). It is based on the determination of a score obtained from hand and wrist skeletal maturation. We did online searches of The New England Journal of Medicine, Pediatrics, American Family Physician, Pediatrics in Review, and the British Medical Journal to identify additional relevant articles. 2015;24(4):143-152. doi:10.1297/cpe.24.143. A table of possible causes of abnormal stature and the expected bone age associated with each condition is provided below. In the latest episode of our podcast series, Jessica L. Peck, DNP, APRN, CPNP-PC, CNE, CNL, FAANP, FAAN shares why she got into medicine, the myths of pediatric, and what the future may hold for the specialty. (2010) 126:93844. [2], In the United States, bone age is usually determined by comparing an x-ray of the patient's left hand and wrist to a set of reference images contained in the Greulich and Pyle atlas. Wong SC, Smyth A, McNeill E, Galloway PJ, Hassan K, McGrogan P, et al. Calculating the midparental height (Table 1) is an important part of the evaluation because most short or tall children have short or tall parents. Berlin; Heidelberg. 1. Patel PS, Chaudhary AR, Dudhia BB, Bhatia PV, Soni NC, Jani YV. Forensic Sci Int. Forensic Sci Int. 110. 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). Philadelphia, PA: Mosby (2008). J Bone Miner Res. The child's hand/ wrist X-ray is interpreted based on the appearance . (2005). A systematic search has been performed in PubMed to identify randomized controlled trials (RCTs), meta-analyses, and retrospective and prospective studies of different methods to evaluate bone age, focusing on strengths and weaknesses of each procedure. The Nemours Foundation. Age, height, weight, BMI z-score, and BA/CA were similar in the PA and control groups . (2016) 37:13587. (1984) 73:5306. The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. doi: 10.1111/j.1365-2265.2010.03799.x, 33. Applicability of the Greulich and Pyle skeletal age standards to black and white children of today. In another study, it was shown that the evaluation of 599 bone age in subjects belonging to different ethnic groups shows a greater variability, especially in African children, in Hispanic women and in Asian and American men (96). (2005) 50:116474. A child's current height and bone age can be used to predict adult height. Khan K, Elayappen AS. Moreover, according to recent studies, BoneXpert computer-automated bone age determination method showed a significant positive correlation with chronological age and GreulichPyle. Soegiharto BM, Cunningham SJ, Moles DR. Skeletal maturation in Indonesian and white children assessed with hand-wrist and cervical vertebrae methods. The X-ray image is black and white. (2000) 12:6105. X-Ray Exam: Bone Age Study - Johns Hopkins All Children's Hospital Bone Age Advancement in Prepubertal Children - Wiley Online Library

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