Age estimation by bones

age estimation from fusion of ossification centres of bones

1. Age Estimation by Bones Dr Chetan Kumar Resident- PG Baroda Medical College

2. Chronological age : is the time elapsed since birth Bone age  is the degree of maturation of a person's bones. As a person grows from fetal life through childhood, puberty, and finishes growth as a young adult, the  bones  of the skeleton change in size and shape. These changes can be seen by x-ray.

3. The major types of human bones are : long (e.g. the arm and leg bones) short (e.g. the small bones in the wrists and ankles) flat (e.g. the bones of the skull or the ribs) irregular (e.g. vertebrae) Long, short, and irregular bones develop by  endochondral ossification , where  cartilage  is replaced by bone. Flat bones develop by intramembranous ossification , where bone develops within sheets of connective tissue. Compact cortical bone, representing about 80 percent of the mature skeleton, supports the body, and features extra thickness at the midpoint in long bones to prevent the bones from bending. Cancellous bone, whose porous structure with small cavities resembles sponge, predominates in the pelvis and the 33 vertebrae from the neck to the tailbone.

4. FIRST STUDIES 1921- Bardeen examined and described the changes in form of ossifiction centres in course of growth; from an initial pointed form to an adult bone 1928 -Hellman made important contribution 1937 - significant contribution by Todd who published “Atlas of skeletal maturation of hand” many subsequent studies were made on basis of Grehlich & Pyle’s indicators

5. INDIAN STUDIES Basu (1938 ) tackled the problem of epiphyseal union rather than appearance in Bengalese children. He stated that diaphyseo – epiphyseal union had a “climatic and racial variability” questioning the comparability of American Standards. He doubted that “there may be evolved one common standard for the whole of the heterogenous population of India ”. MODI (’57) : The most extensive tabulation for non-whites is that of Modi for East Indian Children. He has stated that “Owing to the variations in climatic, dietetic, hereditary and other factors affecting the people of the different provinces of India it cannot be reasonably expected to formulate a uniform standard for the determination of age of the union of epiphyses for the whole of India. However, from investigations carried out in certain provinces it has been concluded that age at which the union of epiphyses takes place in Indians is 2-3 years in advance of the age in Europeans and epipyseal unions earlier in females.

6. Various studies Quereshi studies skeletal maturity in Pakistani children Murata in his study compared skeletal maturation with population from U.K ., Belgium , North India, South China and Japan. Japanese children were found to attain skeletal maturity 1-2 years earlier than present day European and Chinese children. A relative lack of data for North Indian population made comparison impossible . Galstaun study was done in Bengali population(1930-’37) and Bajaj et al., study was done at Delhi. Greulich - Pyle study was done in children of the upper socio economic status White children in 1931-1942 .

7. X ray showing the skeleton of a newborn. Gaps between bones indicate cartilage, which will develop into bone tissue as the child ages

8. “There is nothing called average individual because each individual is different”

9. illustration depicting the stages of long bone growth, showing the process of cartilage calcifying and becoming mature, compact bone.

10. Stages of Epiphyseal Union Stage 0 Non union Stage 1 ¼ united Stage 2 ½ united Stage 3 ¾ united Stage 4 complete union

11. In females the bone maturity is advanced because of an advancing pubertal age. Pubertal age is found to advance by 4 months per decade throughout the world . Galstaun study indicates that uniformly the Females bone maturity has advanced 1 year

12. Why the difference The difference in appearance & fusion of ossification centres & with various standard studies could be due to factors like R acial, Genetic, Socio economic, N utritional and Climate factors- which need to be evaluated .  Generally ossification activities occur earlier in the Indian population than western  Skeletal maturation has accelerated in 20 th centruy and the study done by Grehlich , FELS are distant

13. Scar of recent union ? “ The period of fusion indicated by radiographs of the bony extremities are approximately three (3) years (?) earlier than the periods of fusion indicated by anatomical evidence..because epiphyseal lines can remain visible on the bone for a considerable time after the radiographs indicate that fusion has taken place”.  Actually the difference b/w this stage 1 & 2 is + 6 months

14. SCAPULA CENTRES APPEARANCE FUSION FOR CORACOID 1 st year Puberty SUB CORACOID for lateral part of root of coracoid & upper 1/3 rd of Glenoid cavity 10 th year Puberty MARGINS OF GLENOID CAVITY Puberty 20-25 yrs INFERIOR ANGLE Puberty 20-25 yrs VERTEBRAL BORDER Puberty 20-25 yrs TWO ACROMION Puberty 20-25 yrs

15. Scapula

16. Scapula (23 yrs) krogman says- ‘Though the epiphysis for the medial border lags in the early twenties, fusion for all three { acromion , medial border, and inferior angle} is completed by the Twenty-third year (23). The lipping of the circumferential margin of the acromial facet and glenoid fossa usually begins by 30-35 yrs and at the clavicular facet begins at 35-40 yrs. Appearance of a ‘plaque’ or facet on under side of acromical process begins by 40-45 yrs Increasing demarcation of the triangular area at the base of scapular spine begins at 50 yrs of age Appearance of cristae scapulae occurs 50 yrs & above

17. Clavicle As early as 18 yrs, but any time between 18-25 yrs, the epiphyseal cap begins to unite to the billowed surface of the medial end of the clavicle. Union begins at the approximate centre of the face and spreads ot the superior margins where it may progress either anteriorly or posteriorly . From 25- 30 yrs the majority of cases are undergoing terminal union. The last site of union is located in the form of a fissure along the inferior border. With obliteration of this ( 31 yrs ) the union is completed

18. Ribs & vertebrae Centres for Head & Tubercles (No tubercles in 11 th & 12 th Ribs) and appears at 14 yrs and fuses at 25 yrs. Ossification occurs at upper and lower Ribs and spreads towards the middle. Thus the last ribs to become fully united are 4-9 th Ribs Occurs 2-3 years earlier in females The presacral vertebral column is completely ossified by the 24 th year. Last signs of maturity occurs in upper Thoracic vertebrae (T4- T5) Striations tend to disappear from surface of centre starting at 23yr but may persist in lumbar region for many years

19. Elbow Joint

20. BEFORE BIRTH – Appearance of Head of Humerus , Distal end of femur Proximal tibia Calcaneum , Talus cuboid

21. Ossification Time Table Age Male Age Female 2-3 yrs Metacarpals II,III, IV Distal end of radius 1-2 yrs Metacarpals II,III, IV, V 3-4 yrs Metacarpal V 2-3 yrs Metacarpal I, Triquitrum 4-5 yrs Metacarpal I 4-5 yrs Medial epicondyle , 6-7 yrs Lunate 5-6 yrs Lunate 7-8 yrs Trapezoid, Scaphoid , Head of Radius 6-7 yrs Trapezium, Trapezoid, Scaphoid 8-9 yrs Trapezium, Distal Ulna 7-8 yrs Distal Ulna Medial epicondyle 10-11 yrs Pisiform

22. Table : Comparison of age (in years) of appearance of ossification centres of males in various studies Sl. no BONE Bajaj (Delhi) Garn(’67) 50 th percentile Galstaun (1930’s) Bengalis Greulich -Pyle Std. ( 1959) mean ( age in years ) Chennai study Thesis (2008) 1 Metacarpal I 4.2 yrs 2 yrs 7 mnts 4 yrs 2 Yrs 6 Mnts 4-5 Yrs 2 Metacarpal II 1.07 yrs 1yrs 7mnts 3-4 yrs 1 Yr 5 Mnts 2-3 yrs 3 Metacarpal III 1.07 yrs 1yrs 9mnts 3-4 yrs 1 Yr 9 Mnts 2-3yrs 4 Metacarpal IV 1.7 yrs 2 yrs 3-4 yrs 2 Yrs 2-3 yrs 5 Metacarpal V 1.7 yrs 2 yrs 3-4 yrs 2 Yrs 4 mnts 3-4 yrs 6 Trapezium 7.5 yrs 5 yrs 1 mnts 7 yrs 5 Yrs 4 mnts 8-9 yrs 7 Trapezoid N A 6 yrs 3 mnts NA 5 Yrs 4 mnts 7-8 yrs

23. Table : Comparison of age (in years) of appearance of ossification centres of males in various studies Sl. no BONE Bajaj (Delhi) Garn(’67) 50 th percentile Galstaun (1930’s) Bengalis Greulich -Pyle Std. ( 1959) mean ( age in years ) Chennai study Thesis (2008) 8 Scaphoid 8.4 yrs 5 yrs 8 mnts 7-11 yrs 5 Yrs 7-8 yrs 9 Lunate 6.5 yrs 4 yrs 1 mnts 5 yrs 3 Yrs 10 mnts 6-7 yrs 10 Triquitrum 3.7 yrs 2 yrs 5 mnts 3yrs - 4 yrs 2 Yrs 3 mnts 3-4 yrs 11 Pisiform 10yrs 2 mnts N A 9 -12 yrs - - 10-11 Yrs 12 Distal radius 3.5 yrs 10 mnts 1 yr 11 Mnts 1-2 yrs 13 Distal ulna 6.5 yrs 5 yrs 5 m nts 8-10 yrs 5 Yr 3 Mnts 7-8 yrs 14 Head of Radius 3.5 yrs 3 yrs 11 mnts 6 yrs 4 Yrs 5-6 yrs 15 Medial epicondyle 5 yrs 3 yrs 5 mnts 5 yrs 3 Yrs 5 mnts 4-5 yrs

24. STERNUM Age related change in morphology of sternal end of 4 th rib can be measured and compared to standards. Ossificatioin of Hyaline cartilages- cartilage which connects ribs to sternum turns stony with age- can be considered a general indicator of age.

25. S T E R N U M 5-6 m 7 m 7 m 10 m 3yr About 40-45 yrs

26. Risser’s sign The  Risser sign  refers to the amount of  calcification  of the  human pelvis  as a measure of maturity. On a scale of 5, it gives a measure of progression of  ossification ; the grade of 5 means that skeletal maturity is reached. Risser sign is based on the observation of an  X-ray  image. Grade 1 is given when the  ilium (bone)  is calcified at a level of 25%; it corresponds to pre-puberty  or early  puberty . Grade 2 is given when the  ilium (bone)  is calcified at a level of 50%; it corresponds to the stage before or during  growth spurt . Grade 3 is given when the  ilium (bone)  is calcified at a level of 75%; it corresponds to the slowing of growth. Grade 4 is given when the  ilium (bone)  is calcified at a level of 100%; it corresponds to an almost cessation of growth. Grade 5 is given when the  ilium (bone)  is calcified at a level of 100% and the iliac apophysis is fused to iliac crest; it corresponds to the end of growth. The Risser sign is referenced in clinical decision-making regarding adolescent idiopathic scoliosis.

27. Appearance and fusion of Hip bone Bone-region Appearance Fusion Iliac crest 14 yrs 18-20 yrs Tri-Radiate cartilage _ _ 11-14 yrs Ischium 15-17 yrs 19-21 yrs Pubis 14 yrs 20 yrs Ischio -pubic ramus _ _ 6 yrs

28. SACRUM The five sacral vertebrae remain separated by cartilage until puberty, ossification of intervertebral discs starts from below upwards and the fusion of the sacral segments beocme complete by 20-25 yrs

29. CHRONOLOGICAL ORDER OF APPEARANCE AND FUSION OF EPIPHYSIS

30. BEFORE BIRTH In both sexes Appearance of Head of Humerus , distal femur, proximal tibia, calcaneum , Talus In Females appearance of Cuboid

31. During first year of life In both sexes Appearance of Hamate , Capitate , Head of femur Third cuneiform In Males In Females Cuboid Capitulum Distal Radius Distal Tibia Distal Fibula

32. During second year of life In both sexes Appearance of Proximal phalanges of inner four fingers In Males In Females Capitulum , Distal Epiphysis of Radius Distal Fibula First Metacarpal, Distal Phalanges of Thumb, Middle & Ring Fingers, Tarsal Navicular , I & II Cuneiforms

33. At age of TWO In both sexes Appearance of Inner four metacarpals, first metaTarsal , proximal phalanges of Toes, distal phalanx of Hallux In Males In Females First Metacarpal, Distal Phalanx of Thumb, Distal Phalanx of Index Finger, & First Cuneiform Proximal Phalanges of Thumb, Middle Row of Phalanges of Fingers

34. At age of THREE appearance of- In Males In Females Triquetrum , Proximal Phalanx of Thumb, Middle Phalanges of Middle & Ring Fingers, Tarsal Navicular , II Cuneiform Patella, Proximal Fibula , II Metatarsal, III Metatarsal, middle Phalanges of II, III, & IV toes, distal phalanges of III & IV toes

35. X-ray of three-year-old girl showing the ossification of Triquitrum

36. At age of FOUR In both sexes Appearance of Fourth Metatarsal In Males In Females Appearance of Lunate , middle Phalanges of index & little fingers, Distal Phalanges of middle & ring fingers, II metatarsal, III Metatarsal, Middle Phalanx of II toe Appearance of Head of Radius, fifth metatarsal Fusion of greater tubercle to Head of Humerus

37. At age of FIVE In Both Sexes Appearance Of Carpal Navicular , Multangulum Majus , Greater Trochanter , Distal Phalanx, Distal Phalanx Of II Toe In Males In Females Appearance of Head of Radius, distal phalanx of little finger, patella, proximal Fibula, V Metarasal , middle Phalanges of III & IV toes, Distal Phalanges of III & IV toes Appearance of medial epicondyle , distal Ulna, Lunate,Triquetrum , Multangulum Minus, distal Phalanx of Index finger

38. At age of SIX In Males In Females Fusion of Greater tubercle of Head of Humerus . Appearance of Medial epicondyle , Distal Ulna, Multangulum minus. __ __

39. X-ray of six-year-old girl showing the ossification of Lunate

40. At age of SEVEN In Males In Females __ __ Appearanc e of Distal Phalanx of little finger. Fusion of Rami of Ischium and Pubis

41. X-ray of seven-year-old girl with ossification center of Medial epicondyle

42. X-ray of 7 yr girl with ossification center of Trapezium, trapezoid and Scaphoid

43. X-ray of seven-year-old boy with ossification center of Trapezium and trapezoid

44. At age of EIGHT In both sexes Appearance of Apophysis of Calcaneus In Males In Females __ __ Appearance of Olecranon

45. X-ray of eight year-old girl showing the ossification centre of distal ulna

46. X-ray of eight year-old boy showing the ossification center of Trapezium and Distal ulna

47. At age of NINE In Males In Females Fusion of Rami of Ischium and Pubis Appearance of Trochlea , Pisiform

48. At age of TEN In Males In Females Appearance of Trochlea , Olecranon __ ___N

49. At age of ELEVEN In Males In Females Appearance of Pisiform Appearance of Lateral Epicondyle

50. At age of TWELVE In Males Females Appearance of Lateral Epicondyle __ __

51. At age of THIRTEEN In Males In Females Fusion of Capitulum to Trochlea and Lateral Epicondyle Appearance of Proximal Sesamoid of thumb. Fusion of Lower conjoint epiphysis of humerus , Distal Phalanx of thumb, Fusion Bodies of Ilium, Ischium and Pubis.

52. At age of FOURTEEN In Males Appearance of Head of Radius, distal phalanx of little finger, patella, proximal Fibula, V Metarasal , middle Phalanges of III & IV toes, Distal Phalanges of III & IV toes

53. At age of FOURTEEN In Females Appearance of Acromion , Iliac crest, Lesser trochanter . Fusion of Olecranon , Upper Radius, Proximal phalanx of ring finger, Distal phalanx of thumb, Head of Femur, Greater Trochanter , Distal Tibia and Fibula, Apophysis Calcaneus , First Metatarsal,Proximal phalanges of toes.

54. At age of FIFTEEN In both sexes Appearance of Sesamoid of little finger. Fusion of Distal phalanges of second,third & fourth toes. In Males Appearance of Acromion . Fusion of Ilium, Ischium and Pubis.

55. At age of FIFTEEN (15) In both sexes Appearance of Sesamoid of little finger. Fusion of Distal phalanges of second,third & fourth toes. In Females Appearance of Sesamoid of index and little fingers. Fusion of Medial epicondyle,First metacarpal,Proximal phalanx of thumb,Distal phalanges of inner four fingers,Proximal tibia,Outer four metatarsals,Middle phalanx of second toe,Distal phalanges of inner four toes.

56. At age of SIXTEEN (16) In Females Appearance of Distal sesamoid of thumb,Tuber Ischii . Fusion of Inner four metacarpals,Proximal phalanges of index,middle and little fingers,middle phalanges of fingers.

57. At age of SIXTEEN In Males Fusion of Lower conjoint epiphysis of humerus , medial epicondyle , Olecranon , Head of Radius, Distal phalanx of middle finger, Apophysis of Calcaneus .

58. At age of SEVENTEEN In both sexes Fusion of Acromion In Females Fusion of Upper conjoint epiphysis of humerus , Distal ulna, Distal femur, Proximal fibula. Appearance of Distal sesamoid of thumb.

59. At age of SEVENTEEN (17) In both sexes Fusion of Acromion In Males Appearance of Distal sesamoid of thumb. Fusion of First metacarpal, Proximal phalanges of thumb and ring finger, Middle phalanges of Index, Middle and ring finger Distal phalanges of thumb, Index, ring and little fingers, Head of femur, Greater trochanter , Distal tibia and fibula, Metatarsals, Proximal phalanges of toes, middle phalanx of second toe, distal phalanx of hallux .

60. At age of EIGHTEEN In Males In Females Fusion of Inner four metacarpals, Proximal phalanges of index, middle and little fingers, middle phalanges of little finger, Proximal tibia. Fusion of Distal radius.

61. At age of NINETEEN In Males Appearanc e of Sesamoid of index, Tuber ischii . Fusion of Upper conjoint epiphysis of humerus , Distal radius and ulna, Distal femur, Proximal fibula.

62. At age of TWENTY In both sexes Fusion of Iliac crest. In Males Fusion of Tuber Ischii .

63. At age of 21 In both sexes Appearance of Clavicle. In Females Fusion of Tuber Ischii .

64. At age of 22 In both sexes Fusion of Clavicle.

65. After 25 years If all epiphysis of long bones are united the individual is most probably >25 years. After 25 age estm . becomes more uncertain. Between 40-60 yrs The ossification of Hyoid bone. Fusion of greater cornu with body of hyoid bone Xiphisternum with body Lipping of verebrae > 45 yrs Rarefaction of bones(osteoporosis) after 60 yrs Calcification of costal cartilage(30) yrs & Laryngeal cartilage 50 + 12.7 yrs Changes in Mandible with age

66. Symphyseal surface in Estimation of age accuracy + 2 years Below 20yr Symphyseal surface has an even appearance with layer of compact bone over its surface 20-30 yrs It looks markedly ridged and irregular.- the ridges or billowing run transeversely and irregular across articular surface 25- 35 yrs the billowing gradually disappears and the articular surface in macerated bone presents granular appearance with well-defined anterior and posterior margins 35-45 yrs The articular surface looks smooth and oval with raised upper and lower extremities 45-50 yrs Narrow beaded rims develop in and around the margins of the articular surface showing some erosion Above 50 yrs Symphyseal surface presents varying degrees of erosion with varying degrees of erosion with breaking down of the ventral margins

67. Skull Sutures In Estimation Of Age Posterior fontanelle closes b/w birth 1.5 months Anterior fontanelle closes by second year 2 postero -lateral fontanelles closes within a short period after birth & antero -lateral fontanelles within first 6 months. Metopic suture b/w 2 frontal bones closes b/w 2 yrs-8 yrs but rarely may remain intact The basi-occiput fuses with basi -sphenoid by about 18-20 yrs in Females & 20-22 in Males

68. Suture Closure in the Skull Closure begins in inner table 5-10 years earlier than outer table In contrast to others the fusion occurs earlier in Males Endocranially suture closure is more uniform & complete and might not close ectocranially known as LAPSED UNION – eg sagittal suture Estimation of age by sutural closure of skull is not reliable, it can be given only in decades The order of reliability is sagittal lamboid  & coronal

69. Order of suture closure in skull 30-40 yrs :- Posterior 1/3 rd of sagittal suture-about 40-50 yrs :- Anterior 1/3 rd of sagittal suture & lower half of coronal suture-about 50-60 yrs :- Middle sagittal and upper half of coronal suture at about In Lamboid suture fusion activity occurs late and the progress is also slow, the closure starts about 25-30 yrs near Asterion maximum closure at about 55 yrs Squamous part of temporla bone with its surrounding after 60yrs Towne’s view useful

70. T H Y A O N U K YOU