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E2419. Bone Age Determination: Age-Old Tips and Tricks
Authors
  1. Deanna Kitchen; UT Southwestern Medical Center
  2. Nadine Zeidan; UT Southwestern Medical Center
  3. Devri Weakley; UT Southwestern Medical Center
  4. Mary Yang; UT Southwestern Medical Center
  5. Elizabeth Lagomarsino; UT Southwestern Medical Center
  6. Cory Pfeifer; UT Southwestern Medical Center
Background
Determination of the appropriate bone age has important consequences for evaluating the endocrine function of a child. It plays a key role in the diagnostic approach to precocious and delayed puberty, and it provides essential information regarding the status of the physes (1). It may also be used to predict chronological age in regions lacking accurate birth records. Bone age interpretation has largely been a skill favored by pediatric radiologists, although pediatric endocrinologists often prefer their independent interpretations with some proven diagnostic accuracy (2,3). Standard bone age atlases including Greulich and Pyle (4) have also been questioned for their applicability in all ethnicities (5,6). Bone age interpretation is also a target for artificial intelligence (7). This educational exhibit explores bone age determination (without the use of machine learning) in a concise format for radiologists to review the most current information.

Educational Goals / Teaching Points
The use of the Greulich and Pyle, Gilsanz, and Ratib, and Tanner Whitehouse methods are described. Techniques to streamline determination using the method of Greulich and Pyle are specified based on greater than 30 years of collective experience by the authors. Studies describing comparisons between pediatric radiologists and endocrinologists are detailed. Commentary regarding the ability to apply the Greulich and Pyle standards to non-Caucasian populations is made. A discussion of studies comparing human interpretation to machine learning is included.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
The method of Greulich and Pyle is time-tested and accepted among most pediatric radiologists and pediatric endocrinologists. When using the Greulich and Pyle standards, evaluation of the distal epiphyses are the most helpful in determining the bone age. The carpal bones are not useful in bone age assignment. A paradox in the standards exists between the 11- and 12-year old female standards. At least one study reports an inability to apply the Greulich and Pyle standards to Asian and African children (5). Recognition patterns beyond those described in the Greulich and Pyle atlas are important in efficiently assigning bone age (1).

Conclusion
Artificial intelligence is not necessary in the determination of skeletal maturity. Despite the age of the Greulich and Pyle standards, these remain a mainstay in the practice of pediatric radiology. Specific recommendations on how to interpret the standards are helpful for trainees and radiologists not experienced in bone age determination.