1. Age Estimation by BonesDr Chetan KumarResident- PGBaroda Medical College

2. Chronological age: is the time elapsed sincebirth Bone age is the degree of maturation of aperson's bones. As a person grows from fetallife through childhood, puberty, and finishesgrowth as a young adult, the bones of theskeleton change in size and shape. Thesechanges 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 endochondralossification, where cartilage is replaced by bone. Flat bones develop by intramembranous ossification, wherebone develops within sheets of connective tissue. Compact cortical bone, representing about 80 percent of themature skeleton, supports the body, and features extrathickness at the midpoint in long bones to prevent the bonesfrom bending. Cancellous bone, whose porous structure with small cavitiesresembles sponge, predominates in the pelvis and the 33vertebrae from the neck to the tailbone. 4. FIRST STUDIES 1921- Bardeen examined and described thechanges in form of ossifiction centres in courseof growth; from an initial pointed form to anadult bone 1928 -Hellman made important contribution 1937 - significant contribution by Todd whopublished Atlas of skeletal maturation ofhand many subsequent studies were made on basisof Grehlich & Pyles indicators 5. INDIAN STUDIES Basu (1938) tackled the problem of epiphyseal union rather thanappearance in Bengalese children. He stated that diaphyseo epiphyseal union had a climatic and racial variability questioningthe comparability of American Standards. He doubted that theremay be evolved one common standard for the whole of theheterogenous population of India. MODI (57) : The most extensive tabulation for non-whites is thatof Modi for East Indian Children. He has stated that Owing to thevariations in climatic, dietetic, hereditary and other factors affectingthe people of the different provinces of India it cannot be reasonablyexpected to formulate a uniform standard for the determination ofage of the union of epiphyses for the whole of India. However, frominvestigations carried out in certain provinces it has been concludedthat age at which the union of epiphyses takes place in Indians is 2-3years in advance of the age in Europeans and epipyseal unionsearlier in females. 6. Various studies Quereshi studies skeletal maturity in Pakistani children Murata in his study compared skeletal maturation withpopulation from U.K., Belgium, North India, South Chinaand Japan. Japanese children were found to attain skeletalmaturity 1-2 years earlier than present day European andChinese children. A relative lack of data for North Indianpopulation 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 uppersocio economic status White children in 1931-1942. 7. X ray showing the skeleton of a newborn. Gaps between bonesindicate cartilage, which will develop into bone tissue as the childages 8. There is nothing called average individualbecause each individual is different 9. illustration depicting the stages of long bonegrowth, showing the process of cartilagecalcifying and becoming mature, compactbone. 10. Stages of Epiphyseal UnionStage 0 Non unionStage 1 unitedStage 2 unitedStage 3 unitedStage 4 complete union 11. In females the bone maturity isadvanced because of an advancingpubertal age. Pubertal age is foundto advance by 4 months per decadethroughout the world. Galstaun study indicates thatuniformly the Females bone maturityhas advanced 1 year 12. Why the differenceThe difference in appearance & fusion of ossificationcentres & with various standard studies could bedue to factors like Racial, Genetic, Socio economic, Nutritional and Climate factors-whichneed to be evaluated.Generally ossification activities occur earlier in theIndian population than western Skeletal maturation has accelerated in 20th centruyand the study done by Grehlich, FELS are distant 13. Scar of recent union ?The period of fusion indicated by radiographs ofthe bony extremities are approximately three(3) years (?) earlier than the periods of fusionindicated by anatomical evidence..becauseepiphyseal lines can remain visible on the bonefor a considerable time after the radiographsindicate that fusion has taken place. Actually the difference b/w this stage 1 & 2 is+ 6 months 14. SCAPULACENTRES APPEARANCE FUSIONFOR CORACOID 1st year PubertySUB CORACOID forlateral part of root ofcoracoid & upper1/3rd of Glenoid cavity10th year PubertyMARGINS OF GLENOIDCAVITYPuberty 20-25 yrsINFERIOR ANGLE Puberty 20-25 yrsVERTEBRAL BORDER Puberty 20-25 yrsTWO ACROMION Puberty 20-25 yrs 15. Scapula 16. Scapula (23 yrs) krogman says- Though the epiphysis for the medialborder lags in the early twenties, fusion for all three{acromion, medial border, and inferior angle} iscompleted by the Twenty-third year (23). The lipping of the circumferential margin of theacromial 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 ofacromical process begins by 40-45 yrs Increasing demarcation of the triangular area at thebase 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 billowedsurface of the medial end of the clavicle. Union begins at the approximate centre of the faceand spreads ot the superior margins where it mayprogress either anteriorly or posteriorly. From 25- 30 yrs the majority of cases areundergoing terminal union. The last site of union is located in the form of afissure along the inferior border. With obliterationof this (31 yrs) the union is completed 18. Ribs & vertebrae Centres for Head & Tubercles (No tubercles in11th & 12th Ribs) and appears at 14 yrs and fusesat 25 yrs. Ossification occurs at upper and lower Ribs andspreads towards the middle. Thus the last ribs tobecome fully united are 4-9th Ribs Occurs 2-3 years earlier in females The presacral vertebral column is completelyossified by the 24th year. Last signs of maturity occurs in upper Thoracicvertebrae (T4- T5) Striations tend to disappear from surface ofcentre starting at 23yr but may persist in lumbarregion 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 TableAge Male Age Female2-3 yrs Metacarpals II,III, IVDistal end of radius1-2 yrs Metacarpals II,III, IV,V3-4 yrs Metacarpal V 2-3 yrs Metacarpal I,Triquitrum4-5 yrs Metacarpal I 4-5 yrs Medial epicondyle,6-7 yrs Lunate 5-6 yrs Lunate7-8 yrs Trapezoid, Scaphoid,Head of Radius6-7 yrs Trapezium,Trapezoid, Scaphoid8-9 yrs Trapezium,Distal Ulna7-8 yrs Distal UlnaMedial epicondyle 10-11 yrs Pisiform 22. Table : Comparison of age (in years) of appearance ofossification centres of males in various studiesSl. noBONE Bajaj(Delhi)Garn(67)50thpercentileGalstaun(1930s)BengalisGreulich-PyleStd. (1959) mean(age in years)Chennai studyThesis (2008)1 Metacarpal I 4 . 2 yrs 2yrs 7mnts 4 yrs 2 Yrs 6 Mnts 4-5 Yrs2 Metacarpal II 1 . 0 7 yrs 1yrs 7mnts 3-4 yrs 1 Y r 5 M n t s 2-3 yrs3 Metacarpal III 1 . 0 7 yrs 1yrs 9mnts 3-4 yrs 1 Yr 9 Mnts 2-3yrs4 Metacarpal IV 1 . 7 yrs 2 yrs 3-4 yrs 2 Yrs 2-3 yrs5 Metacarpal V 1 .7 yrs 2 yrs 3-4 yrs 2 Yrs 4 mnts 3-4 yrs6 Trapezium 7.5 yrs 5 yrs 1 mnts 7 yrs 5 Yrs 4 mnts 8-9 yrs7 Trapezoid N A 6 yrs 3 mnts NA 5 Yrs 4 mnts 7-8 yrs 23. Table : Comparison of age (in years) of appearance ofossification centres of males in various studiesSl.no BONE Bajaj(Delhi)Garn(67)50thpercentileGalstaun(1930s)BengalisGreulich-PyleStd. (1959) mean(age in years)Chennai studyThesis (2008)8 Scaphoid 8.4 yrs 5 yrs 8 mnts 7-11 yrs 5 Yrs 7-8 yrs9 Lunate 6.5 yrs 4 yrs 1 mnts 5 yrs 3 Yrs 10 mnts 6-7 yrs10 Triquitrum 3.7 yrs 2 yrs 5 mnts 3yrs - 4 yrs 2 Yrs 3 mnts 3-4 yrs11 Pisiform 10yrs 2 mnts N A 9 -12 yrs - - 10-11 Yrs12 Distal radius 3.5 yrs 10 mnts 1 yr 1 1 M n t s 1-2 yrs13 Distal ulna 6.5 yrs 5 yrs 5 mnts 8-10 yrs 5 Yr 3 Mnts 7-8 yrs14 Head of Radius 3.5 yrs 3 yrs 11 mnts 6 yrs 4 Yrs 5-6 yrs15 Medialepicondyle5 yrs 3 yrs 5 mnts 5 yrs 3 Yrs 5 mnts 4-5 yrs 24. STERNUM Age related change in morphology of sternalend of 4th rib can be measured and comparedto standards. Ossificatioin of Hyaline cartilages- cartilagewhich connects ribs to sternum turns stonywith age- can be considered a generalindicator of age. 25. STERNUM5-6m7 m7 m10m3yrAbout 40-45 yrs 26. Rissers sign The Risser sign refers to the amount of calcification ofthe human pelvis as a measure of maturity. On a scale of 5, it gives a measure of progressionof ossification; the grade of 5 means that skeletal maturity isreached. Risser sign is based on the observation of an X-rayimage. Grade 1 is given when the ilium (bone) is calcified at a level of25%; it corresponds to pre-puberty or early puberty. Grade 2 isgiven when the ilium (bone) is calcified at a level of 50%; itcorresponds to the stage before or during growth spurt. Grade 3 is given when the ilium (bone) is calcified at a level of75%; it corresponds to the slowing of growth. Grade 4 is given when the ilium (bone) is calcified at a level of100%; it corresponds to an almost cessation of growth. Grade 5 is given when the ilium (bone) is calcified at a level of100% and the iliac apophysis is fused to iliac crest; itcorresponds to the end of growth. The Risser sign is referenced in clinical decision-makingregarding adolescent idiopathic scoliosis. 27. Appearance and fusion of Hip boneBone-region Appearance FusionIliac crest 14 yrs 18-20 yrsTri-Radiate cartilage _ _ 11-14 yrsIschium 15-17 yrs 19-21 yrsPubis 14 yrs 20 yrsIschio-pubic ramus _ _ 6 yrs 28. SACRUM The five sacral vertebrae remain separated bycartilage until puberty, ossification ofintervertebral discs starts from below upwardsand the fusion of the sacral segments beocmecomplete by 20-25 yrs 29. CHRONOLOGICALORDER OF APPEARANCEAND FUSION OFEPIPHYSIS 30. BEFORE BIRTHIn both sexes Appearance of Head of Humerus, distal femur, proximal tibia, calcaneum, TalusIn Females appearance of Cuboid 31. During first year of lifeIn both sexes Appearance of Hamate, Capitate, Head of femur Third cuneiformIn Males In FemalesCuboidCapitulumDistal RadiusDistal TibiaDistal Fibula 32. During second year of lifeIn both sexes Appearance of Proximal phalanges of inner four fingersIn Males In FemalesCapitulum,Distal Epiphysis ofRadiusDistal FibulaFirst Metacarpal,Distal Phalanges ofThumb, Middle & RingFingers,Tarsal Navicular,I & II Cuneiforms 33. At age of TWOIn both sexes Appearance of Inner four metacarpals, first metaTarsal, proximal phalanges of Toes, distal phalanx ofHalluxIn Males In FemalesFirst Metacarpal,Distal Phalanx of Thumb,Distal Phalanx of IndexFinger, & First CuneiformProximal Phalanges ofThumb,Middle Row ofPhalanges of Fingers 34. At age of THREE appearance of-In Males In FemalesTriquetrum,Proximal Phalanx ofThumb,Middle Phalanges ofMiddle & Ring Fingers,Tarsal Navicular,II CuneiformPatella,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 showingthe ossification of Triquitrum 36. At age of FOURIn both sexes Appearance of Fourth MetatarsalIn Males In FemalesAppearance of Lunate,middle Phalanges ofindex & little fingers,Distal Phalanges ofmiddle & ring fingers,II metatarsal,III Metatarsal,Middle Phalanx of II toeAppearance of Head ofRadius, fifth metatarsalFusion of greatertubercle to Head ofHumerus 37. At age of FIVEIn Both Sexes Appearance Of Carpal Navicular,Multangulum Majus, Greater Trochanter, DistalPhalanx, Distal Phalanx Of II ToeIn Males In FemalesAppearance of Head ofRadius, distal phalanx oflittle finger, patella,proximal Fibula, VMetarasal, middlePhalanges of III & IV toes,Distal Phalanges of III &IV toesAppearance of medialepicondyle, distal Ulna,Lunate,Triquetrum,Multangulum Minus,distal Phalanx ofIndex finger 38. At age of SIXIn Males InFemalesFusion of Greater tubercle ofHead of Humerus.Appearance ofMedial epicondyle,Distal Ulna,Multangulum minus.____ 39. X-ray of six-year-old girl showing theossification of Lunate 40. At age of SEVENInMalesIn Females____Appearance of Distal Phalanx oflittle finger.Fusion of Rami of Ischium andPubis 41. X-ray of seven-year-old girl with ossificationcenter of Medial epicondyle 42. X-ray of 7 yr girl with ossificationcenter of Trapezium, trapezoid and Scaphoid 43. X-ray of seven-year-old boy with ossificationcenter of Trapezium and trapezoid 44. At age of EIGHTIn both sexes Appearance of Apophysis ofCalcaneusInMalesIn Females____ Appearance of Olecranon 45. X-RAY OF EIGHT YEAR-OLDGIRL SHOWING THEOSSIFICATION CENTRE OFDISTAL ULNA 46. X-ray of eight year-old boy showing the ossificationcenter of Trapezium and Distal ulna 47. At age of NINEIn Males In FemalesFusion of Rami ofIschium and PubisAppearance ofTrochlea,Pisiform 48. At age of TENIn Males In FemalesAppearance ofTrochlea,Olecranon_____N 49. At age of ELEVENIn Males In FemalesAppearance of Pisiform Appearance of LateralEpicondyle 50. At age of TWELVEIn Males FemalesAppearance of LateralEpicondyle____ 51. At age of THIRTEENIn Males In FemalesFusion ofCapitulum toTrochlea andLateral EpicondyleAppearance of ProximalSesamoid of thumb.Fusion of Lower conjointepiphysis of humerus,Distal Phalanx of thumb,Fusion Bodies of Ilium, Ischiumand Pubis. 52. At age of FOURTEENIn MalesAppearance of Head of Radius, distal phalanx oflittle finger, patella, proximal Fibula,V Metarasal, middle Phalanges of III & IV toes,Distal Phalanges of III & IV toes 53. At age of FOURTEENIn FemalesAppearance of Acromion, Iliac crest,Lesser trochanter.Fusion of Olecranon, Upper Radius, Proximalphalanx of ring finger, Distal phalanx of thumb,Head of Femur, Greater Trochanter, Distal Tibiaand Fibula, Apophysis Calcaneus,First Metatarsal,Proximal phalanges of toes. 54. At age of FIFTEENIn both sexes Appearance of Sesamoid of littlefinger. Fusion of Distal phalanges ofsecond,third & fourth toes.In MalesAppearance of Acromion.Fusion of Ilium, Ischium and Pubis. 55. At age of FIFTEEN (15)In both sexes Appearance of Sesamoid of littlefinger. Fusion of Distal phalanges ofsecond,third & fourth toes.In FemalesAppearance of Sesamoid of index and little fingers.Fusion of Medial epicondyle,Firstmetacarpal,Proximal phalanx of thumb,Distalphalanges of inner four fingers,Proximal tibia,Outerfour metatarsals,Middle phalanx of second toe,Distalphalanges of inner four toes. 56. At age of SIXTEEN (16)In FemalesAppearance of Distal sesamoid of thumb,TuberIschii.Fusion of Inner four metacarpals,Proximalphalanges of index,middle and littlefingers,middle phalanges of fingers. 57. At age of SIXTEENIn MalesFusion of Lower conjoint epiphysis of humerus,medial epicondyle, Olecranon, Head of Radius,Distal phalanx of middle finger, Apophysis ofCalcaneus. 58. At age of SEVENTEENIn both sexes Fusion of AcromionIn FemalesFusion 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 AcromionIn MalesAppearance of Distal sesamoid of thumb.Fusion of First metacarpal,Proximal phalanges of thumb and ring finger,Middle phalanges of Index, Middle and ring fingerDistal phalanges of thumb, Index, ring and littlefingers, Head of femur, Greater trochanter, Distaltibia and fibula,Metatarsals, Proximal phalanges of toes, middlephalanx of second toe, distal phalanx of hallux. 60. At age of EIGHTEENIn Males In FemalesFusion of Inner fourmetacarpals,Proximal phalanges ofindex, middle and littlefingers,middle phalanges of littlefinger,Proximal tibia.Fusion of Distal radius. 61. At age of NINETEENIn MalesAppearance of Sesamoid of index, Tuber ischii.Fusion of Upper conjoint epiphysis of humerus,Distal radius and ulna, Distal femur, Proximalfibula. 62. At age of TWENTYIn both sexes Fusion of Iliac crest.In MalesFusion of Tuber Ischii. 63. At age of 21In both sexes Appearance of Clavicle.In FemalesFusion of Tuber Ischii. 64. At age of 22In both sexes Fusion of Clavicle. 65. After 25 years If all epiphysis of long bones are united the individual ismost probably >25 years. After 25 age estm. becomes more uncertain.Between 40-60 yrsThe ossification of Hyoid bone.Fusion of greater cornu with body of hyoid boneXiphisternum with bodyLipping of verebrae > 45 yrsRarefaction of bones(osteoporosis) after 60 yrsCalcification of costal cartilage(30) yrs & Laryngealcartilage 50+ 12.7 yrsChanges in Mandible with age 66. Symphyseal surface in Estimation of ageaccuracy + 2 yearsBelow 20yr Symphyseal surface has an even appearance with layerof compact bone over its surface20-30 yrs It looks markedly ridged and irregular.- the ridges orbillowing run transeversely and irregular across articularsurface25- 35 yrs the billowing gradually disappears and the articularsurface in macerated bone presents granular appearancewith well-defined anterior and posterior margins35-45 yrs The articular surface looks smooth and oval with raisedupper and lower extremities45-50 yrs Narrow beaded rims develop in and around the marginsof the articular surface showing some erosionAbove 50yrsSymphyseal surface presents varying degrees of erosion withvarying degrees of erosion with breaking down of theventral margins 67. Skull Sutures In Estimation Of AgePosterior fontanelle closes b/w birth 1.5 monthsAnterior fontanelle closes by second year2 postero-lateral fontanelles closes within ashort period after birth & antero-lateralfontanelles within first 6 months.Metopic suture b/w 2 frontal bones closes b/w2 yrs-8 yrs but rarely may remain intactThe basi-occiput fuses with basi-sphenoid byabout 18-20 yrs in Females & 20-22 in Males 68. Suture Closure in the Skull Closure begins in inner table 5-10 years earlierthan outer table In contrast to others the fusion occurs earlierin Males Endocranially suture closure is more uniform& complete and might not close ectocraniallyknown as LAPSED UNION eg sagittal suture Estimation of age by sutural closure of skull isnot reliable, it can be given only in decades The order of reliability is sagittallamboid& coronal 69. Order of suture closure in skull30-40 yrs:- Posterior 1/3rd of sagittal suture-about40-50 yrs:- Anterior 1/3rd of sagittal suture & lowerhalf of coronal suture-about50-60 yrs:- Middle sagittal and upper half ofcoronal suture at aboutIn Lamboid suture fusion activity occurs late andthe progress is also slow, the closure starts about25-30 yrs near Asterion maximum closure atabout 55 yrsSquamous part of temporla bone with itssurrounding after 60yrsTownes view useful 70. HYAONUKYOU