APPENDIX 1 The Rating System Radiographic Technique The correct positioning of the hand and wrist is shown in Appendix Fig. 1. It is of great importance since faulty posing causes some bones to have appearances different from those described below. The radiographer must be brought to look on this technique as an attempt to be quantitative, and the anode-film distance should be exact. The left hand is used. The palm faces downwards, in contact with the cassette, with the axis of the middle finger in direct line with the axis of the forearm; the upper arm and fore-arm should be in the same horizontal plane. The fingers are just not touching and the thumb is placed in the comfortable, natural degree of rotation with its axis making an angle of about 30 degrees with the first finger. The palm is pressed lightly downwards on the film cassette by the subject; or if the child is too young to follow these instructions the hand is secured in this position with bandage or tape. Fig. Al. Correct positioning of hand for skeletal maturity radiograph. The tube is centred above the head of the 3rd metacarpal, at a tube-film distance of 30 inches or 76 cm. High definition screens should be used since high quality definition is essential. The skin dose is 8-10 millirads. The X-ray table is topped with lead sheeting and a lead-material apron is attached to its edge and is pulled well up into the child's lap to shield the gonads from radiation. The development of the film should preferably be rather light. 41 42 SKELETAL MATURITY AND HEIGHT PREDICTION Assigning the Ratings The bones are shown in Appendix Fig. 2. They are rated in the order radius, ulna, metacarpals 1, 3, 5; proximal phalanges 1, 3, 5; middle phalanges 3, 5; distal phalanges 1, 3, 5; capitate, hamate, triquetral, lunate, scaphoid, trapezium, trapezoid. It is convenient to use a standard form for recording. In all drawings the hand is seen with the fingers pointing upward with the thumb on the right hand side of the viewer. Thus, the lateral side is to the viewer's right always, the medial side to his left, distal away from him (or upwards), proximal towards him (or downwards). Reference is frequently made to dorsal and palmer margins or surfaces. It is important to remember that the appearance on the film is a plan in two dimensions of a structure built in three with the added and helpful complication that two superimposed surfaces both penetrated by the X-rays produce a greater degree of whiteness than either of the surfaces penetrated alone. In general the word "margin" or "border" is used where a single line, or edge, is visible on the film: when dorsal and palmer lips become visible the wording has been changed to "surface". The only apparatus required for reading the films is a pair of dividers; these are used for making a rough comparison of diameters of bones in the cases where a criterion requires one bone to be a half or more the width of another. Finer comparisons are not required. Fig. A2. Bones of the hand and wrist. Ratings are assigned by comparing the bone in question with the descriptions and diagrams which follow: the nomenclature of the epiphyseal regions is shown in Appendix Fig. 3. If no sign of the bone is present the rating A is given. Appearances corresponding to the descriptions given of H plus or I plus should be rated H or I respectively (they are the old I and J ratings for capitate, triquetral, lunate and trapezoid bones in system TW1). We give on pp. 44—75 a written description of the criteria for each stage together with a diagram of the typical appearance. In all cases of doubt it is the written description that should be APPENDIX 1: THE RATING SYSTEM 43 followed; the diagrams should serve as an aide-memoire, not as the sole means of comparison. Inevitably some individual variation of shape occurs and raters will not always find an exact match to the diagrams. For this reason we have given two radiographs as examples of each stage, indicating the range of variation within the stages. The radiographs are reproduced in all cases actual size. The diagrams of the carpal bones are of similar size; those of the radius, ulna, metacarpals and phalanges are reduced by about one-third. In some radiographs of the earlier stages the ends of the radiographers fingers appeared; to avoid confusion these have been shaded out in the reproduction (e.g. lower stage B, p. 56). For each stage there are one two or three written criteria marked (i), (ii) and (iii). If only one criteria is given, then this must be satisfied for the stage to be taken as reached; if two criteria are given, then it is sufficient if one of them only is met: if three criteria are given, two of them must be met. Descriptions in brackets are not criteria, and are a help in assigning a rating, but a help only. If at a particular stage a feature described in brackets is not present, this does not affect the rating: if it is, this confirms, but does not diagnose, the stage in question. At each stage, in addition to the criteria for that stage, the criterion (i) for the previous stage must be satisfied, i.e. for a rating stage E to be given, criterion stage D (i) must be met. Epiphyseal centre Metaphysis Fig. A3. Nomenclature of epiphyseal areas. Some bones show greater variation between persons than others. The styloid process of the ulna, and to a lesser extent of the radius also, is sometimes considerably reduced in size; so that it hardly projects at all. The ratings however may still be made by the distinction of the density of the ulna or radial head contrasted with the density of the base of the styloid (ulna stage E). The hook of the hamate varies considerably in size from person to person, and is occasionally absent. In this case, ratings have to be approximated using the remaining criteria. The lunate sometimes develops palmar and dorsal portions separately; they then slowly fuse. This may be confusing in stage C, which should be given if the two portions though distinct are both distinct and rounded. In cases where cone-shaped epiphyses develop, most usually in distal phalanx of the thumb (Iturriza and Tanner, 1969) or other fingers, or more rarely in the middle phalanges, the distal border of the epiphyses follows the shape of the developing cavity rather than being exactly as our descriptions. In brachyphalangy of the fifth finger, the middle phalanx fuses early and this epiphysis should be given the same rating as the middle phalanx epiphysis for the third finger. Other rarer fusions are described in Hughes and Tanner (1966). Following these descriptions there are tables for obtaining bone ages (RUS, Carpal, 20-bone) and full page charts of standards for bone maturity (Figs A4-A9) and bone age (Figs A10-A11) on which the status of a given child may be plotted. Tables of the coefficients of the prediction equations for adult height are also given. References Hughes, P. C. R. and Tanner, J. M. (1966). The development of carpal bone fusion as seen in serial radiographs. British Journal of Radiology, 39, 943—949. Iturriza, J. R. de and Tanner, J. M. (1969). Cone-shaped epiphyses and other anomalies in the hands of normal British children. Journal of Pediatrics, 75, 265-272. DISTAL MEDIAL ■«--LATERAL Radius PROXIMAL B D Boys' Scores TW2 RUS 15 16 Stage B (i) The centre is just visible as a single deposit of calcium, or more rarely as multiple deposits. The border is frequently ill-defined. Girls' Scores tw2 rus 17 23 TW2 RUS 17 21 Stage C (i) The centre is distinct in appearance and oval in shape with a smooth continuous border. (The maximum diameter is less than half the width of the metaphysis.) tw2 rus 19 30 Stage D (i) The maximum diameter is half or more the width of the metaphysis. (ii) The epiphysis has broadened chiefly at its lateral side, so that this portion is TW2 RUS thicker and more rounded, the medial portion more tapering. 21 30 (iii) The centre third of the proximal surface is flat and slightly thickened and the gap between it and the radial metaphysis has narrowed to about a millimeter. tw2 rus 25 44 TW2 RUS 27 39 Stage E (i) A thickened white line has appeared just inside the distal border of the epiphysis; this represents the edge of the palmar surface and the newly appeared bone distal to it is the edge of the dorsal surface. tw2 rus 33 56 44 H Boys' Scores TW2 RUS 48 59 TW2 77 RUS 87 Stage F (i) The proximal border of the epiphysis is now differentiated into palmar and dorsal surfaces; the palmar surface is visible as a broad irregularly thickened white line at the proximal edge of the epiphysis. (ii) Both ends of the epiphysis, but particularly the medial one, have grown outward and proximally since the last stage so that the proximal border now conforms to the shape of the metaphysis along most of its extent. Stage G (i) The dorsal surface now has distinct lunate and scaphoid articular edges joined at a small hump. Lateral to the scaphoid surface the styloid process carries the border distally in a distinct convexity. (ii) The medial border of the epiphysis has developed palmar and dorsal surfaces for articulation with the ulnar epiphysis; either palmar or dorsal surface may be the one which projects medially, depending on the position of the wrist. (iii) The proximal border of the epiphysis is now slightly concave. Girls' Scores tw2 rus 54 78 tw2 rus 85 114 TW2 RUS 96 138 Stage H (i) The epiphysis now caps the metaphysis on one (usually the medial) or both sides. (The styloid process is much further developed than in the last stage.) tw2 rus 99 160 Stage I (i) Fusion of epiphysis and metaphysis has begun. A line may still be visible TW2 RUS composed partly of black areas where the epiphyseal cartilage remains and 106 213 partly of dense white areas where fusion is proceeding; or the line may have disappeared. 45 tw2 rus 106 218 DISTAL Ulna B Boys' Scores TW2 RUS 22 27 Stage B (i) The centre is just visible as a single deposit of calcium, or more rarely as multiple deposits. The border is frequently ill-defined. Girls' Scores tw2 rus 22 30 Stage C TW2 RUS (i) The centre is distinct in appearance, with a smooth continuous border. 26 30 (The maximum diameter is less than half the width of the metaphysis.) tw2 rus 26 33 Stage D (i) The maximum diameter is half or more the width of the metaphysis. (ii) The epiphysis is now elongated so that the transverse diameter is considerably TW2 RUS greater than the longitudinal. 30 32 (iii) Proximal and distal borders are both flattened, though not necessarily parallel. (In many children at this stage the medial half of the epiphysis has broadened in the longitudinal direction more than the lateral half, so that the epiphysis is wedge-shaped with the point facing laterally.) tw2 rus 30 37 TW2 RUS 39 40 Stage E (i) The styloid process is now visible as a distinct though small projection. In some cases it is more clearly distinguished from the head by a difference in density than by actual projection distally. (Apart from the styloid process, the epiphysis is once more approximately symmetrical about its longitudinal axis, the wedge-shape present in many children in the previous stage now having been eliminated through growth of the lateral half of the epiphysis). tw2 rus 39 45 46 Gfer H Boys' Scores TW2 RUS 56 58 Stage F (i) The head of the ulna is now distinctly defined and denser than the styloid process. Its medial surface usually appears as a thickened white line differentiating it from the styloid process, and there is often a concavity of the proximal and or distal border of the epiphysis where the head and styloid meet. (ii) The border adjacent to the radial epiphysis is flattened. Girls' Scores tw2 rus 60 74 Stage G (i) The epiphysis is now as wide as the metaphysis. TW2 RUS (ii) The proximal border of the epiphysis and the distal border of the metaphysis 73 107 overlap in their central one-third. The metaphysis has a concavity or saddle into which the epiphyseal head appears to fit. tw2 rus 73 118 Stage H (i) Fusion of epiphysis and metaphysis has begun. A line may be still visible TW2 RUS composed partly of black areas where the epiphyseal cartilage remains, and 84 181 partly of dense white areas where fusion is proceeding; or the line may have disappeared. tw2 rus 80 173 47 First Metacarpal DISTAL MEDIAL -«--LATERAL PROXIMAL B D Boys' Scores TW2 RUS 4 6 Stage B (i) The centre is just visible as a single deposit of calcium, or more rarely as multiple deposits. The border is frequently ill-defined. Girls' Scores tw2 rus 5 8 TW2 RUS 5 9 Stage C (i) The epiphysis is distinct in appearance and oval in shape, with a smooth continuous border. (The maximum diameter is less than half the width of the metaphysis.) tw2 rus 6 12 Stage D TW2 RUS ^ ^e max'mum diameter is half or more the width of the metaphysis. JW2 Rus ^ (The distal surface has flattened so that it is less convex than the proximal ?? ?g surface. The base of the adjacent metaphysis has a central indentation.) Stage E (i) The epiphysis is as wide as the metaphysis. TW2 RUS (ii) A concavity is present in the proximal border; this is due to the first appear- tw2 rus 19 21 ance of palmar and dorsal surfaces of the epiphysis, though as yet these js 24 surfaces themselves are not distinct. 48 First Metacarpal Stage F (i) The differentiation of the proximal surface into palmar and dorsal portions is now distinct and the full extent of the dorsal surface can be made out; due to the rotation of the thumb in its position on the film, these surfaces appear as latero-dorsal and medio-palmar. The saddle formed by these surfaces conforms to the adjacent border of the trapezium bone. (Towards the end of this stage the medial border of the epiphysis changes from a rounded shape to a flat distinct border.) Girls' Scores tw2 24 rus 31 Stage G (i) The epiphysis caps the metaphysis on one or both sides; the capping is usually seen better on the medial than on the lateral side, due to the rotation tw2 rus of the thumb in positioning the hand. 29 43 (The medial border of the epiphysis usually overlaps the base of the second metacarpal at their point of articulation.) Stage H (i) Fusion of epiphysis and metaphysis has begun. (A line is still visible, composed partly of black areas where the epiphyseal cartilage remains and partly of dense white areas where fusion is proceeding.) Stage I (i) Fusion of epiphysis and metaphysis is completed. (Over the majority of its length the line of fusion has entirely disappeared, but some thickened remnant of it may still be visible.) 49 Third (III) and Fifth (V) Metacarpals DISTAL MEDIAL « j » LATERAL PROXIMAL B a CI U ft D u e n Boys' Scores TW2 RUS III 3 4 V 3 4 TW2 RUS III 4 5 V 3 6 Stage B (i) The centre is just visible as a single deposit of calcium, or more rarely as multiple deposits. The border is frequently ill-defined. Stage C (i) The epiphysis is distinct in appearance and rounded in shape with a smooth continuous border. (The transverse diameter is less than half the width of the metaphysis.) Girls' Scores TW2 3 3 TW2 5 4 RUS 5 6 RUS 8 III V III V Stage D TW2 RUS (i) The transverse diameter is half or more the width of the metaphysis. TW2 RUS III 6 9 (The proximal border may or may not have begun to flatten, but the 7 12 ill V 6 9 lateral and medial borders seen in the next stage are not yet visible.) 7 12 v Stage E (i) Since the last stage the shape of the epiphysis has changed from being an TW2 RUS oval or semicircle to that of a spade or finger-nail. This occurs by virtue of TW2 RUS III 10 12 the lateral, medial and proximal borders of the epiphysis becoming distinct 11 16 ill V 12 14 one from another. 72 17 V (The palmar and dorsal surfaces are not yet differentiated.) 50 Third (III) and Fifth (V) Metacarpals Boys' Scores TW2 RUS III 16 19 V 17 18 Stage F (i) It is now possible, in a good film, to distinguish the palmar from the dorsal surface of the epiphysis. Since the last stage the medial and or lateral edges of the dorsal surface have grown outwards to overlap the palmar surface of the epiphysis. The outlines of the palmar edges now appear as longitudinal thickened white lines. (The epiphysis is not yet as wide as the metaphysis.) Girls' Scores TW2 RUS 77 23 III 18 23 V TW2 RUS III 22 31 V 21 29 Stage G (i) The epiphysis is as wide as, or wider than, the metaphysis. (This stage would seem to be the equivalent of the stage of capping in the epiphysis of the phalanges.) (The longitudinal white lines that signify the edges of the palmar surface now curve outwards to the proximal corners.) (A translucent line of cartilage still remains, but due to positioning of the hand it does not usually extend right across the bone; it should, however, be visible over at least three-quarters of the bone's breadth.) TW2 RUS 23 37 III 22 35 V TW2 RUS III 23 43 V 23 43 Stage H (i) Fusion of epiphysis and metaphysis has begun. (The dark line of cartilage TW2 RUS extends over less than three-quarters of the bone's breadth, but is not 24 47 m entirely obliterated.) 24 48 v III v TW2 RUS 25 52 25 52 Stage I (i) Fusion of epiphysis and metaphysis is completed. (Over the majority of its TW2 RUS length the line of fusion has entirely disappeared, but some thickened remnant 26 53 III of it may still be visible.) 25 52 V 51 DISTAL MEDIAL ■«--► LATERAL Proximal Phalanx of the Thumb PROXIMAL B 0 Ü Ü Boys' Scores TW2 RUS 4 7 Stage B (i) The centre is just visible as a single deposit of calcium or more rarely as multiple deposits. The border is frequently ill-defined. Girls' Scores TW2 RUS 5 9 TW2 RUS 5 8 Stage C (i) The centre is distinct in appearance and disc-shaped, with a smooth continuous border. (The maximum diameter is less than half the width of the metaphysis.) (Multiple centres may occur whose summed maximum diameters exceed half the width of the metaphysis, they should however be rated stage C.) TW2 5 RUS 11 Stage D (i) The maximum diameter is half or more the width of the metaphysis. TW2 RUS (The epiphysis has acquired distinct blunt medial and lateral ends and 8 11 has the appearance of a broad ring; the borders may or may not show slight thickening.) TW2 8 RUS 14 Stage E (i) The proximal border is concave and usually thickened, which is a forerunner TW2 RUS of its differentiation into palmar and dorsal surfaces seen in the next stage. 15 17 (ii) The medial side is longer than the lateral, giving a wedge-shaped appearance. (The epiphysis is very nearly as wide as the metaphysis.) TW2 RUS 14 20 52 Proximal Phalanx of the Thumb H Boys' Scores TW2 RUS 23 26 Stage F (i) The epiphysis is distinctly wider than the metaphysis, particularly at the medial side; it follows closely its shape although it does not yet cap it at the edges. (Further development of the metacarpal articular surfaces has produced a differentiation of palmar and dorsal edges, which are now visible. The dorsal edge is represented by a thickened white line, which runs in an arc concentric with the end of the metacarpal head, from one proximal corner of the epiphysis to the other. The palmar surface is visible as the proximal border of the epiphysis.) Girls' Scores TW2 RUS 24 31 Stage G TW2 RUS (i) The epiphysis caps the metaphysis; the capping is seen better on the medial 28 38 than on the lateral side. TW2 29 RUS 44 TW2 RUS 30 52 Stage H (i) Fusion of epiphysis and metaphysis has begun. (A line is still visible, composed partly of black areas where the epiphyseal cartilage remains and partly of dense white areas where fusion is proceeding.) TW2 RUS 30 56 TW2 RUS 32 67 Stage I (i) Fusion of epiphysis and metaphysis is completed. (Over the majority of its length the line of fusion has entirely disappeared, but some thickened remnant of it may still be visible.) TW2 32 RUS 67 53 Proximal Phalanges of Third (III) and Fifth (V) Fingers B /J C U D U LI Boys' Scores TW2 RUS III 3 4 V 3 4 Stage B (i) The centre is just visible as a single deposit of calcium, or more rarely as multiple deposits. The border is frequently ill-defined. Girls' Scores TW2 RUS 4 5 III 4 6V Stage C TW2 RUS (i) The centre is distinct in appearance and disc-shaped, with a smooth TW2 RUS III 4 4 continuous border. 4 7 /// V 3 5 (The maximum diameter is less than half the width of the metaphysis.) 4 7 V TW2 RUS III 6 9 V 6 9 Stage D (i) The epiphysis is half or more the width of the metaphysis. TW2 RUS 7 12 III 7 12 V TW2 RUS III 13 15 V 13 15 Stage E (i) The proximal border of the epiphysis is concave and distinctly thickened. (This is the forerunner of the development of the metacarpal articular surface, which usually takes place only in the next stage. Sometimes in stage E, however, some differentiation into palmar and dorsal surfaces, as described in stage F, can be seen.) (The epiphysis is not yet as wide as the metaphysis.) TW2 RUS 13 19 III 13 18 V 54 Proximal Phalanges of Third (III) and Fifth (V) Fingers Boys' Girls' Scores Stage F Scores (i) The epiphysis is as wide as the metaphysis and follows closely its shape, although it does not yet cap it at the edges. (Further development of the metacarpal articular surface has taken place since the last stage and, at least on the third metacarpal at this stage, although not always on the fifth, a distinct differentiation of palmar and dorsal edges tw2 rus Can ^e seen' The palmar surface is visible as the proximal border of the TW2 R(JS 2Q 23 epiphysis. The dorsal edge is represented by the thickened white line which 2Q 27 lg runs in an arc concentric with the end of the metacarpal head from one ^ proximal corner of the epiphysis to the other. In some positions of the hand, however, the palmar edge may coincide with the dorsal, and the dorsal thickened concave white line is all that can be seen.) tw2 rus Stage G TW2 RUS iii 23 31 (i) The epiphysis caps the metaphysis. 24 37 III v 22 30 23 35 V Stage H tw2 rus (i) Fusion of epiphysis and metaphysis has now begun. (A line is still visible TW2 RUS ill 24 40 composed partly of black areas where the epiphyseal cartilage remains and 25 44 ill v 23 39 partly of dense white areas where fusion is proceeding.) 24 42 V Stage I tw2 rus (i) Fusion of epiphysis and metaphysis is completed. (Over the majority of its TW2 RUS in 26 53 length the line of fusion has entirely disappeared, but some thickened 26 54 III v 25 51 remnant of it may still be visible.) 25 51 V 55 Middle Phalanges of Third (III) and Fifth (V) Fingers PROXIMAL B n D a n n Boys' Scores TW2 RUS III 3 4 V 4 6 TW2 RUS III 4 6 V 4 7 TW2 RUS III 7 9 V 8 9 Stage B (i) The centre is just visible as a single deposit of calcium, or more rarely as multiple deposits. The border is frequently ill-defined. Stage C (i) The centre is distinct in appearance and disc-shaped, with a smooth continuous border. (The maximum diameter is less than half the width of the metaphysis.) Stage D (i) The maximum diameter is half or more the width of the metaphysis. (The borders are slightly thickened, and the proximal border somewhat convex.) Girls' Scores TW2 RUS III V TW2 RUS 4 8 III 5 8V TW2 RUS 12 12 III V Stage E (i) The central portion of the proximal border has thickened and grown towards the end of the adjacent phalanx, shaping to its trochlear surface. TW2 RUS (This thickened white line represents the dorsal surface of the epiphysis; TW2 RUS III 13 15 proximal to it the palmar surface is usually visible on one or both sides as a 13 18 /// V 14 15 convex projection. In some positions of the hand, however, these proximal 14 18 v edges of palmar and dorsal surfaces appear superimposed.) (The distal border of the proximal phalanx shows a small concavity.) 56 Middle Phalanges of Third (III) and Fifth (V) Fingers Girls' Stage F Scores (i) The epiphysis is as wide as the metaphysis. TW2 RUS (The thickened dorsal proximal surface shows an out-growth at its centre 20 27 to fit into the now well marked concavity at the distal border of the proximal 20 28 phalanx.) Stage G (i) The epiphysis caps the metaphysis. (The facets for the collateral ligaments are now visible on either side of TW2 RUS the head of the proximal phalanx. This is largely a result of the outward 23 36 growth of the sides of the phalanx in its terminal portion, which creates the 22 35 appearance of a distinct head.) Stage H (i) Fusion of epiphysis and metaphysis has begun. A line is still visible, composed partly of black areas where the epiphyseal cartilage remains and partly of dense white areas where fusion is proceeding. (The facets for the collateral ligaments on the head of the proximal phalanx have developed further since the last stage so that their palmar and dorsal borders can often be distinguished.) Stage I (i) Fusion of epiphysis and metaphysis is completed. (Over the majority of its TW2 RUS length the line of fusion has entirely disappeared, but some thickened remnant 25 52 of it may still be visible.) 23 49 57 Distal Phalanx of the Thumb DISTAL , f MEDIAL -——- LATERAL PROXIMAL B n n D n n Stage C TW2 RUS ® The centre is distinct in appearance and disc-shaped, with a smooth continuous border. 4 6 . . 5 9 (The maximum diameter is less than half the width of the metaphysis.) Stage D TW2 RUS (i) The maximum diameter is half or more the width of the metaphysis. TW2 RUS 1 11 (The epiphysis is oval in shape.) 8 15 Stage E (i) The epiphysis is as wide as the metaphysis. (ii) The shape has changed, so that there is now a somewhat flattened distal border and an angulated proximal border. (The change in shape of the TW2 RUS proximal border comes about through a down-growth similar to that seen TW2 RUS 14 17 at this stage in the epiphysis of the middle and distal phalanges of the fingers 15 22 in their central axis. Due to the rotation of the thumb in its position on the film, however, this down-growth appears usually at the proximo-medial edge, although sometimes it may be nearly central.) 58 Distal Phalanx of the Thumb H Boys' Scores TW2 RUS 23 26 TW2 RUS 30 38 TW2 RUS 31 46 TW2 RUS 33 66 Stage F (i) The proximo-lateral border of the epiphysis is now concave and shapes to the head of the proximal phalanx. (In some positions of the thumb this border is not visible as such. Instead the articular surface of the epiphysis can be seen shaping to the trochlear head of the proximal phalanx.) (ii) On the distal border the medial and lateral surfaces can both be seen, with the base of the terminal phalanx conforming to the saddle shape between them. (iii) The epiphysis is now considerably wider than the metaphysis. Stage G (i) The epiphysis caps the metaphysis; because of the position of the thumb this is better seen on the medial side. (The head of the proximal phalanx has developed its saddle shape into which the medio-proximal projection of the epiphysis fits.) Stage H (i) Fusion of the epiphysis and metaphysis has begun. (A line is still visible, composed partly of black areas where the epiphyseal cartilage remains, and partly of dense white areas where fusion is proceeding.) (Differentiation of the head of the proximal phalanx has progressed so that its medial and lateral enlargements can be clearly seen, being medio-dorsal and latero-palmar in this projection.) Stage I (i) Fusion of epiphysis and metaphysis is completed. (Over the majority of its length the line of fusion has entirely disappeared, but some thickened remnant of it may still be visible.) 59 Girls' Scores TW2 RUS 24 33 TW2 RUS 31 48 TW2 32 RUS 51 TW2 RUS 34 68 DISTAL Distal Phalanges of Third (III) and Fifth (V) Fingers PROXIMAL B 0 n Q n D 0 n Boys' Scores TW2 RUS III 3 4 V 3 5 TW2 RUS iii 4 6 V 4 6 TW2 RUS iii 6 8 V 7 9 TW2 RUS iii 10 13 V 11 13 Stage B (i) The centre is just visible as a single deposit of calcium, or more rarely as multiple deposits. The border is frequently ill-defined. Stage C (i) The centre is distinct in appearance and disc-shaped, with a smooth continuous border. (The maximum diameter is less than half the width of the metaphysis.) Stage D (i) The maximum diameter is half or more the width of the metaphysis. (The borders are slightly thickened, and the proximal border somewhat convex.) Stage E (i) The epiphysis is as wide as the metaphysis. (ii) The central portion of the proximal border has grown towards the end of the middle phalanx, so that the proximal border no longer consists of a single convex surface; no differentiation into palmar and dorsal surfaces, however, can yet be seen. (The distal border of the head of the middle phalanx is flat or still slightly convex.) Girls' Scores TW2 RUS 3 7 3 7 TW2 RUS 4 8 4 8 III V III V TW2 RUS 6 11 III 7 11V TW2 RUS 10 15 III 11 15 V 60 Distal Phalanges of Third (III) and Fifth (V) Fingers Girls' Stage F Scores (i) Palmar and dorsal proximal surfaces are distinct, and each has shaped to the trochlear articulation of the middle phalanx. The palmar surface appears TW2 RUS as a projection proximal to the thickened white line representing the dorsal 77 22 surface. 77 22 (The distal border of the middle phalanx is flat or slightly concave.) Stage G (i) The epiphysis caps the metaphysis. (The facets for the collateral ligaments are now visible on either side of TW2 RUS the head of the middle phalanx. This is largely a result of the outward growth 22 33 of the sides of the phalanx in its distal portion, which creates the appearance 21 32 of a distinct head.) Stage H (i) Fusion of epiphysis and metaphysis has begun. (A line is still visible, composed partly of black areas where the epiphyseal cartilage remains and partly of dense white areas where fusion is proceeding.) (The facets for the collateral ligaments on the head of the middle phalanx have developed further since the^last stage so that their palmar and dorsal surfaces can often be distinguished.) TW2 RUS 23 37 22 36 Stage i (i) Fusion of epiphysis and metaphysis is completed. (Over the majority of its TW2 RUS length the line of fusion has entirely disappeared, but some thickened remnant of it may still be visible.) 23 61 24 49 47 DISTAL Boys' Scores TW2 Carp 60 100 Stage B (i) The centre is just visible as a single deposit of calcium, or more rarely as multiple deposits. The border is frequently ill-defined. Girls' Scores TW2 Carp 53 84 TW2 Carp 62 104 Stage C (i) The centre is distinct in appearance and oval in shape, with a smooth continuous border. (The maximum diameter is less than half the width of the radial metaphysis.) TW2 Carp 56 88 Stage D (i) The maximum diameter is half or more the width of the radial metaphysis. TW2 Carp (ii) The border adjacent to the hamate is now flat or only slightly convex. TW2 Carp 65 106 (iii) The border adjacent to the second metacarpal is also beginning to become 61 91 distinct so that the centre now appears somewhat D-shaped. Stage E (i) The hamate border is now concave and slightly thickened. TW2 Carp (ii) The bone has lengthened, so that the longitudinal diameter is distinctly TW2 Carp 71 113 greater than the transverse. 67 99 (The longitudinal diameter is however less than the distance from its proximal border to the radial metaphysis.) 62 Capitate H Boys' Scores TW2 Carp 79 133 Stage F (i) The longitudinal diameter is now equal to or greater than the distance from its proximal border to the radial metaphysis. (Apart from this lengthening, the main features of the bone are unchanged since the last stage.) Girls' Scores TW2 Carp 76 121 Stage G (i) The articular facets with the second and third metacarpals have begun to TW2 Carp form, causing the appearance of a thickened white line along the latero- 89 160 distal border of the bone. (ii) The articular facet with the hamate has just begun to form and may be seen at the middle of the concavity of the hamate border. TW2 Carp 85 149 Stage H (i) The articular facets for the second and third metacarpals have now developed so that both palmar and dorsal surfaces are visible. The thickened white line seen along the border of the bone in the last stage is now placed TW2 Carp inside the bone's outer margin, because of the growth of the dorsal surface TW2 Carp 116 214 out beyond it. 113 203 (ii) The spur towards the fourth metacarpal may be such that the bone now overlaps and articulates with the hamate, and usually, the bases of the third and fourth metacarpals (H + ). 63 Hamate DISTAL MEDIAL ■ PROXIMAL Boys' Girls' Scores Stage B Scores TW2 Carp (i) The centre is just visible as a single deposit of calcium, or more rarely as TW2 Carp 42 73 multiple deposits. The border is frequently ill-defined. 44 72 Stage C (i) The centre is distinct in appearance and round in shape, with a smooth TW2 Carp . , , ^ TW2 Carp continuous border. 44 75 47 74 (The maximum diameter is less than half the width of the radial metaphysis.) Stage D (i) The maximum diameter is half or more the width of the radial metaphysis. (ii) The surface that later articulates with the triquetral has flattened so that TW2 Carp appearance of the hamate (like that of the capitate at the same stage) TW2 Carp is D-shaped, with the straight side running diagonally to the long axis of the hand. Stage E (i) The capitate border has now begun to shape to the hamate indentation of the capitate. This shaping usually takes the form of a slight bulge appearing TW2 Carp about half to two-thirds of the way down the border, with somewhat flattened TW2 Carp 59 100 edges proximal and distal to it. 64 102 (ii) The metacarpal and capitate borders have become differentiated so that the shape has changed from a D to a three-sided figure. 64 Hamate Boys' Girls' Scores Stage F Scores TW2 Carp (i) A concavity is now present in the triquetral border (because of considerable TW2 Carp 70 128 growth upwards towards the base of the fifth metacarpal since the last stage). 74 131 Stage G (i) The articular facet for the fourth metacarpal has now begun to form and differentiation into palmar and dorsal surfaces can be seen as a thickening TW2 Carp .. , , , 8 TW2 Carp ^ ^ running along or inside the distal border ot the bone. g5 (Palmar and dorsal surfaces of the articulation with the capitate are visible.) Stage H (i) The hook of the hamate has begun to appear as a white line (to be distinguished from the articular surfaces adjacent to metacarpals four and five, described below.) (ii) The articulations with the fourth and fifth metacarpals have now progressed TW2 Carp v ' , , ... - . ,. , , r , K B TW2 Carp 92 so that there are two distinct surfaces at the distal edge ot the bone, one ^ ^ running transversely and the other, on the medial side, running diagonally to the axis of the hand. (The triquetral articulation has also advanced so that the proximal part of the hamate is now triangular in shape with a pointed apex proximally.) Stage I (i) The hook of the hamate is now visible throughout its entire outline. TW2 Carp (ii) The spaces between the hamate and the capitate and between the hamate 7W2 Carp 106 194 and the triquetral are now reduced to a thin black line or entirely obliterated 70S 194 by overlapping. 65 Triquetral DISTAL MEDIAL ■«--«■ LATERAL PKOXIMAL B • CO D Qf E ^) Boys' Girls' Scores Stage B Scores TW2 Carp (i) The centre is just visible as a single deposit of calcium, or more rarely as TW2 Carp 1 10 multiple deposits. The border is frequently ill-defined. 8 11 Stage C _.,„ „ (i) The centre is distinct in appearance and round in shape with a smooth „,.,„ _ TW2 Carp . . ■ TW2 Carp continuous border. (The maximum diameter is less than half the width of the ulnar metaphysis.) Stage D (i) The maximum diameter is half or more the width of the ulnar metaphysis. TW2 Carp (ii) The border adjacent to the hamate has flattened. TW2 Carp 17 28 (The bone is still D-shaped, not elongated; no one diameter is much 19 31 larger than any other.) Stage E ____ „ (i) The bone is elongated in shape with the longitudinal diameter distinctly TW2 Carp w , , & , • • . i • , , , • TW2 Carp 2g 57 greater than the transverse; this is due to growth since the last stage having ^ been relatively greatest at the medio-distal border. 66 Triquetral Boys' Scores TW2 Carp 38 84 Stage F (i) The lunate border has now become flat and distinct and forms a sharp angle of a little over 90 degrees with the hamate border. One or both borders show slight thickening as the articular facets begin to form. (Growth of the bone has been relatively greatest in the direction of the base of the fifth metacarpal, so that the distal border, instead of being round as in the last stage, is now peaked with the tip extending towards the most medial point of the hamate.) Girls' Scores TW2 36 Carp 80 TW2 Carp 45 102 Stage G (i) Palmar and dorsal surfaces are now visible on the hamate and or lunate borders so that the white lines seen in the last stage at the borders of the bone are now slightly inside the borders. (There is still considerable separation between the borders of triquetral and hamate, in particular medio-distally.) TW2 46 Carp 704 TW2 62 Carp 124 Stage H (i) The broadening, chiefly of the distal half of the bone, since the last stage has caused a concavity to appear in the medial border. (The contour of the bone now follows the outline of the hamate all the way to the hamate's most medial point.) (ii) The distal portion of the bone has broadened so that it is nearly or quite as wide as the proximal portion. There may be overlapping between the edges of the triquetral and the hamate (H + ). TW2 63 Carp 126 67 DISTAL Lunate PROXIMAL Boys' Girls' Scores Stage B Scores TW2 Carp (i) The centre is just visible as a single deposit of calcium, or more rarely as TW2 Carp 10 14 multiple deposits. The border is frequently ill-defined. 10 16 Stage C (i) The centre is distinct in appearance and oval in shape, with a smooth 13 22 continuous border. TW2 Carp (The maximum diameter is less than half the width of the ulnar metaphysis.) 14 24 Stage D c (i) The maximum diameter is half or more the width of the ulnar metaphysis. c TW2 Carp .... rp^ jjstai border of the bone is now thickened (but palmar and dorsal T a'P 20 39 . • 20 40 surfaces there are not yet visible.) Stage E (i) The palmar and dorsal surfaces of the distal part of the bone are now clearly defined with one of the other, or both, projecting distal to the thickened TW2 Carp white line which marks their area of confluence. The dorsal surface may TW2 Carp 27 58 project towards the scaphoid but no proper saddle, as in the next stage, is yet 27 59 formed. (ii) There is flattening of the border adjacent to the radius. 68 Lunate Boys' Girls' Scores Stage F Scores (i) The distal surface now forms a definite saddle for articulation with the capitate, due chiefly to an out-growth of its dorsal part towards the scaphoid. TW2 Carp This dorsal part extends out beyond the lateral edge of the palmar (thickened) TW2 Carp 36 84 part of the saddle, but less than half way from the palmar edge to the edge 35 84 of the scaphoid. (ii) The scaphoid and triquetral borders are now flat and slightly thickened. Stage G (i) The dorsal surface of the capitate saddle has further enlarged since the last _._ „ stage and now covers more than half the distance from the palmar edge of „Ain _ TW2 Carp , . j, , , ■ , TW2 Ca'P 44 101 saddle to the scaphoid. ^g (ii) There is a definite angle between the scaphoid border (which is still straight) and the radial border. Stage H (i) The dorsal surface of the capitate saddle now extends laterally to touch or overlap the edge of the scaphoid. (Either palmar or dorsal surface, or both, depending on individual shape TW2 Carp and positioning, touch or overlap the capitate.) TW2 Carp 60 120 (ii) The scaphoid border is now concave. 60 122 (There is now a definite projection in the direction of the ulnar styloid process culminating in a relatively sharp point. The gap between lunate and scaphoid is often almost or entirely obliterated (H + ).) 69 Scaphoid DISTAL MEDIAL---- LATERAL PROXIMAL Boys' Girls' Scores Stage B Scores TW2 Carp (i) The centre is just visible as a single deposit of calcium, or more rarely as TW2 Carp 14 26 multiple deposits. The border is frequently ill-defined. 13 24 Stage C TW2 Carp ^ ^ne centre 's distinct in appearance and round in shape with a smooth TW2 Cgrp 18 36 P continuous border. ?/ J5 (The maximum diameter is less than half the width of the ulnar metaphysis.) Stage D (i) The maximum diameter is half or more the width of the ulnar metaphysis. TW2 Carp (The capitate border is flattened and may show slight thickening.) TW2 Carp 23 52 (The border adjacent to the radial epiphysis is well defined and runs 23 51 parallel to it, making the shape of the bone like that of a sector of a circle, with capitate and radial-epiphyseal borders as the radii.) Stage E (i) The dorsal surface of the capitate articulation is visible outside the thickened TW2 Carp white line, which represents the palmar articular surface. TW2 Carp 30 71 (Since the last stage the bone has elongated so that its longitudinal is now 29 71 considerably greater than its transverse diameter.) 70 Scaphoid -6 0 Boys' Scores TW2 Carp 35 85 Stage F (i) The capitate surface is concave in both its palmar and dorsal aspects. (ii) The border adjacent to the trapezium and trapezoid is flat. Girls' Scores TW2 Carp 36 88 Stage G (i) The bone has grown chiefly in a proximal and medial direction, so that its dorsal surface now extends beyond the thickened white line over towards TW2 Carp the lunate and the proximal part of the capitate. TW2 Carp 42 100 (ii) There is now a distinct border running adjacent to the lunate, its direction 44 104 such that its capitate end is nearer the midline than its radial-epiphyseal end. The border is as yet in contact with the lunate only at the capitate end. Stage H (i) The capitate surface conforms closely to the capitate bone throughout the whole of its extent. (The distal border meets or overlaps the edge of the capitate at the angle on the capitate formed by the junction of the trapezoid and scaphoid borders.) TW2 Carp (ii) The lunate border has changed its direction so that now its radial-epiphyseal TW2 Carp 58 116 end is as near or nearer the midline than the capitate end. The border is now 57 7 rs in contact with the lunate bone over most of its distal portion, (iii) Lateral enlargement of the distal portion of the bone and differentiation of the radial styloid articular surface has resulted either in a concavity appearing in the distal part of its lateral border, or in the appearance of a distinct distal head. 71 Trapezium DISTAL MEDIAL « J - LATERAL PROXIMAL mm B C o E'0 Boys' Girls' Scores Stage B Scores TW2 Carp (i) The centre is just visible as a single deposit of calcium, or more rarely as TW2 Carp 12 23 multiple deposits. The border is frequently ill-defined. 12 20 Stage C (i) The centre is distinct in appearance and round in shape with a smooth TW2 Carp continuous border. TW2 Carp 15 31 (The maximum diameter of the bone is less than half the width of the 14 27 first metacarpal metaphysis.) Stage D (i) The maximum diameter is half or more the width of the first metacarpal metaphysis. TW2 Carp (ii) There is flattening of the border adjacent to the first metacarpal and/or of the TW2 Carp 21 46 scaphoid border; the distance between these two borders is now distinctly 20 42 less than the diameter at right-angles to them. (The gap between the base of the second metacarpal and the trapezium is still one-third or more the maximum diameter of the bone.) TW2 Carp 28 66 Stage E (i) Since the last stage, the bone has grown chiefly upwards towards the base TW2 Carp of the second metacarpal, so that the gap between the two is less than 25 60 one-third the maximum diameter of the trapezium. 72 Trapezium Boys' Girls' Scores Stage F Scores (i) The first metacarpal border is now distinctly concave and slightly thickened TW2 Carp at about its central portion. The concavity is due to growth since the last TW2 Carp 34 83 stage being chiefly in the direction of the lateral edge of the base of the first 32 80 metacarpal. Stage G (i) The distal edge of the bone now overlaps slightly the lateral tip of the base of TW2 Carp t'ie second metacarpal. c 3g 95 (ii) The scaphoid border is now flat and thickened and, in a good film, palmar ^_ and dorsal articular surfaces of this border can just be made out in the area beyond the overlapping edge of the trapezoid. Stage H (i) There is a newly-appeared straight border forming the distal part of the radial side of the bone; the first metacarpal surface meets this border at a sharp point. ,.,„ „ (Since the last stage, there has been further growth of the projection TW2 Carp , v , . . ° ' , . s , , , ■ TW2 Carp ___ between the bases or the first and second metacarpal, so that the maximum „ ^ 47 108 . 49 111 concavity of the first metacarpal surface is now usually about two-thirds the way below the distal tip of the bone.) (ii) The first metacarpal surface conforms to the saddle shape of the epiphysis of the first metacarpal with palmar and dorsal surfaces now differentiated. Stage I (i) Since the last stage the radial border has further bulged outward so that it TW2 Carp has two distinct portions, the distal facing laterally and the proximal facing 59 117 the radial styloid; this proximal portion is now flat or, as a rule, slightly concave. 73 TW2 Carp 59 119 DISTAL B • Co DO E Boys' Girls' Scores Stage B Scores TW2 Carp (i) The centre is just visible as a single deposit of calcium, or more rarely as TW2 Carp 14 27 multiple deposits. The border is frequently ill-defined. 13 21 Stage C (i) The centre is distinct in appearance and round in shape with a smooth TW2 Carp continuous border. TW2 Carp 16 32 (The maximum diameter is less than half the width of the first metacarpal 16 30 metaphysis.) Stage D (i) The maximum diameter is half or more the width of the first metacarpal metaphysis. 7W2 Carp (The bone is still round in shape.) 20 43 TW2 Carp 20 42 Stage E (i) There is now flattening of the capitate border and or of the border which TW2 Carp j. right-angles to it and which will eventually articulate with the medial 23 51 . 24 53 side of the base of the second metacarpal. 74 F0 H Boys' Scores TW2 32 Carp 77 TW2 Carp 39 93 TW2 56 Carp 115 Stage F (i) Thickened white lines have appeared along the capitate and or medial second metacarpal borders. Differentiation of one but not both of these borders into palmar and dorsal surfaces may have taken place. (ii) The distal edge of the bone has grown since the last stage and now forms a rounded peak which will later articulate with the central indentation of the second metacarpal base. Though this peak is part of the future dorsal surface and may appear as such, there is at this stage no very clear differentiation into palmar and dorsal surfaces. (The scaphoid surface is flattened.) Stage G (i) The dorsal surface of the articulation with the second metacarpal is now visible distal to the thickened white line which marks the edge of the palmar surface. The dorsal surface of the capitate articulation is also now visible. These dorsal outgrowths have developed so as nearly or quite to overlap the edges of the second metacarpal and capitate. Stage H (i) The dorsal proximal border of the bone is concave, although the palmar aspect of this border, which shows as a thickened line, remains straight. (ii) The lateral border has enlarged so that it is now distinctly convex. The outlines of the trapezoid may no longer be clearly visible over their whole extent (H + ). Girls' Scores TW2 Carp 31 77 TW2 Carp 40 97 TW2 Carp 57 118 75 Maturation of the Hand and Wrist in a Girl Followed Longitudinally CA 15-5 years CA 165 years CA 17-5 years Vfxkumn? foUv pefetoWf 77 Inw4«ni 5%m, "mmh^ t Table A1 RUS (TW2) Bone Age for Given Maturity Score BOYS Maturity Bone Maturity Bone Maturity Bone Maturity Bone score "age" score "age" score "age" score "age" — 10 189 6-0 330 110 744 160 — 1 192 •1 334 1 762 •1 — •2 194 ■2 337 •2 780 ■2 — ■3 197 ■3 340 •3 798 ■3 — •4 199 •4 342 ■4 816 •4 — ■5 202 ■5 346 •5 833 •5 26 ■6 z04 •6 349 •6 850 •6 32 ■7 207 •7 352 •7 867 •7 38 •8 209 ■8 354 •8 883 •8 43 ■9 212 •9 358 ■9 899 ■9 49 2-0 215 7-0 361 120 915 170 55 •1 218 ■1 365 ■1 928 •1 61 •2 222 ■2 369 •2 940 •2 65 •3 224 •3 373 •3 951 •3 70 •4 227 •4 378 ■4 962 •4 75 •5 230 •5 382 ■5 971 •5 80 •6 233 •6 386 ■6 980 ■6 84 •7 235 ■7 391 ■7 986 ■7 89 ■8 238 •8 395 ■8 992 ■8 93 ■9 240 ■9 400 ■9 995 •9 98 3-0 243 8-0 405 13-0 997 180 101 •1 245 •1 410 •1 999 ■1 105 ■2 248 •2 416 •2 1000 ADULT 108 •3 251 •3 422 ■3 112 •4 253 ■4 427 •4v 115 •5 257 •5 434 ■5 118 ■6 260 •6 440 •6 122 •7 263 •7 447 •7 125 •8 266 ■8 454 -8 128 •9 269 ■9 463 •9 132 4-0 272 90 472 14-0 135 ■1 275 •1 481 •1 138 •2 278 ■2 490 ■2 141 •3 281 •3 501 •3 144 ■4 283 ■4 512 •4 147 •5 286 ■5 524 ■5 150 •6 289 ■6 536 •6 153 •7 292 ■7 548 •7 156 •8 295 •8 560 ■8 159 ■9 297 ■9 574 •9 162 50 300 10-0 588 15-0 165 •1 303 •1 602 •1 168 ■2 306 ■2 616 •2 171 ■3 309 •3 630 ■3 173 •4 312 •4 645 •4 177 •5 316 •5 660 •S 180 ■6 319 •6 675 •6 182 •7 321 •7 692 ■7 185 •8 325 ■8 708 ■8 187 ■9 328 •9 726 •9 78 Score 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20Score 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Fig. A4. Standards for RUS skeletal maturity score: boys. 79 1 Table A2 Carpal (TW2) Bone Age for Given Maturity Score BOYS Maturity Bone Maturity Bone Maturity Bone Maturity Bone score "age" score "age" score "age" score "age" 1-0 281 5-0 632 90 944 130 — •1 287 ■1 641 ■1 950 •1 — •2 294 •2 650 •2 955 ■2 _ •3 300 -3 659 •3 960 •3 — ■4 307 ■4 668 •4 964 ■4 — •5 314 ■5 677 •5 968 ■5 — ■6 322 •6 686 •6 972 ■6 _ ■7 330 •7 695 •7 976 ■7 — •8 338 •8 705 ■8 980 ■8 — •9 346 ■9 715 ■9 983 ■9 20 354 60 724 10-0 986 140 — •1 362 1 733 ■1 989 ■1 — ■2 371 ■2 742 •2 991 ■2 — •3 380 •3 751 ■3 992 ■3 190 •4 389 ■4 760 ■4 994 •4 190 •5 398 •5 769 ■5 995 •5 191 •6 407 •6 in ■6 996 •6 192 ■7 417 ■7 786 •7 997 ■7 194 •8 426 ■8 794 •8 998 ■8 195 •9 436 •9 802 •9 999 ■9 197 3-0 445 7-0 810 110 1000 ADULT 198 •1 454 ■1 818 •1 200 ■2 463 •2 825 •2 202 ■3 472 •3 833 •3 203 •4 481 ■4 840 ■4 206 •5 491 •5 848 •5 209 •6 500 ■6 856 •6 213 ■7 509 ■7 863 •7 217 •8 518 •8 870 ■8 221 ■9 526 •9 877 ■9 225 4-0 535 80 884 12-0 229 •1 544 •1 890 •1 234 •2 552 •2 897 •2 - 239 •3 562 ■3 903 •3 244 •4 571 •4 910 •4 250 ■5 581 ■5 915 ■5 256 ■6 591 ■6 921 ■6 262 ■7 601 ■7 927 ■7 268 ■8 611 ■8 933 ■8 274 •9 621 ■9 939 ■9 80 Score 1 100 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 Carpals (TW2) Maturity Score / 7 l V 17 18 19 20Score 100 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Fig. A5. Standards for Carpal skeletal maturity score: boys. 81 Table A3 20-Bone (TW2) Bone Age for Given Maturity Score BOYS Maturity Bone Maturity Bone Maturity Bone Maturity Boric score "age" score "age" score "age" score "age" 114 10 355 60 678 110 970 16-0 116 •1 360 •1 684 ■1 973 •1 119 •2 366 ■2 690 ■2 976 ■2 123 ■3 372 •3 697 •3 979 ■3 126 ■4 378 •4 703 ■4 981 •4 129 ■5 384 ■5 711 ■5 983 •5 133 •6 390 •6 718 •6 985 •6 136 •7 396 ■7 725 •7 987 •7 139 •8 402 ■8 732 •8 989 ■8 142 ■9 409 ■9 740 •9 991 •9 146 20 415 7-0 747 12-0 992 170 150 ■1 422 ■1 754 1 994 •1 154 •2 428 •2 761 •2 995 •2 159 ■3 435 ■3 768 •3 996 ■3 163 •4 441 •4 - 774 •4 996 ■4 168 ■5 447 ■5 781 ■5 997 ■5 172 ■6 454 ■6 788 •6 998 •6 176 ■1 460 •7 795 •7 999 •7 181 •8 466 ■8 802 •8 999 •8 185 ■9 472 ■9 809 •9 999 •9 190 3-0 477 8-0 817 130 1000 ADULT 195 •1 483 ■1 823 •1 200 •2 489 •2 830 •2 205 ■3 495 ■3 836 •3 210 •4 501 ■4 842 •4 215 •5 507 •5 849 ■5 220 ■6 513 ■6 855 •6 226 *7 520 •7 861 •7 231 ■8 526 ■8 867 •8 236 ■9 533 •9 873 •9 242 40 540 9-0 879 140 247 1 546 •1 884 1 252 ■2 553 •2 889 •2 258 •3 560 •3 895 •3 264 ■4 566 •4 900 •4 270 •5 573 ■5 906 ■5 276 •6 580 ■6 911 •6 282 •7 587 •7 916 ■7 287 •8 594 •8 921 •8 292 ■9 601 •9 926 •9 298 5-0 608 100 931 15-0 303 •1 615 •1 936 ■1 308 •2 622 •2 940 ■2 314 •3 629 •3 944 ■3 319 ■4 636 •4 948 ■4 325 ■5 643 ■5 952 ■5 331 •6 650 •6 956 ■6 337 •7 657 •7 959 •7 343 ■8 664 ■8 963 •8 349 •9 671 •9 967 •9 82 Score 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20Score 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Fig. A6. Standards for 20-bone (TW2) skeletal maturity score: boys.