How to determine a child's bone age. X-ray examination of the hand

Diseases associated with the hands are quite common; these limbs also account for a large number of various injuries, because a person tries to substitute them during a fall or to cover himself with his hands from something. Unfortunately, a specialist will not always be able to immediately understand what’s wrong, because there are a huge number of problems, the symptoms of which are somewhat similar. X-ray of the hand is the simplest and most effective method diagnostics, used everywhere, let's take a closer look at its essence.

Indications for use

Every person can take an X-ray of the hand, but doctors strongly do not recommend resorting to such procedures on a regular basis, because they are based on X-ray radiation, which negatively affects the human body. Of course, in most situations there will be no serious harm from one or several shots, but the procedure should definitely not be carried out constantly. For this reason, X-rays of the hands of children and adults are not performed unless there are certain complaints; most often it is used to diagnose the consequences of injury, as well as various pathological processes, for example, X-ray examination is necessary in case of growth retardation (a child with growth retardation needs such an X-ray examination for the reason that it will provide information that is important for doctors). In addition to situations where the child is stunted, radiography is recommended in the following cases:

the presence of pain of various types in the area of the hands;
any signs of swelling, as well as redness of the joints themselves;
deformations of varying degrees, extending primarily to the joints;
there are suspicions of fractures, dislocations or any other injuries;
inflammatory processes that have begun in any joints of the hand;
there is a need to determine bone age;
the need to identify destructive disorders associated with bone tissue;
tumors, and we are talking about both benign and malignant neoplasms;
the presence of any anomalies associated with the joints (in most situations they are hereditary).

X-ray of a healthy hand.

Here are the main disorders and diseases that can be seen in the pictures:

Calcifications. This term hides formations that indicate the onset of arthritis.
Synovitis. This means that for some reason fluid begins to accumulate in the wrist joints (this disorder is diagnosed by the appearance of a wider joint space).
Osteoporosis. This disorder is one of the earliest symptoms of the development of polyarthritis. On x-ray, osteoporosis will appear as thinning of the cortical layer of the short tubular bones.
Joint erosion. This manifestation is also characteristic of polyarthritis, and in most cases it already indicates the transition of the disease to a chronic form.
Cysts. The appearance of cysts, that is, round formations, always occurs in large numbers; they are most often found in the bone epiphysis, namely in its central section.
Osteophytes. Such irregularities in the photo (we are talking about the same photograph of the hand) are revealed as some kind of bone growths, and this applies to the surface of the joints.

Note! As mentioned earlier, there are a huge number of diseases associated with the hands, so diagnostic procedure should be carried out in these situations without fail, but this does not mean that the specialist must definitely choose an x-ray, where to do which you will know exactly. There are other diagnostic methods that will be preferable in some situations, but all this should be discussed individually. Most of them are much more informative and safer, but x-rays are much cheaper and more accessible. Specialists always pay attention not only to the patient’s wishes, but also to many factors associated with the disease.

Contraindications

Fortunately, large quantity X-rays have no contraindications; almost everyone does them, but you need to know some rules. This study Pregnant women, as well as those who are breastfeeding, are prohibited from passing through, because radiation tends to accumulate in breast milk, and the negative effect on the fetus has long been proven. Also, doctors do not recommend conducting research on young children, except in situations where the purpose justifies it, for example, if there is a threat to life or health. An alternative would be a much safer magnetic resonance imaging scan. It is worth noting that healthy people It is completely safe to do such an x-ray, because the radiation dose will not be exceeded.

Preparation

When X-raying hands, it is important to pay special attention to the preparation process, because it is very important. If something is done incorrectly, the pictures may turn out to be of poor quality, which is why they often have to be redone, which means that additional harm will be caused to the body due to the presence of the same X-ray radiation. Here are the main nuances to remember:

Be sure to remove all jewelry present, because they may well negatively affect the quality of the photo; it is better not to take them with you to the procedure at all.
Follow all recommendations of specialists.
Do not remove previously applied limb immobilization devices.

In this image you can see polyarthritis.

Carrying out the procedure

Let's briefly look at the process of the procedure. A prerequisite is that you must wear special protection before the procedure, namely a lead apron that can at least slightly reduce the harm from X-ray radiation for those parts of the body that do not need examination. This is important especially if we are talking about children, then it is better to leave only the brushes themselves open. Upon completion of the examination, the specialist will always compare the results with the norms specified in the information about bone age.

It is worth noting that about 2-3 minutes are allocated for photographs, this time is quite enough to take them in several projections. The doctor will tell you important details about the procedure and tell you to place your hand on a special surface. The scan is almost always carried out in a sitting position, because it is important to keep your arm bent at the elbow. The fact is that the accuracy and information content of the image depends on the correct position of not only the hand, but also the entire arm. Here are the main projections in which photographs are taken:

Straight. This position is almost always used, and it may involve scanning from the back or from the palmar side. In this case, the X-ray beam should pass through the middle of the hand itself.
Lateral. As you can easily guess from the name of this projection, it involves placing the brush edgewise, and you will also need to move it back a little thumb. This option is also used quite often, because the lateral projection allows the specialist to determine the condition of the contour of the wrist, as well as much more. It is worth noting that this projection is almost always used in traumatology, because it is important for identifying displacements.
Palmar oblique. This option involves placing the hand with the palm side up at an angle of approximately 45 degrees; a specialist will tell you the details. This method is used less frequently; in most situations it is required to study the scaphoid or trapezoid bone.
Dorsal oblique. The method is similar to the previous one, but differs in that the brush should be positioned with the back side up, and still with an angle of 45 degrees. The projection is aimed at studying the pisiform, as well as the hamate and triquetrum bones.

BONE AGEThe study of bone age has
important for comprehensive assessment
growth. The degree of skeletal maturation can
be assessed by different bones, but
most widespread
X-ray examination of bones
brushes This is due to the presence in this
areas of multiple ossification centers, which
allows you to identify different
stages of skeletal maturation throughout
throughout the growth period.

Methods for assessing bone age:

Buchman's method (common in Russia):
X-rays are taken of both
hands with wrist joints and
special tables based on gender
the child's age range is determined,
which corresponds to the quantity
ossified nuclei with one or the other
sides

Greulich-Pahl method: assessment by radiograph
one left hand with a wrist joint.
Bone age is determined by
atlas by comparison with photographs and
descriptions of radiographs, which in certain
age periods differ not only
number of ossification nuclei, but also their sizes and
mutual position. After selecting from the atlas
the most similar X-ray picture with
using tables to estimate the age of each
individual bone, and then calculate the average
index.

Tanner-Whitehouse method: also
use a radiograph of the left hand and
wrist joint. In accordance with
attached descriptions and drawings
alternately assess the degree of maturity 20
ossification centers, and then along
calculated using the appropriate formula
bone age.

X-ray of an unchanged hand and wrist: 1 - trapezium, 2 - trapezoid, 3 - capitate, 4 - hooked, 5 -

X-ray image unchanged
hands and wrists:
1 - trapezoid,
2 - trapezoidal,
3 - capitate,
4 - hooked,
5 - scaphoid,
6 - semilunar,
7 - triangular

Radiographs of the hand

Up to 3 years
3 years
9 years
16 years

10.

11.

12. 13. Radiographs of unchanged pelvic bones in children of different ages: a - a 10-month-old child; b - child 3 years old; c - child 7

years;
g - child 10 years old

14. Radiographs of unchanged knee joints in a newborn (a) and an 8-year-old child (b): a - in a newborn they are determined

Radiographs of unchanged knee joints in a newborn(s)
and a child 8 years old (b):
a - in a newborn, only ossification nuclei are detected in the epiphyses of bones,
forming the joint (arrows). The patella is not radiologically
visualized;
b - in an 8-year-old child, preserved growth zones (arrows) are determined
border of the epiphysis and metaphyses. The patella is clearly defined (double
arrow)

15. 16. It should be noted that the study of bone age itself is of relative importance. Bone age may

differ from chronological
only with different
diseases, but also in healthy children, in
of which this difference is sometimes 2-3
of the year.
At the same time, comparison of bone
age with the growth of the child, especially in
dynamics, can provide very valuable
information about further growth
forecast.

Methods for assessing bone age:

X-ray of an unchanged hand and wrist: 1 - trapezium, 2 - trapezoid, 3 - capitate, 4 - hooked, 5 -

X-ray image unchanged
hands and wrists:
1 - trapezoid,
2 - trapezoidal,
3 - capitate,
4 - hooked,
5 - scaphoid,
6 - semilunar,
7 - triangular

Radiographs of the hand

Up to 3 years
3 years
9 years
16 years

Radiographs of unchanged pelvic bones in children of different ages: a - a 10-month-old child; b - child 3 years old; c - child 7

years;
g - child 10 years old

Radiographs of unchanged knee joints in a newborn (a) and an 8-year-old child (b): a - in a newborn they are determined

Radiographs of unchanged knee joints in a newborn (a)
and a child 8 years old (b):
a - in a newborn, only ossification nuclei are detected in the epiphyses of bones,
forming the joint (arrows). The patella is not radiologically
visualized;
b - in an 8-year-old child, preserved growth zones (arrows) are determined
border of the epiphysis and metaphyses. The patella is clearly defined (double
arrow)

It should be noted that bone age testing itself is of relative importance. Bone age may

DETERMINATION OF AGE BY RADIOGRAMS OF HAND BONES Introduction Determination of age by radiographs of the hand skeleton is of great importance in the diagnosis of many diseases. Typically, developmental age (biological age) is determined by the degree of skeletal ossification. In world practice, it is customary to define “bone” or “radiological” age as a convenient criterion of biological age, since it is a more subtle indicator of the physiological state and originality of the constitution of the subject than passport age and any anthropometric data. The passport age itself only indicates the number of years lived and does not always coincide with biological age. The state of the skeletal system reflects the general development processes taking place in the body. To determine bone age, it is enough to study the ossification, size and relationship of the skeleton of the hand and the distal forearm, as the most accessible part of the skeleton for radiography and providing the most complete information about the development of the entire organism. Over the past decades, there has been and continues to be an acceleration in the physical development of children and adolescents, called acceleration. Acceleration forces us to take a new approach to assessing norms and pathologies in physical development. The effect of acceleration on the growth and development of the skeleton is manifested by accelerated ossification, an increase in bone size, earlier disappearance and a decrease in the frequency of occurrence of pseudoepiphyses. Therefore, assessment according to old standards is methodologically incorrect, since it leads to errors. To determine bone age, you should use tables developed in 1968-1977. Determination of bone age has a large diagnostic value primarily for growth pathologies in children and adolescents. Correct determination of bone age is of great practical value in endocrinology for diagnosis and differential diagnosis myxedema, pituitary and cerebral dwarfism, some chromosomal diseases, disorders of sexual differentiation, Itsenko-Cushing's disease and syndrome, virile and diencephalic syndrome, some tumors of the adrenal glands and ovaries, etc. Determining bone age allows you to control the treatment of patients hormonal drugs, which are widely used for the treatment of many diseases, including growth stimulation. The resulting standards for ossification and size of hand bones can be used in forensic medical examination. Therefore, mastering the technique of determining age from radiographs of the bones of the hand and distal forearm is necessary not only for radiologists, but also for doctors of other specialties, since establishing the correct diagnosis and carrying out rational treatment of the patient often depends on this. The order and timing of ossification of the skeleton of the hand and distal forearm. Bone development is characterized by both qualitative and quantitative indicators. Qualitative indicators include the timely appearance of ossification points and synostosis of the hand bones. These processes are known as skeletal differentiation (ossification, ossification). TO quantitative indicators refers to an increase in bone size. Thanks to X-ray examination, it is possible to deeply penetrate into the dynamics of ossification and observe all the features of this complex process for many years. In addition, the X-ray method of examination allows one to establish control over the effect of various therapeutic measures, especially hormonal drugs. The most convenient object for x-ray study of the rate of ossification are the hands with the distal parts of the forearms, since here the appearance of individual points of ossification and synostosis are distributed sequentially and evenly over a long period of time (13-18 years). A large number of works are devoted to the order, timing of ossification and synostosis of the skeleton. However, it has now been established that, thanks to acceleration processes, skeletal ossification occurs faster than 20-40 years ago. Despite this fact, manuals on anatomy, radiology, pediatrics, endocrinology, and forensic medicine provide information based on research from the 30s and 40s. The current use of these tables leads to erroneous conclusions. To determine bone age, one should take into account standards not only for skeletal ossification, but also for the size of the hand bones in the age aspect. Determining bone age using tables of ossification dates and sizes of the carpal bones, metacarpal bones and phalanges of the fingers makes it possible to obtain more reliable conclusions about the age of the subject. This should be especially remembered when determining bone age in forensic practice. Taking into account the above, we have developed tables of standards for the timing of ossification, the size of the bones of the hand and distal forearms, the development of epiphyseal cartilage and a number of indicators characterizing the processes of bone evolution at the present time. The results of a study of age-related changes in the hand skeleton in children and adolescents in Kyiv for the period 1969-1974 are presented. For this purpose, we studied 2675 radiographs of the hand bones and distal forearms in individuals aged from several days to 20 years. There were 1460 boys and young men, 1215 girls and boys. The obtained radiographs were grouped taking into account age-related physiology. Each age group consisted of 30-100 people. When processing the material, the fact of the presence or absence of a particular ossification point is taken into account, regardless of its size. As for synostosis, the age at which the cartilaginous layer between the metaphysis and the epiphysis disappears is taken into account. We have established the earliest and latest dates for the appearance of ossification points and the onset of synostosis. In addition, the “average” periods of ossification have been determined. The average period of ossification is considered when at least 50% of representatives of a certain age exhibit this phase of differentiation of the bones of the hand skeleton. To determine age, it is enough to determine the average period of ossification; in forensic practice, the earliest and latest periods of ossification are also taken into account. Correct determination of bone age and the presence of signs of growth disturbance requires appropriate radiograph technology. It is necessary to take x-rays of both hands, which will make it possible to identify the presence of such a pathological symptom of ossification as asymmetry. The hands should be placed on the cassette so that all phalanges of the fingers and bones of the wrist joint are captured on the radiograph. Both hands are placed on a cassette measuring 18x24 or 24x30 cm (depending on the age of the subject), palms down so that the axis of the middle finger is a continuation of the axis of the forearm. The misalignment of these axes significantly changes the angle of the wrist. The first finger should be in a 30° rotation position relative to the index finger. The central beam is directed to the intersection of the line connecting the heads of the third metacarpal bones of both hands with a vertical line drawn through the center of the cassette. The distance from the anode of the X-ray tube to the film should be 100 cm. From these radiographs, bone age can be determined, as well as the developmental features of the skeletal bones. The order of appearance of ossification points and synostosis were studied in detail by the Leningrad School of Radiologists (1936). In recent years, there has been an increase in the intensity of growth and a decrease in the average duration of individual phases of ossification. There is an acceleration of the rate of ossification by 0.5-3 years, compared to the data of 1936. This acceleration occurs unevenly and depends on the phase of ossification and the sex of the subject. The acceleration of ossification of the hand skeleton is in full accordance with the noted acceleration of physical and sexual development of children and adolescents. The rate of ossification is different at different periods of life. Some age periods are characterized by an increase in the intensity of ossification of the skeleton (the appearance of sesamoid bones in the first metacarpophalangeal joint), others - by a decrease in it (the appearance of the styloid process and the pisiform bone). The duration of individual phases of ossification in boys before synostosis in the first metacarpophalangeal joint is longer than in girls. Their total duration is 15.5 years for boys, 13 years for girls. This is 1.5-2 years faster than according to data from 1936. The phases of synostosis, starting from the distal phalanges and ending with the distal epiphysis of the radius, are longer in girls than in boys (3 and 2 years, respectively). The acceleration of ossification at different age periods occurs unevenly. Until the age of three, there is a slight acceleration in the rate of ossification (2-6 months) and only the triquetral bone appears in girls one year earlier than in boys. Before the appearance of the distal epiphysis ulna , which is determined one year earlier in girls, no acceleration of ossification is observed. The timing of the appearance of the styloid process and pisiform bone in boys is more constant; in girls, these bones appear one year earlier than in 1936. The stability of the appearance of these ossification points in boys was also noted in a study of Moscow children, Extremely! about the North, Poland. Sesamoid bones in the first metacarpophalangeal joint appear 1.5 years earlier in both boys and girls, compared to data from 1936. The next phase of development - the appearance of synostoses of the first metacarpal bone - is an indicator of the inclusion of the gonads in the work of the endocrine apparatus. This phase begins 1.5-2 years earlier. Further synostosis of the bones of the hand skeleton is significantly accelerated (by 2-3 years). Differentiation of the hand bones ends in boys at 18 years old, in girls at 16-17 years old (Table 1). It must be remembered that there is a certain order in the appearance of points of ossification and synostosis of the bones of the hand skeleton (Table 1). Some perversions of the order of ossification are acceptable. Thus, the lunate bone is often found before the appearance of the triquetrum, the trapezoid and scaphoid bones sometimes appear before the lunate, and the distal epiphysis of the ulna - before the trapezoid and scaphoid bones. Synostosis often occurs in the distal phalanges in the absence of synostosis in the first metacarpal bone. These changes should be regarded as pathological only in cases of other symptoms of impaired ossification and bone growth. Sex differences in the rate of ossification appear already from the first days of a child’s life, long before the inclusion of the gonads. Greater differentiation of skeletal bones in girls is observed throughout the entire period of ossification and is especially pronounced during puberty. For many years there was a point of view according to which the rate of ossification depends on nationality and climatic conditions. Many authors have pointed this out directly or indirectly. Currently, most scientists who have studied the processes of ossification in residents of various nations of the USSR, Poland, England, the USA, Africa, Australia, and Peru come to the conclusion that when assessing radiographic age it is not necessary to use local standards for the timing of ossification. A comparison of data on the ossification of the skeleton of the hand of different peoples shows that the order, timing of ossification and synostosis of the skeleton of the hand of representatives of different nationalities living in different climatic conditions are approximately the same. In healthy children and adolescents, bone age corresponds to the passport age. For various disorders, in order to determine the rate of ossification, in addition to bone age, other radiological indicators of the rate of ossification should be taken into account: ossification deficiency (DO) - the difference between passport and bone age (normally DO is zero; fluctuations of ±1 are allowed), ossification coefficient (OS) ) - radiographic age divided by the passport age (normally, EC is equal to one; fluctuations of ±0.2 are allowed). We have found that the CR indicator is the most reliable for assessing the severity of delayed ossification and growth. It can be recommended for the diagnosis and differential diagnosis of various growth disorders, as well as for monitoring the appropriateness and effectiveness of treating patients with hormonal drugs. How to determine radiographic age in cases where there is asymmetry or distortion of ossification? With asymmetry of ossification, the presence of an ossification point is taken into account, regardless of the fact that it is present on only one hand. For example: a boy has a triquetral bone on his right hand, but it is absent on his left; there are also ossification points that appear before the triquetral bone (see Table 1). The X-ray age according to the table for this boy corresponds to three years. In cases of ossification distortion, the sequence of appearance of ossification points is disrupted due to “jumping” over the row. In such cases, age is determined by the presence of later points of ossification and synostosis, without taking into account the absence of previous points of ossification. Accessory epiphyses and pseudoepiphyses of the metacarpal bones and phalanges of the fingers. During normal development, short tubular bones have one epiphysis or ossification point. In addition to the true epiphyses, there are additional psendoepiphyses. The presence of pseudoepiphyses is additional information for determining bone age. Table 1. Timing of ossification of the skeleton of the hand and distal forearm in children and adolescents of Kyiv (L.A. Perepust). Points of ossification and synostosis Capitate and hamate bones Distal epiphysis of the radius Epiphyses of the proximal phalanges and metacarpals Epiphyses of the middle and distal phalanges Proximal epiphysis of the thumb Triquetral bone Lunate bone Trapezoid bones Scaphoid bone Distal epiphysis of the ulna Styloid process of the ulna Pisiform bone Sesamo prominent bones in the metacarpal joint Synostosis in the first metacarpal bone Synostosis in the distal phalanges Synostosis in the main phalanges Synostosis in the middle phalanges Synostosis in the II-V metacarpal bones Synostosis of the distal epiphysis of the ulna Synostosis of the distal epiphysis of the radius The earliest period boy girl 20 days 20 days The latest period boy girl 7 months . 5 months Average lifespan boy girl 2 months. 1 month 4 months 3 months 2 years 1 year 7 months 6 months 8 months 6 months 3 years 2 years 1.5 years 1 year 9 months. 8 months 3 years 2 years 2 years 1 year 1 year 10 months. 4 years 3 years 2.5 years 1.5 years 1 year 1 year 3 years 4 years 5 years 1 year 1 year 2 years 2 years 4 years 6 years 6 years 7 years 7 years 9 years 4 years 5 years 6 years 6 years 8 years 3 years 4 years 5 years 6 years 7 years 2 years 3 years 4 years 5 years 6 years 7 years 6 years 12 years 11 years 10 years 8 years 8 years 10 years 7 years 9 years 13 years 15 years 11 years 13 years 12 years 13.5 years 9 years 11 years 13 years 12 years 18 years 16 years 15.5 years 13 years 14 years 12 years 18 years 16 years 16 years 14 years 14 years 12 years 19 years 17 years 17 years 15 years 14 years 12 years 19 years 17 years 17 years 16 years 14 years 12 years 19 years 17 years 17 years 16 years 16 years 13 years 19 years 18 years 18 years 16 years 16 years 13 years 19 years 18 years 18 years 16-17 years Table 1a . Average terms of ossification of the skeleton of the hand and distal forearm in children and adolescents of Kyiv (L.A. Perepust). Points of ossification and synostosis Boys Girls Capitate and hamate bones Distal epiphysis of the radius Epiphyses of the proximal phalanges and metacarpal bones 2 months. 7-12 months 1.5 years 1 month 6-12 months 1 year Epiphyses of the middle and distal phalanges Epiphysis of the thumb Triquetral bone Lunate bone Trapezoid and scaphoid bones Distal epiphysis of the ulna Styloid process Pisiform bone Sesamoid bones in 1 metacarpophalangeal joint Synostosis in 1 metacarpal bone Synostosis in the distal phalanges Synostosis in the proximal phalanges gah Synostoses in the middle phalanges Synostosis in the II-V metacarpal bones Synostosis of the distal epiphysis of the ulna Synostosis of the distal epiphysis of the radius 2 years 2.5 years 3 years 4 years 6 years 7 years 10 years 12 years 13.5 years 1 year 1.5 years 2 years 3 years 5 years 6 years 8 years 9 years 11 years 15.5 years 15-16 years 17 years 17 years 17 years 13 years 13-14 years 15 years 15 years 16 years 18 years 18 years 16 years 16-17 years Comparing the data from 1936 and our data, we are convinced that acceleration contributes to an earlier disappearance and a decrease in the frequency of occurrence of pseudoepiphyses. At the age of 1-10 years in boys and 1-9 years in girls, the presence of single pseudoepiphyses in the metacarpal bones (except for the first) is the norm. The presence of pseudoepiphyses in the first metacarpal bone is observed in boys under 16 and in girls under 14 years of age (Table 2). Most often, pseudoepiphyses are found in the I and II metacarpal bones, less often in the V and extremely rarely in the III and IV metacarpal bones. Pseudoepiphyses in two or more bones are rare in healthy children (5% and 1.5%). The presence of pseudoepiphyses over the age of 8-10 years should be regarded as a pathology. Pronounced pseudoepiphyses and the presence of multiple pseudoepiphyses have the same diagnostic value. The presence of pseudoepiphyses indicates inhibition of bone length growth and skeletal maturation. Table 2. Frequency of pseudoepiphyses in different age periods depending on gender (in percentage). Gender Age 1 year 1 year 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years Total VI metacarpal bone 3.6 4.3 23.3 23.1 40.0 42.9 42.3 36.4 41.5 22.0 23.5 20.4 11.7 4.2 1.5 1.8 17.7 Male In other bones 3.6 15.2 23.3 30, 8 40.0 39.3 42.3 31.8 12.2 20.3 9.8 8.1 1.5 12.2 Total In the first metacarpal bone Female In other bones Total 7.2 19.5 46.6 53, 9 80.0 82.2 84.6 68.2 53.7 42.3 33.3 28.5 11.7 4.2 3.0 1.8 29.9 8.1 25.6 13.0 37.0 39.3 52 .0 30.0 25.8 21.3 14.8 4.5 4.8 1.9 14.2 8.1 28.2 56.6 33.3 39.3 32.0 30.0 19.4 2.1 5.6 3.0 11.5 16.2 53.8 69.5 70.3 78.6 84.0 60.0 45.2 23.4 20.4 7.5 4.8 1.9 25.7 Dimensions of metacarpal bones and phalanges of the fingers Quantitative indicators of bone development are studied by measuring the size of the bones of the hand. The length of the metacarpals and phalanges is determined by measuring the distance between the most distant points at the distal and proximal ends of the bone. The width of the metacarpal bones is measured by the smallest diameter of the bone, in the same place the width of the medullary canal and compact layer is determined. Measurements should be made with a compass or colored ruler with an accuracy of 1 mm. The existing standards for the age sizes of the metacarpal bones and phalanges of the fingers for 1936 are outdated and should not be used. We have developed new modern standards for the sizes of short tubular bones of the hand (Table 3). Studying individual differences the sizes of the metacarpal bones and phalanges of the fingers can be used in different directions. Table 3. Metacarpal length in male children and adolescents. Metacarpal bones Age 1 2 3 4 5 m Id m Id m Id m Id m Id 1 year 17 15-19 27 24-30 24 21-30 23 20-26 21 18-23 2 years 3 years 4 years years 6 years 7 years 0 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years 20 years 19 23 24 28 30 31 34 34 37 39 39 ig 43 44 46 48 48 48 49 16-22 20 -26 21-28 25-31 28-31 29-33 31-36 32-36 34-40 36-42 36-42 38-46 39-48 41-48 43-49 45-51 45-52 45-53 45-53 31 37 39 44 46 49 53 55 56 58 59 62 63 68 70 72 72 73 73 28-34 33-41 35-43 41-47 43-50 46-52 49-58 50-59 50-62 52 -64 55-64 57-67 57-71 63-73 64-76 67-77 67-78 67-79 67-79 29 35 37 41 44 47 50 52 55 56 57 60 61 65 68 70 70 70 70 26- 32 31-39 34-40 36-46 41-47 45-48 46-54 49-56 50-59 51-61 51-64 55-64 56-67 60-70 62-74 66-74 66-74 66 -74 66-75 27 31 33 36 39 42 45 46 48 49 50 53 53 57 61 62 62 63 63 24-29 28-34 28-37 33-39 37-42 40-45 41-48 43-49 45- 51 45-53 46 55 49-58 49-61 53-62 55-66 57-67 59 68 59-68 59-68 24 28 29 33 36 37 40 40 43 45 45 48 50 53 56 57 57 57 57 21 - 26 24-31 26-32 30-37 33-38 34-40 37-44 37-44 38-47 42-49 42-49 44-52 46-53 49-57 52-60 53-60 53-61 53 -62 53-63 Table 4. Length of metacarpal bones in female children and adolescents. depth (cm) color structure build depth (cm) color structure build 0-65 dark brownish-gray blocky-silty-grained, below nutty-grainy on the surface fissured-loose 65-180 dark gray with a brownish-brown tint, transitional in dirty brown in the upper part lumpy-grainy-nutty, in the lower part nutty-lumpy dense Having the standards for the sizes of short tubular bones of the hand, you can obtain additional information about the age of the subject. This is of particular value in forensic medical examination, when the individual parts skeleton, it is necessary to establish the age and determine the identity of the subject. Data on the sizes of the short tubular bones of the hand make it possible to study the patterns of bone growth in the light of the problem of acceleration in normal and pathological conditions. The development of standards for the physical development of children is one of the necessary conditions for the proper organization of preventive monitoring of children. The effect of acceleration on the growth of the metacarpal bones and phalanges of the fingers is manifested by a significant increase in the length of these bones (but compared with the data of 1936) by 3-6 mm in girls and young women and by 4-8 mm in boys and young men. The size of the metacarpal bones up to 12 years of age is slightly larger in girls than in boys; at the age of 13, their sizes begin to equalize, and in subsequent years larger sizes are observed in boys. Compared to data from 1936. The alignment and crossover of bone sizes in boys and girls occurs 2 years earlier. Depending on the gender difference in the size of the metacarpal bones of the hand, three periods can be distinguished: 1st period - from one year to 12 years, when the gender difference is weakly expressed; 2nd period - from 13 to 14 years, when sexual differences are expressed and 3rd period - from 15 years and older, when sexual differences are most clearly expressed. The sizes of the proximal phalanges (I-IV) up to 12 years are larger in girls than in boys, V - up to 11 years. At the age of 13, these sizes level off and in subsequent years they are larger in boys. Starting from 15 years for proximal phalanges I-IV and from 13 years for V, the gender difference in size appears clearly. The middle phalanges (III-V) are larger in girls under 10 years old, 11-12 years old, the gender difference is clearly visible from 15 years old for the II-IV middle phalanges and from 17 years old for the V middle phalanx. Distal phalanges and more in girls up to 9-10 years old, gender differences are well expressed from 15-16 years old. It should be noted that sexual differences appear most clearly in bones that differ largest sizes (in the metacarpal bones and middle phalanges of the fingers). Age-related changes in hand proportions and the ratio of bone length to width. A characteristic feature of the human hand is its radiality (a significant excess of the length of the II metacarpal bone over the III and increased development of the I and II metacarpal bones). To determine the degree of relative development of radiality and ulnarity of the metacarpal bones, a number of indices are calculated. The study of these indices showed their small significance for diagnosing growth pathologies. The ratio of the proportions of the metacarpal bones was studied, taking the size of the first metacarpal bone as one. It should be noted that these ratios do not depend on gender. Determining the ratios of the metacarpal bones is more important for diagnosing growth pathology than determining the absolute dimensions of the metacarpal bones. Using these ratios, it is possible to determine the uniformity of growth of the metacarpal bones and determine which metacarpal bones are more retarded in growth, which are less, which makes it possible to identify the characteristic features of the growth of the metacarpal bones in pathology. To study the proportions of the hand, it is of interest to determine the metacarpal symptom (MC.S) and metacarpal index (MC.I). MCS, described for the first time in patients with Shereshevsky-Turner syndrome, also occurs in healthy people. Normally, a tangent line drawn to the heads of the V and IV metacarpal bones passes distal to the head of the III metacarpal bone. When the relationships between the metacarpal bones are disturbed and when the IV metacarpal bone is shortened, this line touches the head of the third metacarpal bone or crosses it, which is called the borderline and positive MCS, respectively. According to our data, positive MCS is four times more common in men than in women. Borderline MCS occurs with equal frequency in both men and women. To study the proportions of the hand, it is of interest to determine the metacarpal index (MCI) - the ratio of the length of the IV metacarpal bone to the length of the II metacarpal bone, multiplied by 100. The MCI does not depend on gender, increasing slightly with age. To assess the formation and morphological variability of the hand skeleton, it is proposed to determine the ratio of the length of the metacarpal bones and phalanges of the fingers to their width (an indicator of grace). For the metacarpal bones, this indicator varies depending on age and gender. It increases unevenly with age. In healthy children and adolescents, the length of the distal and proximal phalanges of the fourth finger is equal to the length of the fourth metacarpal bone ±2 mm, and the distal phalanx can be placed three times in the fourth metacarpal bone. In various diseases, a predominance of the phalanges over the metacarpal bones is observed; this disproportion is best detected in the IV metacarpal bone. We have developed tables of average sizes of phalanges width; nail tuberosity of the distal phalanx and the ratio of their length to width, as well as the ratio of the nail tuberosity to the width of the distal phalanx of the fourth finger. These data provide additional information for determining bone age and allow one to identify a number of symptoms valuable for diagnosing growth pathology. Dimensions of the carpal bones Studying the dimensions of the carpal bones allows us to obtain additional data to determine bone age, as well as to clarify the diagnosis various forms intersexism. The sizes of the capitate and hamate bones up to 9 years are larger in girls than in boys. Starting from the age of 10, their sizes begin to equalize, and from the age of 11, these sizes are larger in boys than in girls. For other carpal bones, their sizes are larger in girls up to 11 years of age; at 12 years of age, the sizes begin to equalize and, starting from the age of 13-14 years, there is a noticeable increase in these sizes in boys. Sex differences in the carpal bones are observed at certain age periods. For the capitate, hamate, lunate bones and epiphysis of the radius, their sizes differ significantly in boys and girls, starting from 13-14 years. For other carpal bones - from 15-16 years. The size of the styloid process, increasing with age, is slightly larger in boys and young men. A study of the effect of acceleration on the growth of the styloid process showed a significant increase in its size (compared to the data of 1936) in both men and women. The carpal angle or carpal angle is formed by the intersection of two lines, one of which touches the proximal edge of the scaphoid and lunate bones, and the other touches the triquetrum and lunate. We have established that the angle of the wrist does not depend on gender and age, and ranges from 121" to 137°, averaging 128.9 ±0.24. Structure of the bones of the hand A feature of the tubular bones on radiographs is the presence of a well-defined compact substance (cortical layer ) in the diaphyses surrounding the medullary canal. The bone consists of the cortex, spongy substance, medullary canal, epiphyseal and articular cartilage. The rate of bone formation and bone destruction can be judged by the thickness of the cortical layer and the medullary canal; the development of the cortical layer is also characterized by the degree of mineralization of the skeleton. the width of the compact layer, the bone marrow canal and the calculation of the compactness indicator is carried out on the second metacarpal bone. canal in boys from 3 to 4 mm and in girls from 2 to 4 mm. The width of the compact layer increases significantly with age, with a sex difference noted at age 8; eleven; 13; 16-20 years old. The width of the compact layer is slightly smaller in girls than in boys. At the age of 7 years, the width of the cortical layer doubles, and at 14 years it triples. The compact layer reaches its greatest width in girls aged 15-16 years; in boys, the thickening of the cortical layer continues until the age of 20. The compactness indicator - the ratio of the compact layer to the width of the metacarpal bone, depends significantly on age. Its increase is uneven; a significant increase was noted at the ages of 7 and 15 years in boys, 7 and 12 years in girls. A significant sex difference was established at age 1; 2; 5, 12-14 years. Development of epiphyseal cartilage or enchondral growth zone Longitudinal bone growth occurs primarily through epiphyseal growth. Radiographs show the cartilaginous zone of the epiphyseal cartilage in the form of a transverse strip of clearing and the zone of preliminary calcification, which is located on the border between the cartilaginous zone and the cancellous substance of the metaphysis of the bone in the form of a smooth dark narrow strip. In children of the first years of life, the zone of preliminary calcification is somewhat convex towards the epiphysis. With age, it gradually flattens, and during puberty it central department bends slightly towards the diaphysis. The cartilaginous zone and the zone of preliminary calcification are widest in the first 5 years of a child’s life. With age, these zones gradually become thinner, and in the synostosis phase they completely disappear. Synostosis indicates cessation of enchondral growth. In place of the former growth zone, a transverse intense stripe, caused by the density of bone tissue, remains for 1–2 years. X-ray signs of impaired growth and ossification Impaired rate of ossification is one of the symptoms of growth pathology. A change in the rate of ossification is usually combined with other radiological signs of growth pathology, which should always be taken into account when determining age from radiographs of the hand bones. Signs of pathological ossification are: 1) distortion of the rate of ossification, 2) asymmetry of ossification, 3) distortion of the sequence of ossification and 4) change in the sources of ossification - the presence of pseudoepiphyses or accessory epiphyses. A change in the rate of ossification is manifested in acceleration or inhibition of ossification. The most pronounced inhibition of ossification is observed with myxedema and pituitary dwarfism (up to 12 years), the delay in ossification is somewhat less with spondylo-epiphyseal dysplasia. Itsenko-Cushing's disease, metabolic type adrenal tumors (up to 7 years). With Shereshevsky-Turner syndrome, cerebral dwarfism, adipose-genital dystrophy, inhibition of ossification up to 6 years. Delayed ossification is observed with disorders of sexual differentiation, eunuchoidism, pituitary gigantism, and diabetes mellitus. With chondrodysplasia, inhibition of ossification occurs during childhood. In the prepubertal period and puberty, ossification is normal or slightly accelerated. Delayed ossification is also observed in many somatic diseases ( bronchial asthma , cardiovascular diseases, kidney diseases, liver diseases, and various chronic infections). Inhibition of ossification was noted in renal rickets, cystine disease, vitamin deficiencies, and malnutrition. It should be noted that in these diseases the delay in ossification is less pronounced (up to 4 years). Acceleration of ossification was noted in tumors of the pineal gland, tumors of the adrenal glands of the virile and exchange-virile type, and some ovarian tumors (up to 7 years). With adrenogenital syndrome and premature sexual development, there is a pronounced acceleration of ossification (3-13 years), these patients often by the age of five years correspond in bone age to the age of a sexually mature subject. Acceleration of ossification is also observed in some brain tumors, diencephalic syndrome, and sometimes in cerebral dwarfism. A slight acceleration of ossification is observed in thyrotoxicosis (1-3 years). Asymmetry of ossification - the appearance of ossification points not at the same time on both hands. This anomaly of ossification is often observed in various endocrine disorders (myxedema, Itsenko-Cushing's disease, pituitary and cerebral dwarfism). Violation of the order of ossification or violation of the correct sequence of appearance of ossification nuclei. This symptom is observed in Itsenko-Cushing's disease and various forms of dwarfism. Changes in the sources of ossification - the presence of pseudoepiphyses of accessory epiphyses. This anomaly often occurs in various forms of growth retardation, in Kaship-Beck disease. It should be taken into account only in cases where this anomaly occurs over the age of 10 years and the presence of multiple pseudoepiphyses. When determining bone age, it is also necessary to take into account other symptoms of impaired bone growth in length. These include changes in the metaepiphyseal zones (determination of pathological niches of the metaphyses, outgrowths of the epiphyses towards the metaphyses and synostoses in the form of bridges), the presence of transverse strands of the metaphyses. X-ray signs of bone growth disorders also include disproportion in the growth of individual bones of the hand (shortening of the IV and V fingers, predominance of the phalanges over the metacarpal bones, thinning of individual bones, increased nail tuberosity of the distal phalanges), changes in the metaphyses (narrowing or widening), changes in the epiphyses (flattening , enlargement, deformation), an increase or decrease in the angle of the wrist, the presence of concretion of the carpal bones (fusion of individual bones), which is observed in Shereshevsky-Turner syndrome and some forms of intersexism. One of the symptoms of growth pathology is the presence of a metacarpal symptom. When determining age from radiographs of the hands for scientific purposes, for the diagnosis and differential diagnosis of certain diseases, as well as for school doctors and pediatricians, it is sufficient to use the average indicators of the timing of ossification and the size of the bones of the hand. During a forensic medical examination, more reliable conclusions about the age of the subject can be obtained by taking into account possible variations in the timing of ossification, the size of the hand bones, their ratios and indicators. Sometimes it is necessary to determine the bone age for each bone separately and derive the average age from the data obtained after measuring the bones of the hand.