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The first page of the digital atlas displays two distinctive icons for selection of male or female images.

Fig. 17. Schematic diagram depicting the main features of the software and the simplified user interface that facilitates navigation between chronological hand radiographs to select a matching image corresponding to the patient image being assessed. The software also provides a simple way to obtain the estimated standard deviation from normal

Fig. 17. Schematic diagram depicting the main features of the software and the simplified user interface that facilitates navigation between chronological hand radiographs to select a matching image corresponding to the patient image being assessed. The software also provides a simple way to obtain the estimated standard deviation from normal

The most practical way of using the software to estimate bone maturity from a hand radiograph is as follows:

1) First, locate the closest matching image to the hand and wrist radiograph to be interpreted. The reviewer should primarily focus on the centers that best characterize skeletal development for the subject's chronological age. As stated previously, during infancy and in toddlers, the presence or absence of certain carpal or epiphyseal ossification centers will provide the most useful clues. Throughout childhood, the size of the epiphyses in relation to the metaphyses in the distal and middle phalanges will be the most helpful markers of skeletal maturity. In younger teenagers, the degree of epiphyseal fusion in the phalanges, and in older teenagers, the degree of epiphyseal fusion in the radius and ulna, are the strongest indicators of skeletal maturity. If the radiograph being evaluated does not exactly correspond to a specific age standard, but falls between two adjacent references, the bone age should also be interpreted as an intermediate between the two standards. Occasionally, there may also be a disparity between the skeletal maturation of the phalanges and carpal bones. In such cases, two different estimated ages can be reported.

2) Once the matching image is identified, press the "SD" button on the lower right corner of the screen.

3) A calculation page will then appear indicating the bone age of the image selected at the top of the screen. Enter the chronological age of the subject being evaluated and press "Calculate". The program will provide the offset of the bone age and chronological age and calculate the standard deviation from the normal population. If needed, the process maybe repeated for separate assessments of the phalangeal and carpal bones.

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Fig. 18. Illustration ofthetwo-step process neededfor bone age assessment usingthe digital atlas

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