WEBVTT 00:00:00.000 --> 00:00:02.339 Welcome to the Deep Dive. Today we're getting 00:00:02.339 --> 00:00:04.740 into something that seems, well, quite simple 00:00:04.740 --> 00:00:06.940 on the surface, how bones grow, specifically 00:00:06.940 --> 00:00:09.720 a child's wrist. But, you know, for something 00:00:09.720 --> 00:00:11.960 so fundamental, it's actually quite surprising 00:00:11.960 --> 00:00:15.880 there's been this, um... real lack of clear age 00:00:15.880 --> 00:00:18.100 -specific guidelines for what's normal. So our 00:00:18.100 --> 00:00:20.460 mission today is to explore some really groundbreaking 00:00:20.460 --> 00:00:23.079 research that's managed to map out normal risk 00:00:23.079 --> 00:00:25.699 development in children. Think of it as a vital 00:00:25.699 --> 00:00:28.280 compass for doctors and surgeons. It's really 00:00:28.280 --> 00:00:30.219 a shortcut to getting properly informed on a 00:00:30.219 --> 00:00:32.780 critical orthopedic topic because understanding 00:00:32.780 --> 00:00:34.359 what's normal, well, that's always the first 00:00:34.359 --> 00:00:36.560 step, isn't it? It's absolutely key for spotting 00:00:36.560 --> 00:00:38.399 problems early and treating them effectively, 00:00:38.820 --> 00:00:40.560 especially when you think about common things 00:00:40.560 --> 00:00:42.840 like fractures in kids or perhaps more complex 00:00:42.840 --> 00:00:45.119 congenital. conditions. And we're incredibly 00:00:45.119 --> 00:00:47.700 fortunate today. We have one of the leading minds 00:00:47.700 --> 00:00:49.340 behind this pivotal research right here with 00:00:49.340 --> 00:00:52.039 us. He's a true pioneer in this area of orthopedic 00:00:52.039 --> 00:00:54.920 surgery. A very warm welcome to Professor Mohi 00:00:54.920 --> 00:00:57.479 Imam, Prof Mohi Imam. Thank you. It's a real 00:00:57.479 --> 00:00:59.140 pleasure to be here and talk about this work. 00:00:59.600 --> 00:01:01.719 Great. Okay. Let's dive right in then. Professor, 00:01:01.759 --> 00:01:04.319 perhaps you could start by explaining why understanding 00:01:04.319 --> 00:01:06.340 this normal development pathway in children's 00:01:06.340 --> 00:01:08.819 wrists is just so important for conditions. It 00:01:08.819 --> 00:01:10.819 sounds basic, but clearly it wasn't straightforward. 00:01:11.400 --> 00:01:14.030 Prof Mohi Imam. Well, it's fundamentally important. 00:01:14.209 --> 00:01:16.269 And the numbers, actually, they really highlight 00:01:16.269 --> 00:01:18.629 why. Wrist fractures, we're talking specifically 00:01:18.629 --> 00:01:20.510 about the distal radius, that's the big forearm 00:01:20.510 --> 00:01:23.010 bone near the wrist. And the carpal bones, the 00:01:23.010 --> 00:01:25.189 small ones in the wrist itself, they're incredibly 00:01:25.189 --> 00:01:27.930 common in children. Prof. Moimam, they account 00:01:27.930 --> 00:01:30.590 for roughly about a quarter of all fractures 00:01:30.590 --> 00:01:33.609 in pediatrics. And what's also quite concerning 00:01:33.609 --> 00:01:36.370 is that the incidence, the rate, of these injuries 00:01:36.370 --> 00:01:38.569 seems to be on the rise. So it's a growing public 00:01:38.569 --> 00:01:41.730 health issue. A quarter. That's a huge proportion, 00:01:41.969 --> 00:01:44.090 Crofmo Eumum. It is. And it's not just injuries, 00:01:44.129 --> 00:01:46.150 not just trauma. We also deal quite frequently 00:01:46.150 --> 00:01:49.629 with various other conditions. Congenital malformations, 00:01:49.689 --> 00:01:51.989 for example, that can significantly impair the 00:01:51.989 --> 00:01:53.769 natural growth and development of those forearm 00:01:53.769 --> 00:01:55.829 bones, the radius and ulna, and the carpal bones 00:01:55.829 --> 00:01:58.310 too, right through childhood and adolescence, 00:01:58.450 --> 00:02:01.620 Crofmo Eumum. So... without having a really precise 00:02:01.620 --> 00:02:04.159 age -specific picture of what normal actually 00:02:04.159 --> 00:02:06.920 looks like at each stage, managing these conditions 00:02:06.920 --> 00:02:10.539 becomes, well, incredibly complex, often relying 00:02:10.539 --> 00:02:13.039 more on, shall we say, educated guesswork than 00:02:13.039 --> 00:02:16.099 hard data. It's a high volume of cases covering 00:02:16.099 --> 00:02:18.139 everything from playground falls to perhaps more 00:02:18.139 --> 00:02:20.500 complex developmental issues. And you mentioned 00:02:20.500 --> 00:02:22.539 this knowledge gap. Can you unpack that a bit? 00:02:22.680 --> 00:02:24.919 What exactly was missing historically? Why was 00:02:24.919 --> 00:02:29.319 it so hard to get this data for kids? Exactly. 00:02:30.699 --> 00:02:32.680 The core challenge historically was that the 00:02:32.680 --> 00:02:35.080 medical literature just lacked standardized measurements. 00:02:35.280 --> 00:02:37.520 There weren't precise radiological indices specifically 00:02:37.520 --> 00:02:39.719 designed for children's wrists, Prophemo imam. 00:02:40.039 --> 00:02:42.599 This meant clinicians Well, they often had little 00:02:42.599 --> 00:02:44.979 choice but to fall back on adult reference values. 00:02:45.219 --> 00:02:46.979 And that's obviously problematic, because adult 00:02:46.979 --> 00:02:48.639 bones are fully formed, presumably, Prof. Mari 00:02:48.639 --> 00:02:51.419 Mimmo. Precisely. Those previously known adult 00:02:51.419 --> 00:02:53.719 values for these anatomical parameters, they're 00:02:53.719 --> 00:02:55.319 often quite far from accurate when you apply 00:02:55.319 --> 00:02:57.219 them to a growing child. And the main reason 00:02:57.219 --> 00:03:00.319 for that is because getting accurate, reliable 00:03:00.319 --> 00:03:02.199 measurements is inherently difficult in very 00:03:02.199 --> 00:03:05.159 young children. Prof mo imam. It's down to the 00:03:05.159 --> 00:03:07.680 developing ossification centers. These are the 00:03:07.680 --> 00:03:09.400 parts of the bone that are still cartilage, still 00:03:09.400 --> 00:03:11.560 hardening into bone. They just aren't consistently 00:03:11.560 --> 00:03:14.680 visible or fully formed on a standard x -ray 00:03:14.680 --> 00:03:17.000 in the same way they are in adults. I see. So 00:03:17.000 --> 00:03:18.939 you're trying to measure something that isn't 00:03:18.939 --> 00:03:23.919 fully there yet on the image. Prof mo imam. In 00:03:23.919 --> 00:03:28.020 essence, yes. It's like trying to restore a painting 00:03:28.020 --> 00:03:29.860 without the original blueprint. You're making 00:03:29.860 --> 00:03:31.699 your best estimate. And that's where this research 00:03:31.699 --> 00:03:33.840 really comes in, profmoemom. What's fascinating 00:03:33.840 --> 00:03:36.060 here, and what we really wanted to address, is 00:03:36.060 --> 00:03:38.479 that without that clear template of normal growth 00:03:38.479 --> 00:03:40.699 stage by stage, it's genuinely like navigating 00:03:40.699 --> 00:03:42.759 in the dark for orthopedic pediatric surgeons, 00:03:42.939 --> 00:03:45.979 for hand surgeons, profmoemom. It becomes incredibly 00:03:45.979 --> 00:03:47.860 challenging to confidently differentiate between 00:03:47.860 --> 00:03:49.919 what's just normal physiological growth variation 00:03:49.919 --> 00:03:52.199 and what's an actual pathological deviation that 00:03:52.199 --> 00:03:54.240 needs treatment. This research provides that 00:03:54.240 --> 00:03:56.860 much needed map effectively. It shines a light. 00:03:57.159 --> 00:03:59.219 That's a powerful analogy navigating in the dark. 00:03:59.319 --> 00:04:02.159 It really highlights the clinical need. So faced 00:04:02.159 --> 00:04:04.139 with this gap, what were the specific goals? 00:04:04.240 --> 00:04:06.199 What did this extensive research actually set 00:04:06.199 --> 00:04:09.069 out to achieve? Prof. Mo Imam. Well, given that 00:04:09.069 --> 00:04:11.009 critical need, we designed the study with two 00:04:11.009 --> 00:04:14.150 very clear interlinked goals. The first was to 00:04:14.150 --> 00:04:16.810 identify, carefully considering the natural ossification 00:04:16.810 --> 00:04:19.170 pattern, precisely when it becomes valid and 00:04:19.170 --> 00:04:21.389 reliable to measure 10 specific radiographic 00:04:21.389 --> 00:04:24.189 parameters of a growing wrist. Prof. Mo Imam. 00:04:24.410 --> 00:04:27.009 Using a reliable standardized method, of course, 00:04:27.350 --> 00:04:29.370 this directly tackles that issue of the varying 00:04:29.370 --> 00:04:31.829 ossification stages we just talked about. Essentially 00:04:31.829 --> 00:04:33.870 pinning down at what age you can actually see 00:04:33.870 --> 00:04:36.050 and measure each feature accurately and consistently 00:04:36.050 --> 00:04:38.970 on a standard x -ray. Finding the window of measurability, 00:04:39.009 --> 00:04:41.389 if you like, right? So step one is figuring out 00:04:41.389 --> 00:04:42.970 when you can actually measure things reliably. 00:04:43.329 --> 00:04:46.250 Prof Mo Imam, exactly. And then secondly, and 00:04:46.250 --> 00:04:48.550 just as importantly, we aim to establish yearly 00:04:48.550 --> 00:04:51.189 -based normal reference values for these 10 measurements 00:04:51.189 --> 00:04:53.889 for both boys and girls right across that development. 00:04:53.769 --> 00:04:57.230 mental span from age 1 to 16, Prof Mo Imam. The 00:04:57.230 --> 00:04:59.769 idea was to provide an indispensable evidence 00:04:59.769 --> 00:05:02.250 -based guide for all clinicians involved in treating 00:05:02.250 --> 00:05:04.290 children with risk problems, be it fractures 00:05:04.290 --> 00:05:08.089 or other pathologies. Prof Mo Imam. If you connect 00:05:08.089 --> 00:05:10.470 this to the bigger picture, I mean, these goals 00:05:10.470 --> 00:05:12.709 are fundamental. They empower clinicians to make 00:05:12.709 --> 00:05:14.870 much more informed, much more precise decisions. 00:05:15.209 --> 00:05:17.189 Whether that's planning the best way to fix a 00:05:17.189 --> 00:05:19.709 fracture or diagnosing a subtle developmental 00:05:19.709 --> 00:05:22.949 issue accurately, it shifts us away from guesswork, 00:05:23.350 --> 00:05:25.810 often based on adult norms, towards precise, 00:05:26.089 --> 00:05:28.750 age -specific, evidence -based pediatric care. 00:05:29.360 --> 00:05:31.899 That sounds incredibly thorough. And you mentioned 00:05:31.899 --> 00:05:33.779 it was extensive research. This wasn't just looking 00:05:33.779 --> 00:05:36.199 at a few x -rays, was it? Can you give us a sense 00:05:36.199 --> 00:05:38.620 of the scale and the methodological rigor involved? 00:05:38.680 --> 00:05:40.399 Because that's what gives the findings their 00:05:40.399 --> 00:05:43.000 weight, isn't it, Prof. Moriamum? Absolutely. 00:05:43.360 --> 00:05:46.819 The scale was, well, it was significant. And 00:05:46.819 --> 00:05:49.160 the methodology had to be meticulous to ensure 00:05:49.160 --> 00:05:51.620 the findings were robust. We conducted what's 00:05:51.620 --> 00:05:53.740 called a retrospective multi -center analysis. 00:05:54.409 --> 00:05:56.790 profmoemum. That means we gather data from several 00:05:56.790 --> 00:05:59.069 different hospitals or clinical centers. This 00:05:59.069 --> 00:06:01.430 automatically helps make the findings more generalizable, 00:06:01.649 --> 00:06:03.329 more applicable across different settings. So 00:06:03.329 --> 00:06:06.730 not just one hospital's patient group, profmoemum. 00:06:07.629 --> 00:06:10.269 Correct. The study analyzed radiographs x -rays 00:06:10.269 --> 00:06:13.550 from 896 children. Specifically, we looked at 00:06:13.550 --> 00:06:15.889 896 posterior anterior views, that's the front 00:06:15.889 --> 00:06:19.639 to back view, and 896 lateral or side views. 00:06:20.180 --> 00:06:22.279 Crucially, all these children had normal, healthy 00:06:22.279 --> 00:06:25.500 wrists, prof mo imam. And this data wasn't elected 00:06:25.500 --> 00:06:27.600 over a short period, it spanned two full decades, 00:06:27.980 --> 00:06:30.839 from January 1996 right up until April 2016. 00:06:31.420 --> 00:06:33.639 That long timeframe was quite deliberate. It 00:06:33.639 --> 00:06:35.680 allowed us to capture a really wide and representative 00:06:35.680 --> 00:06:37.959 range of developmental stages and natural variations 00:06:37.959 --> 00:06:40.399 over time. Two decades worth of data, that's 00:06:40.399 --> 00:06:42.120 quite something. And how did you group the children? 00:06:42.970 --> 00:06:44.910 Prophemo imam. To make sure we had a good understanding 00:06:44.910 --> 00:06:46.850 across the whole growth period, the children 00:06:46.850 --> 00:06:49.110 were meticulously stratified into 16 distinct 00:06:49.110 --> 00:06:51.470 yearly age groups. So from age 1, age 2, all 00:06:51.470 --> 00:06:53.850 the way up to age 16. Prophemo imam. And within 00:06:53.850 --> 00:06:55.430 each S group, they were further divided by sex. 00:06:55.529 --> 00:06:58.589 We had 471 males and 425 females. So a pretty 00:06:58.589 --> 00:07:00.930 even split. And importantly, each single age 00:07:00.930 --> 00:07:03.149 group included a minimum of 50 children. 50 per 00:07:03.149 --> 00:07:05.790 group. Why that number specifically? Prophemo 00:07:05.790 --> 00:07:09.110 imam. That minimum number wasn't arbitrary. It 00:07:09.110 --> 00:07:11.269 came from a power analysis we did before even 00:07:11.269 --> 00:07:13.610 starting the main data collection. It ensured 00:07:13.610 --> 00:07:15.930 we had enough statistical power within each age 00:07:15.930 --> 00:07:18.149 bracket to detect differences that were not just 00:07:18.149 --> 00:07:20.290 statistically significant but also clinically 00:07:20.290 --> 00:07:23.050 meaningful. That makes sense. And I imagine defining 00:07:23.050 --> 00:07:25.170 normal for inclusion must have been incredibly 00:07:25.170 --> 00:07:27.509 strict for a study like this. How did you ensure 00:07:27.509 --> 00:07:29.709 you were really looking at healthy risks? Prof. 00:07:29.889 --> 00:07:32.970 Moimam, oh, absolutely rigorous. We had a very 00:07:32.970 --> 00:07:35.769 strict inclusion and exclusion process. Firstly, 00:07:35.949 --> 00:07:37.730 only x -rays that had been officially reported 00:07:37.730 --> 00:07:40.100 as normal by a specialist radiologist were even 00:07:40.100 --> 00:07:43.839 considered. Profmoimom. But we didn't stop there. 00:07:44.160 --> 00:07:46.279 These normal images then underwent a second, 00:07:46.399 --> 00:07:49.060 independent check by two experienced orthopedic 00:07:49.060 --> 00:07:51.600 investigators, myself included. This two -stage 00:07:51.600 --> 00:07:53.439 process meant we could systematically filter 00:07:53.439 --> 00:07:55.620 out any images showing obvious fractures, of 00:07:55.620 --> 00:07:58.360 course, but also any subtle abnormalities or 00:07:58.360 --> 00:08:00.319 even minor technical errors in how the x -ray 00:08:00.319 --> 00:08:02.459 was taken that could affect measurements. So 00:08:02.459 --> 00:08:04.879 double -checking everything. Profmoimom. And 00:08:04.879 --> 00:08:07.420 we also excluded children if they had any relevant 00:08:07.370 --> 00:08:09.910 medical history, things like congenital problems, 00:08:10.810 --> 00:08:13.170 systemic diseases that affect growth, or even 00:08:13.170 --> 00:08:15.629 previous fractures in that wrist, anything that 00:08:15.629 --> 00:08:17.850 could potentially skew the growth pattern away 00:08:17.850 --> 00:08:21.720 from normal. Prof mo imam. This focus on normal 00:08:21.720 --> 00:08:23.939 is just so critical, you simply can't define 00:08:23.939 --> 00:08:26.399 what's abnormal without a crystal clear robust 00:08:26.399 --> 00:08:28.879 baseline of what normal development looks like 00:08:28.879 --> 00:08:32.320 at every single age. Prof mo imam. The sheer 00:08:32.320 --> 00:08:34.539 number of children involved, combined with this 00:08:34.539 --> 00:08:36.559 very careful selection and double validation 00:08:36.559 --> 00:08:39.240 process, gave us that highly robust baseline. 00:08:39.340 --> 00:08:41.720 It really is the foundation upon which all the 00:08:41.720 --> 00:08:43.899 subsequent findings are built. Getting that right 00:08:43.899 --> 00:08:45.879 was paramount. I can tell you, sifting through 00:08:45.879 --> 00:08:48.419 thousands upon thousands of images, cross -referencing 00:08:48.419 --> 00:08:50.700 clinical histories, it was a huge undertaking, 00:08:50.820 --> 00:08:52.919 but absolutely necessary. That level of scrutiny 00:08:52.919 --> 00:08:54.899 is really impressive. It certainly builds confidence 00:08:54.899 --> 00:08:58.120 in the baseline. So once you had this vast, carefully 00:08:58.120 --> 00:09:00.480 curated dataset of normal wrists, what were the 00:09:00.480 --> 00:09:02.220 specific things you were measuring? These 10 00:09:02.220 --> 00:09:05.120 key radiographic parameters, could you walk us 00:09:05.120 --> 00:09:07.500 through them? What does each one tell you? These 00:09:07.500 --> 00:09:09.600 10 parameters, when taken together, they give 00:09:09.600 --> 00:09:12.100 us a very comprehensive geometric profile of 00:09:12.100 --> 00:09:15.120 the developing wrist. We measured them meticulously, 00:09:15.279 --> 00:09:17.600 but always dependent on the wrist's ossification 00:09:17.600 --> 00:09:20.200 pattern. meaning only when that specific feature 00:09:20.200 --> 00:09:22.480 was clearly visible and reliably measurable on 00:09:22.480 --> 00:09:25.639 the x -ray for that age group. Prophmo imam. 00:09:26.250 --> 00:09:28.769 Okay, so first we looked at ulnar variance. This 00:09:28.769 --> 00:09:30.330 measures the difference in length between the 00:09:30.330 --> 00:09:32.870 two forearm bones, the radius and ulna, right 00:09:32.870 --> 00:09:35.269 at the wrist joint. It's measured as the perpendicular 00:09:35.269 --> 00:09:37.190 distance between their end lines, essentially 00:09:37.190 --> 00:09:39.549 telling us if the ulna is shorter, longer, or 00:09:39.549 --> 00:09:41.409 the same length as the radius at that point. 00:09:41.789 --> 00:09:43.970 Important for load distribution, how they line 00:09:43.970 --> 00:09:46.429 up. Right. Prophemol imam, exactly. Then radial 00:09:46.429 --> 00:09:48.129 height. This is the height of the radius bone 00:09:48.129 --> 00:09:50.029 at the wrist end, measured from its main shaft 00:09:50.029 --> 00:09:52.830 line up to the tip of the radial styloid, the 00:09:52.830 --> 00:09:55.190 bony prominence on the thumb side. It relates 00:09:55.190 --> 00:09:57.529 to the space available for the carpal bones. 00:09:57.850 --> 00:10:01.070 Prophmo Imum. Next is radial inclination. This 00:10:01.070 --> 00:10:03.409 is an angle. It measures the sideways tilt of 00:10:03.409 --> 00:10:04.990 the end surface of the radio. Think of it like 00:10:04.990 --> 00:10:06.629 the slope on the end of the radius where the 00:10:06.629 --> 00:10:08.769 wrist bones sit. It's crucial for how the wrist 00:10:08.769 --> 00:10:12.230 moves side to side, like a ramp. Prophmo Imum. 00:10:12.470 --> 00:10:16.210 Sort of, yes. Then the radial carpal angle. Another 00:10:16.210 --> 00:10:18.169 angle, this one assesses the overall alignment 00:10:18.169 --> 00:10:20.389 of that first row of carpal bones relative to 00:10:20.389 --> 00:10:22.570 the radius. It gives an indication of how well 00:10:22.570 --> 00:10:25.909 the hand is seated on the forearm. prof mo imam. 00:10:26.449 --> 00:10:28.529 Moving to the carpal bones themselves, we measured 00:10:28.529 --> 00:10:30.490 carpal height. This is the overall height of 00:10:30.490 --> 00:10:32.470 that block of small carpal bones measured along 00:10:32.470 --> 00:10:35.009 the line of third metacarpal, the long bone in 00:10:35.009 --> 00:10:37.049 the hand leading to the middle finger. It tells 00:10:37.049 --> 00:10:39.230 us about the compactness or potential collapse 00:10:39.230 --> 00:10:42.269 of the carpus, perfmore imam. And related to 00:10:42.269 --> 00:10:44.149 that is the carpal ratio. This simply compares 00:10:44.149 --> 00:10:46.190 the carpal height to the length of that third 00:10:46.190 --> 00:10:48.649 metacarpal. It gives us a proportional measure, 00:10:48.649 --> 00:10:51.129 which is useful because it adjusts for the child's 00:10:51.129 --> 00:10:53.330 overall hand size. Okay, so those are mostly 00:10:53.330 --> 00:10:55.919 from the front on view, perfmore imam. Those 00:10:55.919 --> 00:10:58.779 first six, yes, are primarily from the PA view. 00:10:59.600 --> 00:11:01.779 Then on the lateral, the side view, we assessed 00:11:01.779 --> 00:11:04.299 volar tilt, sometimes called palmar tilt. This 00:11:04.299 --> 00:11:06.159 measures the forward tilt of the end surface 00:11:06.159 --> 00:11:07.740 of the radius, so how much it slopes towards 00:11:07.740 --> 00:11:09.600 the palm side. Very important for wrist flexion 00:11:09.600 --> 00:11:12.000 and stability. Profmo imam. Then we looked at 00:11:12.000 --> 00:11:14.360 the relationship between two key carpal bones, 00:11:14.740 --> 00:11:17.419 the scaphoid and the lunate. The scapholunate 00:11:17.419 --> 00:11:19.440 angle measures the angle between the axes of 00:11:19.440 --> 00:11:22.299 these two bones. Changes here can indicate instability. 00:11:22.840 --> 00:11:25.639 Prophemo imam. Similarly, the capital lunate 00:11:25.639 --> 00:11:27.580 angle measures the angle between the lunate and 00:11:27.580 --> 00:11:29.879 the capitate, which is the large central carpal 00:11:29.879 --> 00:11:31.899 bone. Again, it's assessing the alignment within 00:11:31.899 --> 00:11:34.580 the carpus itself, Prophemo imam. And finally, 00:11:34.820 --> 00:11:36.980 the scaphelinate distance. This is simply the 00:11:36.980 --> 00:11:39.059 gap measured between the scaphoid and the lunate. 00:11:39.539 --> 00:11:42.100 In adults, a widening of this gap is a classic 00:11:42.100 --> 00:11:46.399 sign of a ligament tear. So you see, each parameter 00:11:46.399 --> 00:11:48.059 gives us a unique piece of the developmental 00:11:48.059 --> 00:11:51.059 puzzle alignment proportion angles. Together, 00:11:51.200 --> 00:11:53.100 they build that comprehensive geometric profile 00:11:53.100 --> 00:11:55.379 we needed. Vital for understanding both normal 00:11:55.379 --> 00:11:57.700 growth and spotting subtle problems. That is 00:11:57.700 --> 00:11:59.759 incredibly detailed. Ten different measurements 00:11:59.759 --> 00:12:02.559 across multiple centers over 20 years. Which 00:12:02.559 --> 00:12:04.740 brings me to the question of consistency. How 00:12:04.740 --> 00:12:06.559 could you be absolutely sure that these measurements 00:12:06.559 --> 00:12:08.860 were accurate and reliable? How did you ensure 00:12:08.860 --> 00:12:13.370 that precision? A critical question indeed. And 00:12:13.370 --> 00:12:17.090 ensuring reliability was a major focus. All the 00:12:17.090 --> 00:12:19.129 radiographs, regardless of when or where they 00:12:19.129 --> 00:12:21.549 were taken over that two -decade span, were rigorously 00:12:21.549 --> 00:12:24.470 checked for quality and adequacy. This was done 00:12:24.470 --> 00:12:27.129 first by a senior radiologist and then independently 00:12:27.129 --> 00:12:29.470 by the two orthopedic investigators involved, 00:12:29.950 --> 00:12:33.580 Prof. Mor Imam. we adhered to a very strict preferred 00:12:33.580 --> 00:12:36.519 imaging protocol. This meant consistent patient 00:12:36.519 --> 00:12:39.360 positioning was paramount. For example, the patient 00:12:39.360 --> 00:12:41.899 always had to be seated, forearm resting flat, 00:12:42.139 --> 00:12:44.000 specific hand and finger positioning for both 00:12:44.000 --> 00:12:46.940 the PA and lateral views. This standardization 00:12:46.940 --> 00:12:49.220 was absolutely key to minimizing variability 00:12:49.220 --> 00:12:51.440 right from the start. So the way the x -ray was 00:12:51.440 --> 00:12:53.759 taken was standardized as much as possible. Prof. 00:12:53.860 --> 00:12:57.080 Mo 'imam, exactly. But beyond that, we rigorously 00:12:57.080 --> 00:12:59.379 tested the reliability of the measurements themselves. 00:12:59.559 --> 00:13:02.100 We calculated what are known as interclass correlation 00:13:02.100 --> 00:13:04.940 coefficients, or ICCs. These statistical measures 00:13:04.940 --> 00:13:07.580 assess agreement. Prophemo imam. And our study 00:13:07.580 --> 00:13:09.980 demonstrated excellent reliability, with ICCs 00:13:09.980 --> 00:13:12.480 consistently above .85 for all 10 parameters. 00:13:12.919 --> 00:13:15.000 This covered both interobserver reliability, 00:13:15.100 --> 00:13:17.139 meaning the same person measuring the same x 00:13:17.139 --> 00:13:19.019 -ray at different times got consistent results, 00:13:19.299 --> 00:13:21.820 and interobserver reliability, meaning different 00:13:21.820 --> 00:13:24.379 people measuring the same x -ray also got consistent 00:13:24.379 --> 00:13:27.980 results. Above .85, that sounds very high. Prophemo 00:13:27.980 --> 00:13:31.250 imam. It is considered excellent in this context. 00:13:31.549 --> 00:13:33.990 This high level of consistency is absolutely 00:13:33.990 --> 00:13:37.230 vital for clinical usefulness. It means the reference 00:13:37.230 --> 00:13:39.970 values we've established are trustworthy. Clinicians 00:13:39.970 --> 00:13:41.850 in different hospitals using these guidelines 00:13:41.850 --> 00:13:43.730 can be confident they will arrive at similar 00:13:43.730 --> 00:13:45.970 reliable conclusions when assessing a child's 00:13:45.970 --> 00:13:48.570 wrist. It provides a shared objective standard 00:13:48.570 --> 00:13:51.070 that really does solidify the findings. Knowing 00:13:51.070 --> 00:13:53.250 the measurements are so reproducible gives immense 00:13:53.250 --> 00:13:56.009 confidence. Okay so professor we have the what 00:13:56.009 --> 00:13:58.110 and the how. Now for the really fascinating part 00:13:58.110 --> 00:14:01.590 the what did you find? Yeah. What did this incredibly 00:14:01.590 --> 00:14:04.009 detailed data actually reveal about the dynamic 00:14:04.009 --> 00:14:06.210 journey of a child's wrist as it grows and matures? 00:14:07.690 --> 00:14:09.330 Right, this is where the developmental picture 00:14:09.330 --> 00:14:12.190 really comes alive. We found very clear age milestones 00:14:12.190 --> 00:14:13.929 for when different parameters actually become 00:14:13.929 --> 00:14:16.129 reliably measurable on these standard x -rays. 00:14:16.509 --> 00:14:19.169 Profmo imam. For instance, four key measurements, 00:14:19.450 --> 00:14:21.690 ulnar variance, radial height, carpal height, 00:14:21.809 --> 00:14:24.549 and the carpal ratio, these were all consistently 00:14:24.549 --> 00:14:26.570 definable and measurable right from the first 00:14:26.570 --> 00:14:28.750 year of life. That's quite significant because 00:14:28.750 --> 00:14:30.549 it means cornitions can start assessing these 00:14:30.549 --> 00:14:33.250 fundamental relationships very early on using 00:14:33.250 --> 00:14:35.570 objective data. So even in a one -year -old, 00:14:35.590 --> 00:14:38.549 you can reliably measure those four things. Yes, 00:14:39.669 --> 00:14:42.200 with the standardized methods we used. Then, 00:14:42.259 --> 00:14:44.679 as children get a bit older, more features become 00:14:44.679 --> 00:14:46.940 clear enough to major accurately. From around 00:14:46.940 --> 00:14:50.159 age 4, radial inclination, the radiocarpal angle, 00:14:50.240 --> 00:14:52.539 and the capital lunet angle became reliably measurable. 00:14:52.879 --> 00:14:55.320 Prof mo imam. This timing makes sense biologically 00:14:55.320 --> 00:14:56.960 because their accurate assessment really depends 00:14:56.960 --> 00:14:59.100 on the epithesis, the end part of the bone being 00:14:59.100 --> 00:15:01.279 sufficiently calcified, hardened into bone, to 00:15:01.279 --> 00:15:03.860 show up clearly on the x -ray. Before age 4, 00:15:04.000 --> 00:15:06.159 these areas are mostly cartilage, still developing 00:15:06.159 --> 00:15:09.120 essentially. Prof mo imam, precisely. Then, a 00:15:09.120 --> 00:15:10.909 bit later, from age 6 onwards, we found that 00:15:10.909 --> 00:15:13.309 the scaphalunid angle and the scaphalunid distance 00:15:13.309 --> 00:15:15.629 could only be reliably measured. This timing 00:15:15.629 --> 00:15:18.450 correlates directly with when the ossific centers 00:15:18.450 --> 00:15:21.090 of the lunate and scaphoid bones themselves typically 00:15:21.090 --> 00:15:23.529 appear as visible bone, usually around ages four 00:15:23.529 --> 00:15:25.970 and five respectively. So you need both bones 00:15:25.970 --> 00:15:28.529 to be sufficiently ossified to measure the relationship 00:15:28.529 --> 00:15:30.909 between them accurately. Okay, so different timings 00:15:30.909 --> 00:15:32.690 for different measurements based on when the 00:15:32.690 --> 00:15:34.809 bones actually develop enough to be seen clearly. 00:15:35.370 --> 00:15:38.470 Prophmo imam, exactly. And what a final example, 00:15:38.610 --> 00:15:41.009 the palmar tilt or voller tilt measured on the 00:15:41.009 --> 00:15:43.470 side view. We found this wasn't really developed 00:15:43.470 --> 00:15:46.009 or consistently measurable until about age 11. 00:15:46.360 --> 00:15:49.179 After that point, it started to gradually increase. 00:15:49.659 --> 00:15:51.580 This relies on the development of the distal 00:15:51.580 --> 00:15:53.659 radius's voller inclination, which typically 00:15:53.659 --> 00:15:57.159 occurs around age 10, so it really underscores 00:15:57.159 --> 00:15:59.279 the dynamic nature of growth. You can't just 00:15:59.279 --> 00:16:01.440 apply one standard measurement technique across 00:16:01.440 --> 00:16:04.840 all ages. Our findings pin down precisely when 00:16:04.840 --> 00:16:06.919 these different parts of the wrist become sufficiently 00:16:06.919 --> 00:16:09.440 ossified and geometrically stable enough for 00:16:09.440 --> 00:16:11.559 accurate radiographic assessment. That's such 00:16:11.559 --> 00:16:13.379 a crucial point. It's not just what you measure, 00:16:13.840 --> 00:16:16.049 but when you can measure it reliably. Beyond 00:16:16.049 --> 00:16:18.029 that timing, what were the most striking growth 00:16:18.029 --> 00:16:20.309 trends or patterns you observed? How did these 00:16:20.309 --> 00:16:22.230 parameters change as children got older? Any 00:16:22.230 --> 00:16:25.710 surprises? Profmo imam. Yes, several really interesting 00:16:25.710 --> 00:16:27.389 clinically important patterns emerged. Let's 00:16:27.389 --> 00:16:29.549 take ulnar variance again. We confirmed a clear 00:16:29.549 --> 00:16:32.850 predominance of what we call ulna minus variance 00:16:32.850 --> 00:16:34.409 in children throughout most of their growth, 00:16:34.509 --> 00:16:36.710 meaning the ulna is shorter than the radius of 00:16:36.710 --> 00:16:39.870 the wrist. Profmo imam. Correct. On average. 00:16:40.570 --> 00:16:42.769 And what was fascinating was that this characteristic 00:16:42.960 --> 00:16:45.919 remained remarkably stable. It didn't consistently 00:16:45.919 --> 00:16:48.259 change from birth right up until about age 14. 00:16:48.580 --> 00:16:51.139 But then, quite abruptly, it showed a rapid increase 00:16:51.139 --> 00:16:53.740 around ages 15 or 16. It typically moved towards 00:16:53.740 --> 00:16:55.759 a neutral variance, or sometimes even a positive 00:16:55.759 --> 00:16:57.940 variance, where the ulna becomes longer than 00:16:57.940 --> 00:17:00.139 the radius as the child nears skeletal maturity. 00:17:00.460 --> 00:17:03.019 That's a really distinct shift. Does that have 00:17:03.019 --> 00:17:05.440 clinical implications, profimo imam? We think 00:17:05.440 --> 00:17:08.039 it does. This predominant ulna minus variance 00:17:08.039 --> 00:17:11.000 during childhood could, hypothetically, be a 00:17:11.000 --> 00:17:13.099 natural protective feature. It might help explain 00:17:13.099 --> 00:17:15.720 why certain conditions common in adults, like 00:17:15.720 --> 00:17:19.059 injuries to the TFCC—that's the triangular fibrocartilage 00:17:19.059 --> 00:17:22.799 complex—a key stabilizer or ulnar impaction syndrome, 00:17:23.299 --> 00:17:25.440 are relatively rare in children. The anatomy 00:17:25.440 --> 00:17:27.839 itself might be protective during those years. 00:17:29.119 --> 00:17:30.819 Interesting. What about the other measurements? 00:17:31.039 --> 00:17:34.490 A prof mot imam? Radial height, radial inclination, 00:17:34.690 --> 00:17:36.809 and the radial carpal angle all showed a very 00:17:36.809 --> 00:17:39.609 consistent pattern, a steady, predictable increase 00:17:39.609 --> 00:17:41.789 throughout the growth period. They generally 00:17:41.789 --> 00:17:43.809 reach their adult values right around the onset 00:17:43.809 --> 00:17:46.509 of the pubertal growth spurt. This clearly reflects 00:17:46.509 --> 00:17:48.809 the gradual expansion and specific shaping of 00:17:48.809 --> 00:17:51.329 the end of the radius bone as it matures. Prof 00:17:51.329 --> 00:17:54.029 Mo Imam. For carpal height, as you'd expect, 00:17:54.130 --> 00:17:56.730 it showed a constant increase with growth, reflecting 00:17:56.730 --> 00:17:59.049 the lengthening of the carpal bones. But the 00:17:59.049 --> 00:18:01.210 carpal ratio comparing carpal height to the third 00:18:01.210 --> 00:18:03.450 metacarpal length showed no obvious increasing 00:18:03.450 --> 00:18:06.150 or decreasing trend. This suggests the proportions 00:18:06.150 --> 00:18:08.569 within the wrist and hand remain remarkably consistent 00:18:08.569 --> 00:18:10.789 relative to each other throughout growth, even 00:18:10.789 --> 00:18:13.029 as the absolute size increases. So the overall 00:18:13.029 --> 00:18:15.410 shape stays proportional. Prof. Mol Imam seems 00:18:15.410 --> 00:18:17.869 so, yes. Now, a particularly important finding, 00:18:18.109 --> 00:18:20.490 especially for avoiding misdiagnosis, relates 00:18:20.490 --> 00:18:23.720 to the scaphoid and lunate. We observed a significantly 00:18:23.720 --> 00:18:25.839 wider scaphelunit distance in younger children, 00:18:26.200 --> 00:18:28.160 and this gap gradually narrowed as they grew 00:18:28.160 --> 00:18:31.640 older, profmo imam. Similarly, the scaphelunit 00:18:31.640 --> 00:18:33.980 and capitalunit angles were found to be larger 00:18:33.980 --> 00:18:36.059 in children compared to adults, and they showed 00:18:36.059 --> 00:18:38.180 a downward trend, becoming smaller as growth 00:18:38.180 --> 00:18:40.579 progressed, generally stabilizing around 12 to 00:18:40.579 --> 00:18:44.759 13 years of age. Why is this so important? Because 00:18:44.759 --> 00:18:47.500 in adults, a wide gap or abnormal angles here 00:18:47.500 --> 00:18:50.019 are signs of instability, often requiring surgery. 00:18:50.539 --> 00:18:52.420 But in children, our data shows this is just 00:18:52.420 --> 00:18:54.940 a normal part of development. As those carpal 00:18:54.940 --> 00:18:57.480 bones ossify, changing from cartilage to solid 00:18:57.480 --> 00:18:59.740 bone, the space between them naturally tightens 00:18:59.740 --> 00:19:02.559 and the angles change. It's crucial not to misinterpret 00:19:02.559 --> 00:19:04.900 this normal developmental phase as pathology. 00:19:06.340 --> 00:19:09.079 And finally, the Palmer radial tilt, once it 00:19:09.079 --> 00:19:11.079 became measurable around age 11, it increased 00:19:11.079 --> 00:19:13.319 gradually, reaching adult values by the time 00:19:13.319 --> 00:19:15.480 puberty finished, finalizing the wrist -adult 00:19:15.480 --> 00:19:18.670 configuration. So if you put it all together, 00:19:18.829 --> 00:19:22.609 these predictable, reproducible anatomical changes 00:19:22.609 --> 00:19:25.970 map out a clear developmental pathway. They establish 00:19:25.970 --> 00:19:28.410 that vital baseline needed to distinguish normal 00:19:28.410 --> 00:19:30.630 variation from true pathology at different ages. 00:19:31.430 --> 00:19:33.950 The consistency we found really strengthens the 00:19:33.950 --> 00:19:36.009 clinical utility that is incredibly clear. The 00:19:36.009 --> 00:19:39.089 pattern seems so distinct. Now, one thing that 00:19:39.089 --> 00:19:40.809 often comes up in development is differences 00:19:40.809 --> 00:19:43.390 between sexes. One might naturally assume boys 00:19:43.390 --> 00:19:45.069 and girls bones might grow differently, maybe 00:19:45.069 --> 00:19:46.970 at different rates. or reaching different final 00:19:46.970 --> 00:19:49.910 configurations. Did your research find significant 00:19:49.910 --> 00:19:52.609 sex differences in these risk parameters? Prof 00:19:52.609 --> 00:19:55.410 mo imam. That's a very common assumption, and 00:19:55.410 --> 00:19:57.190 it's one of the areas where our findings were 00:19:57.190 --> 00:19:59.230 particularly significant, and perhaps, yes, a 00:19:59.230 --> 00:20:01.589 little surprising for clinical practice. Prof 00:20:01.589 --> 00:20:05.490 mo imam. Despite analyzing data for 471 boys 00:20:05.490 --> 00:20:08.970 and 425 girls across 16 age groups, our extensive 00:20:08.970 --> 00:20:11.150 analysis revealed no significant sex differences 00:20:11.150 --> 00:20:14.009 across any of the 10 measured radiographic parameters. 00:20:14.130 --> 00:20:16.490 None at all. It's quite definitive. prof mo imam. 00:20:16.609 --> 00:20:18.509 It was a very clear and consistent finding. When 00:20:18.509 --> 00:20:21.029 we performed the statistical analysis, age was 00:20:21.029 --> 00:20:23.029 the only significant predictor for the changes 00:20:23.029 --> 00:20:25.630 we observed in these measurements. Neither the 00:20:25.630 --> 00:20:28.190 child's sex nor even their hand dominance, whether 00:20:28.190 --> 00:20:30.269 they were right or left handed, were found to 00:20:30.269 --> 00:20:32.890 be significant factors influencing these specific 00:20:32.890 --> 00:20:36.230 wrist parameters. That's really fascinating and 00:20:36.230 --> 00:20:38.150 incredibly practical for clinicians, I imagine. 00:20:38.369 --> 00:20:41.410 It simplifies things considerably. Prof mo imam. 00:20:41.680 --> 00:20:44.559 It does indeed. It means one less variable to 00:20:44.559 --> 00:20:46.759 factor in when a sentiment child's wrist radiograph 00:20:46.759 --> 00:20:49.819 against these norms. Before this research, without 00:20:49.819 --> 00:20:52.079 this definitive pediatric data, there might have 00:20:52.079 --> 00:20:54.200 been, perhaps, a subtle bias or an underlying 00:20:54.200 --> 00:20:55.740 assumption that growth patterns would differ 00:20:55.740 --> 00:20:58.339 between boys and girls, leading to maybe uncertainty 00:20:58.339 --> 00:21:02.450 in diagnosis. Profmoemum? Potentially, yes. A 00:21:02.450 --> 00:21:04.049 clinician might have seen similar measurements 00:21:04.049 --> 00:21:05.849 in a boy and girl of the same age and wondered 00:21:05.849 --> 00:21:08.109 if it meant something different for each, perhaps 00:21:08.109 --> 00:21:10.430 leading to unnecessary follow -up, extra imaging, 00:21:10.650 --> 00:21:13.490 or maybe even just diagnostic uncertainty. Proph 00:21:13.490 --> 00:21:16.529 mo imam. Our finding that, for these specific 00:21:16.529 --> 00:21:18.289 wrist measurements, there are no significant 00:21:18.289 --> 00:21:21.069 sex differences provides a single unified age 00:21:21.069 --> 00:21:23.859 -specific reference range. It streamlines the 00:21:23.859 --> 00:21:26.539 assessment. Clinicians don't need separate charts 00:21:26.539 --> 00:21:29.359 for boys and girls for these parameters. They 00:21:29.359 --> 00:21:32.119 can confidently apply the same age -matched normal 00:21:32.119 --> 00:21:34.960 values regardless of the child's sex. That removes 00:21:34.960 --> 00:21:37.559 a layer of complexity, then, Prof. Moima. Exactly. 00:21:37.859 --> 00:21:40.259 It allows the focus to be purely on the objective 00:21:40.259 --> 00:21:42.039 measurements compared against the established 00:21:42.039 --> 00:21:44.599 norm for that child's chronological and skeletal 00:21:44.599 --> 00:21:47.779 age. It's a powerful message of biological uniformity 00:21:47.779 --> 00:21:50.420 in the specific anatomical context, at least 00:21:50.420 --> 00:21:53.000 concerning these widely used radiographic parameters. 00:21:53.559 --> 00:21:57.019 That clarity is so valuable. Okay, so professor, 00:21:57.039 --> 00:21:58.880 let's bring all these threads together. We have 00:21:58.880 --> 00:22:01.220 the precise measurements, the clear age -related 00:22:01.220 --> 00:22:03.539 changes, the lack of sex differences, the rigorous 00:22:03.539 --> 00:22:05.640 methodology. What does this all mean in practice? 00:22:06.000 --> 00:22:08.059 How did these detailed findings directly benefit 00:22:08.059 --> 00:22:10.160 the orthopedic professionals on the ground, and 00:22:10.160 --> 00:22:12.099 ultimately, the children they're treating? What's 00:22:12.099 --> 00:22:15.180 the real so -what here? Prof Moemem. Right? The 00:22:15.180 --> 00:22:17.299 clinical application is the ultimate goal. Essentially, 00:22:17.460 --> 00:22:19.900 the study's findings collectively provide a unique 00:22:19.900 --> 00:22:22.839 and frankly long overdue template of pediatric 00:22:22.839 --> 00:22:26.160 normal values. This acts as an invaluable practical 00:22:26.160 --> 00:22:28.940 guide for ham surgeons, pediatric orthopedic 00:22:28.940 --> 00:22:31.420 surgeons, even radiologists and pediatricians 00:22:31.420 --> 00:22:33.720 when they're managing children with wrist problems. 00:22:34.160 --> 00:22:37.619 Proth -mo -emome. The core benefit is the ability 00:22:37.619 --> 00:22:39.819 to compare a child's specific risk measurements 00:22:39.819 --> 00:22:42.759 against these robust age -specific normal values. 00:22:43.339 --> 00:22:45.779 This allows for much earlier and more precise 00:22:45.779 --> 00:22:48.480 identification of any deviations from the expected 00:22:48.480 --> 00:22:51.380 normal growth pattern. So, better diagnosis, 00:22:51.759 --> 00:22:54.240 essentially. Prof. Mo 'imam. Better and earlier 00:22:54.240 --> 00:22:57.000 diagnosis, yes, but it goes beyond that. This 00:22:57.000 --> 00:22:59.220 evidence is also crucial for guiding treatment, 00:22:59.220 --> 00:23:01.799 particularly after trauma. For instance, when 00:23:01.799 --> 00:23:04.240 reducing a distal radius fracture, these values 00:23:04.240 --> 00:23:06.579 provide objective targets to aim for, helping 00:23:06.579 --> 00:23:08.900 ensure the fracture heals in the best possible 00:23:08.900 --> 00:23:11.299 anatomical position for long -term function and 00:23:11.299 --> 00:23:13.400 minimizing the risk of later problems like stiffness 00:23:13.400 --> 00:23:16.480 or arthritis. Before, judging the adequacy of 00:23:16.480 --> 00:23:18.680 reduction was often more subjective. That makes 00:23:18.680 --> 00:23:21.000 sense. Can you give some specific examples of 00:23:21.000 --> 00:23:23.200 how these values help differentiate normal from 00:23:23.200 --> 00:23:25.519 abnormal or act as predictive tools? Prophemo 00:23:25.519 --> 00:23:27.740 imam, certainly. Let's look at ulnar variances. 00:23:27.900 --> 00:23:30.059 The reference values we established are now critical 00:23:30.059 --> 00:23:32.400 for distinguishing truly impaired ulnar growth, 00:23:32.740 --> 00:23:34.619 which you might see in conditions like juvenile 00:23:34.619 --> 00:23:37.039 arthritis or certain genetic conditions, like 00:23:37.039 --> 00:23:39.680 hereditary multiple -exhaustoses from an ulnar 00:23:39.680 --> 00:23:41.799 variance that, while maybe appearing short or 00:23:41.799 --> 00:23:43.839 long, still falls within the normal developmental 00:23:43.839 --> 00:23:47.400 range for that specific age. It prevents overdiagnosis 00:23:47.400 --> 00:23:50.759 of pathology. Prof Moimim. Furthermore, tracking 00:23:50.759 --> 00:23:53.500 ulnar variance over time using these norms can 00:23:53.500 --> 00:23:56.000 become a useful prognostic tool. For children 00:23:56.000 --> 00:23:58.140 with known progressive bone or joint diseases, 00:23:58.559 --> 00:24:00.640 monitoring this value can help identify those 00:24:00.640 --> 00:24:02.799 at higher risk for developing secondary problems 00:24:02.799 --> 00:24:05.339 like instability or subluxation of the carpus, 00:24:05.640 --> 00:24:08.119 allowing for early intervention if needed. So 00:24:08.119 --> 00:24:10.940 it helps monitor ongoing conditions too. Profmo 00:24:10.940 --> 00:24:13.670 imim. Absolutely. Then consider carpal height. 00:24:13.950 --> 00:24:16.569 Our study reinforces its value not just for diagnosis, 00:24:16.789 --> 00:24:19.029 but also for assessing disease severity and tracking 00:24:19.029 --> 00:24:21.250 the progression of what's turned carpal collapse. 00:24:21.869 --> 00:24:23.849 For example, we know that reduced carpal height 00:24:23.849 --> 00:24:26.809 can be seen in conditions like multiple epiphyseal 00:24:26.809 --> 00:24:29.990 dysplasia or Turner syndrome. Conversely, an 00:24:29.990 --> 00:24:32.470 increased carpal height can be a feature of achondroplasia. 00:24:32.750 --> 00:24:35.369 Profmo imam. And perhaps even more powerfully, 00:24:35.890 --> 00:24:37.890 subtle early changes in carpal height can actually 00:24:37.890 --> 00:24:40.390 predict poorer long -term outcomes in children 00:24:40.390 --> 00:24:43.329 with juvenile idiopathic arthritis. That's invaluable 00:24:43.329 --> 00:24:45.410 information for managing treatment and counseling 00:24:45.410 --> 00:24:48.049 families. That's a very direct link to predicting 00:24:48.049 --> 00:24:52.140 outcomes. Profmo imam. It is. And similarly for 00:24:52.140 --> 00:24:54.400 radial height and inclination, we confirmed that 00:24:54.400 --> 00:24:56.480 loss of radial height or significant changes 00:24:56.480 --> 00:24:58.799 in radial inclination after a fracture are strong 00:24:58.799 --> 00:25:01.079 predictors of a less favorable outcome, both 00:25:01.079 --> 00:25:03.740 in children and adults. Knowing this helps guide 00:25:03.740 --> 00:25:05.900 how aggressively we might need to intervene to 00:25:05.900 --> 00:25:07.960 restore the anatomy after certain types of distal 00:25:07.960 --> 00:25:11.200 radius fractures. Prophemo imam. The radiocarpal 00:25:11.200 --> 00:25:14.019 angle also proved useful. It aids in diagnosing 00:25:14.019 --> 00:25:16.319 certain congenital anomalies, like the characteristic 00:25:16.319 --> 00:25:18.440 hand shape seen in Hurler syndrome, and it's 00:25:18.440 --> 00:25:19.940 instrumental when we're creating growth plate 00:25:19.940 --> 00:25:22.299 injuries, physial arrests, to assess if we've 00:25:22.299 --> 00:25:25.579 restored the normal alignment. Prof Moimum. So 00:25:25.579 --> 00:25:28.079 taken together, these findings really allow clinicians 00:25:28.079 --> 00:25:30.579 to be more proactive. We can anticipate potential 00:25:30.579 --> 00:25:33.000 issues, intervene more precisely, monitor progress 00:25:33.000 --> 00:25:35.420 objectively, all guided by these evidence -based 00:25:35.420 --> 00:25:37.920 measurements. It leads to better, more tailored 00:25:37.920 --> 00:25:39.920 care. That's a clear shift towards more precise 00:25:39.920 --> 00:25:43.309 proactive care. What about those very young children, 00:25:43.549 --> 00:25:45.190 though, where the bones, as you said, aren't 00:25:45.190 --> 00:25:47.369 fully ossified and might be hard to see clearly 00:25:47.369 --> 00:25:50.450 on an x -ray? How does this research help navigate 00:25:50.450 --> 00:25:53.390 that challenge and avoid misdiagnosis? Crofmo 00:25:53.390 --> 00:25:55.950 Imam. That's a profoundly important application 00:25:55.950 --> 00:25:57.950 because managing injuries in very young children, 00:25:58.109 --> 00:26:01.109 say under four or five, presents unique challenges 00:26:01.109 --> 00:26:03.609 precisely because of that incomplete ossification. 00:26:04.210 --> 00:26:07.880 Crofmo Imam. In situations where the distal radius 00:26:07.880 --> 00:26:10.380 epiphysis isn't yet fully visible on the x -ray, 00:26:10.839 --> 00:26:12.500 the combined measurements of the parameters we 00:26:12.500 --> 00:26:15.319 can see reliably from age 1 ulnar variance, radial 00:26:15.319 --> 00:26:17.359 height, and carpal height become the only reliable 00:26:17.359 --> 00:26:19.359 objective guide for assessing the reduction and 00:26:19.359 --> 00:26:21.720 monitoring the healing of distal radius fractures. 00:26:22.200 --> 00:26:23.980 So you use the relationships you can measure 00:26:23.980 --> 00:26:26.140 to infer the position of the parts you can't 00:26:26.140 --> 00:26:29.279 see clearly. Prophmo Imum. Essentially, yes. 00:26:29.500 --> 00:26:31.940 These established normal values for the measurable 00:26:31.940 --> 00:26:34.000 parameters give us the necessary reference points. 00:26:34.299 --> 00:26:36.299 They provide objective data to guide treatment 00:26:36.299 --> 00:26:38.460 even when the key bone ends are still largely 00:26:38.460 --> 00:26:41.119 invisible cartilage. It allows for accurate management 00:26:41.119 --> 00:26:42.940 where previously it was much more difficult, 00:26:43.140 --> 00:26:46.240 profmoemum. And linked to avoiding misdiagnosis, 00:26:46.279 --> 00:26:48.460 I must re -emphasize the point about the scapulunate 00:26:48.460 --> 00:26:51.299 relationship. It is absolutely crucial that clinicians 00:26:51.299 --> 00:26:54.279 understand the naturally wider scapulunate distance 00:26:54.279 --> 00:26:56.980 and the larger scapulunate and capillunate angles 00:26:56.980 --> 00:26:59.619 seen in children are normal development. features. 00:27:00.420 --> 00:27:03.400 Prof mo imam. They should absolutely not be mistaken 00:27:03.400 --> 00:27:05.500 for carpal instability, which is a significant 00:27:05.500 --> 00:27:08.380 adult pathology often requiring surgery. Our 00:27:08.380 --> 00:27:10.519 study provides the biological explanation the 00:27:10.519 --> 00:27:12.660 gap narrows and angles decrease naturally as 00:27:12.660 --> 00:27:15.339 the cartilage ossifies, so a child's x -ray might 00:27:15.339 --> 00:27:17.680 look alarming if judged by adult standards. Prof 00:27:17.680 --> 00:27:21.150 mo imam. Exactly. Without this knowledge, a child 00:27:21.150 --> 00:27:23.190 with perfectly normal developing risks could 00:27:23.190 --> 00:27:25.750 easily be misdiagnosed with instability. This 00:27:25.750 --> 00:27:28.529 could lead to unnecessary anxiety, further investigations, 00:27:28.829 --> 00:27:30.789 maybe even inappropriate treatment for what is 00:27:30.789 --> 00:27:33.450 simply healthy growth. It really raises the question 00:27:33.450 --> 00:27:35.230 how often might this have happened in the past? 00:27:35.730 --> 00:27:38.109 Our data helps prevent these critical misdiagnoses. 00:27:38.470 --> 00:27:40.630 That impact alone preventing misdiagnosis and 00:27:40.630 --> 00:27:42.930 unnecessary interventions is huge. Now, shifting 00:27:42.930 --> 00:27:45.690 gears slightly, for surgeons planning more complex 00:27:45.690 --> 00:27:48.130 procedures like correcting deformities, time 00:27:48.039 --> 00:27:51.079 Dreaming is everything. Does this research offer 00:27:51.079 --> 00:27:53.619 guidance on when it might be safest or most appropriate 00:27:53.619 --> 00:27:56.220 to perform procedures like corrective osteotomies? 00:27:56.700 --> 00:28:00.400 Prophemo imam. Yes, it does offer a very practical 00:28:00.400 --> 00:28:02.980 guideline for surgical planning. Our findings 00:28:02.980 --> 00:28:05.240 indicate that corrective osteotomies procedures 00:28:05.240 --> 00:28:08.180 where we cut and realign bone to correct a deformity 00:28:08.180 --> 00:28:10.740 can generally be safely performed from the age 00:28:10.740 --> 00:28:13.640 of 12 years onwards without jeopardizing the 00:28:13.640 --> 00:28:16.059 child's remaining normal wrist development. From 00:28:16.059 --> 00:28:19.970 age 12. Why that specific age? Prophmo, Imum. 00:28:20.509 --> 00:28:22.990 The reasoning comes directly from our data. We 00:28:22.990 --> 00:28:25.210 observe that most of the key radiologic parameters 00:28:25.210 --> 00:28:27.470 demonstrate only minimal changes from the 12 00:28:27.470 --> 00:28:29.650 -year -old time point through to skeletal maturity. 00:28:30.289 --> 00:28:32.549 This suggests that by age 12, the wrist has achieved 00:28:32.549 --> 00:28:34.910 a significant degree of anatomical stability 00:28:34.910 --> 00:28:37.410 and maturity. The major developmental changes 00:28:37.410 --> 00:28:40.589 have largely occurred. Prophemo imam. Performing 00:28:40.589 --> 00:28:42.670 the surgery after this point is less likely to 00:28:42.670 --> 00:28:44.769 interfere with unpredictable growth spurts or 00:28:44.769 --> 00:28:46.589 significantly alter the final outcome due to 00:28:46.589 --> 00:28:49.109 ongoing natural development. It provides a clear 00:28:49.109 --> 00:28:51.509 evidence -based window for surgical planning. 00:28:51.819 --> 00:28:53.880 offering clinicians, and importantly parents, 00:28:54.200 --> 00:28:56.460 greater confidence about the timing of such interventions. 00:28:57.200 --> 00:28:59.460 It helps ensure we choose the optimal time for 00:28:59.460 --> 00:29:02.599 the best possible long -term result. That's incredibly 00:29:02.599 --> 00:29:05.019 helpful, providing that objective marker for 00:29:05.019 --> 00:29:07.920 surgical decision -making. Professor, as with 00:29:07.920 --> 00:29:09.660 any research, it's important to understand the 00:29:09.660 --> 00:29:12.160 context. Are there any nuances or limitations 00:29:12.160 --> 00:29:14.160 to this study that clinicians should bear in 00:29:14.160 --> 00:29:17.039 mind when applying these findings? Prophemo imam. 00:29:17.740 --> 00:29:20.200 That's a very fair point, and acknowledging limitations 00:29:20.200 --> 00:29:22.740 is always crucial in science. Firstly, while 00:29:22.740 --> 00:29:25.420 it was extensive, this was primarily a radiological 00:29:25.420 --> 00:29:28.500 analysis based on existing X -rays. Retrospective 00:29:28.500 --> 00:29:30.720 studies like this always carry an inherent, though 00:29:30.720 --> 00:29:33.279 hopefully small, risk of certain biases, perhaps 00:29:33.279 --> 00:29:35.720 in patient selection over the years, or potential 00:29:35.720 --> 00:29:38.400 under -representation of some very specific demographic 00:29:38.400 --> 00:29:41.200 groups. Prof. Mo Imam, however, we believe the 00:29:41.200 --> 00:29:43.259 study's rigorous design, the multi -center nature, 00:29:43.680 --> 00:29:45.759 the large sample size with at least 50 children 00:29:45.759 --> 00:29:48.460 per age group, Adding two decades significantly 00:29:48.460 --> 00:29:50.559 mitigates these concerns and makes the data highly 00:29:50.559 --> 00:29:53.299 robust and broadly applicable. What about the 00:29:53.299 --> 00:29:56.579 lack of sex difference? Could there be very subtle 00:29:56.579 --> 00:30:00.039 differences the study missed? Procmo imum. It's 00:30:00.039 --> 00:30:03.859 possible. While we found no statistically significant 00:30:03.859 --> 00:30:06.019 sex differences, which is the key message for 00:30:06.019 --> 00:30:08.339 clinical practice, we do acknowledge that the 00:30:08.339 --> 00:30:10.460 study might theoretically have been underpowered 00:30:10.460 --> 00:30:12.720 to detect extremely subtle differences related 00:30:12.720 --> 00:30:15.880 to sex, or perhaps even handedness, if they exist 00:30:15.880 --> 00:30:19.039 at a very minor level. Our focus was on identifying 00:30:19.039 --> 00:30:21.559 clinically relevant significant trends and differences, 00:30:21.680 --> 00:30:24.559 which we did with high confidence. Prof Mo Imam. 00:30:25.299 --> 00:30:27.559 Also, we did have to exclude a small percentage 00:30:27.559 --> 00:30:30.220 of radiographs due to technical errors or suboptimal 00:30:30.220 --> 00:30:32.789 positioning. This was necessary to maintain the 00:30:32.789 --> 00:30:35.230 quality of the data used for measurements. Given 00:30:35.230 --> 00:30:38.029 the huge overall number of images analyzed, it's 00:30:38.029 --> 00:30:39.829 highly unlikely this skewed the results, but 00:30:39.829 --> 00:30:42.109 it's a factor to note. And what about the fact 00:30:42.109 --> 00:30:44.549 that x -rays mainly show bone, not cartilage? 00:30:45.029 --> 00:30:47.789 Prof Mo Imam. That's a fundamental point about 00:30:47.789 --> 00:30:50.369 the imaging modality itself. Plane radiographs 00:30:50.369 --> 00:30:52.690 primarily visualize ossified bone. They can't 00:30:52.690 --> 00:30:54.430 definitively tell us about the precise shape, 00:30:54.549 --> 00:30:56.589 position, or motion of the parts that are still 00:30:56.589 --> 00:30:58.849 cartilage, especially in very young children. 00:30:59.049 --> 00:31:01.309 So we can't say for certain if the angle and 00:31:01.309 --> 00:31:03.630 intervals we measured perfectly reflect the cartilaginous 00:31:03.630 --> 00:31:06.450 structure, or if they partly reflect asymmetries 00:31:06.450 --> 00:31:08.529 in how the bone itself is forming within that 00:31:08.529 --> 00:31:12.079 cartilage. profmo imam. However, the study's 00:31:12.079 --> 00:31:14.299 core aim wasn't necessarily to map the cartilage, 00:31:14.440 --> 00:31:16.819 but to map the developmental array of the wrist 00:31:16.819 --> 00:31:19.299 as seen on standard clinical imaging to define 00:31:19.299 --> 00:31:21.819 what is consistently visible and reliably measurable 00:31:21.819 --> 00:31:24.519 using the most common tool, the plane radiograph. 00:31:25.180 --> 00:31:28.430 And that... it achieves successfully. So while 00:31:28.430 --> 00:31:30.109 it's important to be transparent about these 00:31:30.109 --> 00:31:32.509 natural boundaries of the technique, the practical 00:31:32.509 --> 00:31:34.990 reliability and clinical utility of the developmental 00:31:34.990 --> 00:31:36.970 map we've created remain exceptionally high. 00:31:37.309 --> 00:31:39.690 That transparency is really helpful. And it does 00:31:39.690 --> 00:31:42.029 raise that question with advanced imaging like 00:31:42.029 --> 00:31:44.329 MRI available now, which shows cartilage well. 00:31:44.630 --> 00:31:46.849 Why focus a foundational study like this on plane 00:31:46.849 --> 00:31:48.829 x -rays? What's their enduring value here? Pro, 00:31:48.869 --> 00:31:51.490 mo, ima? That's an excellent practical question. 00:31:51.950 --> 00:31:54.369 MRI certainly offers incredibly detailed anatomical 00:31:54.369 --> 00:31:56.710 information, including cartilage. And it definitely 00:31:56.710 --> 00:31:59.049 has its place for specific diagnostic questions. 00:31:59.390 --> 00:32:01.750 However, plain radiographs remain the absolute 00:32:01.750 --> 00:32:04.349 cornerstone of musculoskeletal imaging for several 00:32:04.349 --> 00:32:08.589 very good reasons. Prof mo imam. Firstly, they 00:32:08.589 --> 00:32:10.809 are simple, quick, and remarkably inexpensive 00:32:10.809 --> 00:32:14.029 compared to MRI. Secondly, they are highly feasible 00:32:14.029 --> 00:32:16.190 to perform on young children who might struggle 00:32:16.190 --> 00:32:18.109 to stay still for the length of time required 00:32:18.109 --> 00:32:21.750 for an MRI scan. Prof mo imam. Thirdly, they 00:32:21.750 --> 00:32:24.150 provide an excellent immediate overview of the 00:32:24.150 --> 00:32:26.970 wrist's overall geometry, bony alignment, fracture 00:32:26.970 --> 00:32:28.930 patterns, and the stage of skeletal development. 00:32:29.369 --> 00:32:31.349 This makes them the most practical and accessible 00:32:31.349 --> 00:32:34.269 tool for broad clinical application, particularly 00:32:34.269 --> 00:32:37.130 in high -volume settings like A &E or busy outpatient 00:32:37.130 --> 00:32:39.589 clinics. For establishing these fundamental, 00:32:39.710 --> 00:32:41.809 widely applicable normal reference values across 00:32:41.809 --> 00:32:44.289 diverse healthcare systems, plain radiography 00:32:44.289 --> 00:32:47.289 was, and remains, the ideal tool, profmo imam. 00:32:47.690 --> 00:32:50.569 So, in essence, this research provides that age 00:32:50.569 --> 00:32:52.609 -stratified reference for normal wrist development 00:32:52.609 --> 00:32:55.269 using the most commonly available imaging. By 00:32:55.269 --> 00:32:57.250 doing so, it truly empowers clinicians, giving 00:32:57.250 --> 00:32:59.109 them the knowledge needed to provide superior, 00:32:59.210 --> 00:33:01.609 more confident care, leading to better outcomes 00:33:01.609 --> 00:33:03.609 for countless children with wrist injuries and 00:33:03.609 --> 00:33:06.269 conditions. It's about building a more evidence 00:33:06.269 --> 00:33:09.089 -based foundation for pediatric orthopedics. 00:33:09.670 --> 00:33:12.720 Professor Mo Imam, thank you so much. That was 00:33:12.720 --> 00:33:14.880 an incredibly insightful journey through the 00:33:14.880 --> 00:33:17.700 intricacies of the growing wrist. It's absolutely 00:33:17.700 --> 00:33:20.319 clear how this work reshapes understanding and 00:33:20.319 --> 00:33:22.400 provides such practical tools for clinicians. 00:33:22.920 --> 00:33:25.039 And for you, our listener, we've really taken 00:33:25.039 --> 00:33:28.000 a deep dive today, haven't we? Into how a child's 00:33:28.000 --> 00:33:30.539 wrist develops, why adult measurements just don't 00:33:30.539 --> 00:33:32.740 cut it, and how this groundbreaking research 00:33:32.740 --> 00:33:35.259 offers that essential map for doctors and surgeons. 00:33:35.640 --> 00:33:37.720 We've seen how understanding normal growth allows 00:33:37.720 --> 00:33:39.839 for early diagnosis, more precise treatment, 00:33:40.019 --> 00:33:42.549 and crucially helps avoid those misinterpretations 00:33:42.549 --> 00:33:45.250 of normal development as something pathological. 00:33:45.930 --> 00:33:47.690 If you found this deep dive valuable, please 00:33:47.690 --> 00:33:49.529 do take a moment to rate and share the show. 00:33:49.750 --> 00:33:51.490 It genuinely helps more professionals like you 00:33:51.490 --> 00:33:53.809 discover these crucial insights. And finally, 00:33:53.849 --> 00:33:56.470 as we reflect on the detailed age -specific changes 00:33:56.470 --> 00:33:58.470 within something like a child's wrist, it really 00:33:58.470 --> 00:34:00.609 makes you wonder, doesn't it? What other seemingly 00:34:00.609 --> 00:34:03.150 fundamental parts of our anatomy hold similarly 00:34:03.150 --> 00:34:06.109 complex developmental secrets just waiting to 00:34:06.109 --> 00:34:08.269 be unlocked to improve health care for everyone 00:34:08.269 --> 00:34:09.489 at every age?