Welcome to the Deep Dive. Today we're getting
into something that seems, well, quite simple
on the surface, how bones grow, specifically
a child's wrist. But, you know, for something
so fundamental, it's actually quite surprising
there's been this, um... real lack of clear age
-specific guidelines for what's normal. So our
mission today is to explore some really groundbreaking
research that's managed to map out normal risk
development in children. Think of it as a vital
compass for doctors and surgeons. It's really
a shortcut to getting properly informed on a
critical orthopedic topic because understanding
what's normal, well, that's always the first
step, isn't it? It's absolutely key for spotting
problems early and treating them effectively,
especially when you think about common things
like fractures in kids or perhaps more complex
congenital. conditions. And we're incredibly
fortunate today. We have one of the leading minds
behind this pivotal research right here with
us. He's a true pioneer in this area of orthopedic
surgery. A very warm welcome to Professor Mohi
Imam, Prof Mohi Imam. Thank you. It's a real
pleasure to be here and talk about this work.
Great. Okay. Let's dive right in then. Professor,
perhaps you could start by explaining why understanding
this normal development pathway in children's
wrists is just so important for conditions. It
sounds basic, but clearly it wasn't straightforward.
Prof Mohi Imam. Well, it's fundamentally important.
And the numbers, actually, they really highlight
why. Wrist fractures, we're talking specifically
about the distal radius, that's the big forearm
bone near the wrist. And the carpal bones, the
small ones in the wrist itself, they're incredibly
common in children. Prof. Moimam, they account
for roughly about a quarter of all fractures
in pediatrics. And what's also quite concerning
is that the incidence, the rate, of these injuries
seems to be on the rise. So it's a growing public
health issue. A quarter. That's a huge proportion,
Crofmo Eumum. It is. And it's not just injuries,
not just trauma. We also deal quite frequently
with various other conditions. Congenital malformations,
for example, that can significantly impair the
natural growth and development of those forearm
bones, the radius and ulna, and the carpal bones
too, right through childhood and adolescence,
Crofmo Eumum. So... without having a really precise
age -specific picture of what normal actually
looks like at each stage, managing these conditions
becomes, well, incredibly complex, often relying
more on, shall we say, educated guesswork than
hard data. It's a high volume of cases covering
everything from playground falls to perhaps more
complex developmental issues. And you mentioned
this knowledge gap. Can you unpack that a bit?
What exactly was missing historically? Why was
it so hard to get this data for kids? Exactly.
The core challenge historically was that the
medical literature just lacked standardized measurements.
There weren't precise radiological indices specifically
designed for children's wrists, Prophemo imam.
This meant clinicians Well, they often had little
choice but to fall back on adult reference values.
And that's obviously problematic, because adult
bones are fully formed, presumably, Prof. Mari
Mimmo. Precisely. Those previously known adult
values for these anatomical parameters, they're
often quite far from accurate when you apply
them to a growing child. And the main reason
for that is because getting accurate, reliable
measurements is inherently difficult in very
young children. Prof mo imam. It's down to the
developing ossification centers. These are the
parts of the bone that are still cartilage, still
hardening into bone. They just aren't consistently
visible or fully formed on a standard x -ray
in the same way they are in adults. I see. So
you're trying to measure something that isn't
fully there yet on the image. Prof mo imam. In
essence, yes. It's like trying to restore a painting
without the original blueprint. You're making
your best estimate. And that's where this research
really comes in, profmoemom. What's fascinating
here, and what we really wanted to address, is
that without that clear template of normal growth
stage by stage, it's genuinely like navigating
in the dark for orthopedic pediatric surgeons,
for hand surgeons, profmoemom. It becomes incredibly
challenging to confidently differentiate between
what's just normal physiological growth variation
and what's an actual pathological deviation that
needs treatment. This research provides that
much needed map effectively. It shines a light.
That's a powerful analogy navigating in the dark.
It really highlights the clinical need. So faced
with this gap, what were the specific goals?
What did this extensive research actually set
out to achieve? Prof. Mo Imam. Well, given that
critical need, we designed the study with two
very clear interlinked goals. The first was to
identify, carefully considering the natural ossification
pattern, precisely when it becomes valid and
reliable to measure 10 specific radiographic
parameters of a growing wrist. Prof. Mo Imam.
Using a reliable standardized method, of course,
this directly tackles that issue of the varying
ossification stages we just talked about. Essentially
pinning down at what age you can actually see
and measure each feature accurately and consistently
on a standard x -ray. Finding the window of measurability,
if you like, right? So step one is figuring out
when you can actually measure things reliably.
Prof Mo Imam, exactly. And then secondly, and
just as importantly, we aim to establish yearly
-based normal reference values for these 10 measurements
for both boys and girls right across that development.
mental span from age 1 to 16, Prof Mo Imam. The
idea was to provide an indispensable evidence
-based guide for all clinicians involved in treating
children with risk problems, be it fractures
or other pathologies. Prof Mo Imam. If you connect
this to the bigger picture, I mean, these goals
are fundamental. They empower clinicians to make
much more informed, much more precise decisions.
Whether that's planning the best way to fix a
fracture or diagnosing a subtle developmental
issue accurately, it shifts us away from guesswork,
often based on adult norms, towards precise,
age -specific, evidence -based pediatric care.
That sounds incredibly thorough. And you mentioned
it was extensive research. This wasn't just looking
at a few x -rays, was it? Can you give us a sense
of the scale and the methodological rigor involved?
Because that's what gives the findings their
weight, isn't it, Prof. Moriamum? Absolutely.
The scale was, well, it was significant. And
the methodology had to be meticulous to ensure
the findings were robust. We conducted what's
called a retrospective multi -center analysis.
profmoemum. That means we gather data from several
different hospitals or clinical centers. This
automatically helps make the findings more generalizable,
more applicable across different settings. So
not just one hospital's patient group, profmoemum.
Correct. The study analyzed radiographs x -rays
from 896 children. Specifically, we looked at
896 posterior anterior views, that's the front
to back view, and 896 lateral or side views.
Crucially, all these children had normal, healthy
wrists, prof mo imam. And this data wasn't elected
over a short period, it spanned two full decades,
from January 1996 right up until April 2016.
That long timeframe was quite deliberate. It
allowed us to capture a really wide and representative
range of developmental stages and natural variations
over time. Two decades worth of data, that's
quite something. And how did you group the children?
Prophemo imam. To make sure we had a good understanding
across the whole growth period, the children
were meticulously stratified into 16 distinct
yearly age groups. So from age 1, age 2, all
the way up to age 16. Prophemo imam. And within
each S group, they were further divided by sex.
We had 471 males and 425 females. So a pretty
even split. And importantly, each single age
group included a minimum of 50 children. 50 per
group. Why that number specifically? Prophemo
imam. That minimum number wasn't arbitrary. It
came from a power analysis we did before even
starting the main data collection. It ensured
we had enough statistical power within each age
bracket to detect differences that were not just
statistically significant but also clinically
meaningful. That makes sense. And I imagine defining
normal for inclusion must have been incredibly
strict for a study like this. How did you ensure
you were really looking at healthy risks? Prof.
Moimam, oh, absolutely rigorous. We had a very
strict inclusion and exclusion process. Firstly,
only x -rays that had been officially reported
as normal by a specialist radiologist were even
considered. Profmoimom. But we didn't stop there.
These normal images then underwent a second,
independent check by two experienced orthopedic
investigators, myself included. This two -stage
process meant we could systematically filter
out any images showing obvious fractures, of
course, but also any subtle abnormalities or
even minor technical errors in how the x -ray
was taken that could affect measurements. So
double -checking everything. Profmoimom. And
we also excluded children if they had any relevant
medical history, things like congenital problems,
systemic diseases that affect growth, or even
previous fractures in that wrist, anything that
could potentially skew the growth pattern away
from normal. Prof mo imam. This focus on normal
is just so critical, you simply can't define
what's abnormal without a crystal clear robust
baseline of what normal development looks like
at every single age. Prof mo imam. The sheer
number of children involved, combined with this
very careful selection and double validation
process, gave us that highly robust baseline.
It really is the foundation upon which all the
subsequent findings are built. Getting that right
was paramount. I can tell you, sifting through
thousands upon thousands of images, cross -referencing
clinical histories, it was a huge undertaking,
but absolutely necessary. That level of scrutiny
is really impressive. It certainly builds confidence
in the baseline. So once you had this vast, carefully
curated dataset of normal wrists, what were the
specific things you were measuring? These 10
key radiographic parameters, could you walk us
through them? What does each one tell you? These
10 parameters, when taken together, they give
us a very comprehensive geometric profile of
the developing wrist. We measured them meticulously,
but always dependent on the wrist's ossification
pattern. meaning only when that specific feature
was clearly visible and reliably measurable on
the x -ray for that age group. Prophmo imam.
Okay, so first we looked at ulnar variance. This
measures the difference in length between the
two forearm bones, the radius and ulna, right
at the wrist joint. It's measured as the perpendicular
distance between their end lines, essentially
telling us if the ulna is shorter, longer, or
the same length as the radius at that point.
Important for load distribution, how they line
up. Right. Prophemol imam, exactly. Then radial
height. This is the height of the radius bone
at the wrist end, measured from its main shaft
line up to the tip of the radial styloid, the
bony prominence on the thumb side. It relates
to the space available for the carpal bones.
Prophmo Imum. Next is radial inclination. This
is an angle. It measures the sideways tilt of
the end surface of the radio. Think of it like
the slope on the end of the radius where the
wrist bones sit. It's crucial for how the wrist
moves side to side, like a ramp. Prophmo Imum.
Sort of, yes. Then the radial carpal angle. Another
angle, this one assesses the overall alignment
of that first row of carpal bones relative to
the radius. It gives an indication of how well
the hand is seated on the forearm. prof mo imam.
Moving to the carpal bones themselves, we measured
carpal height. This is the overall height of
that block of small carpal bones measured along
the line of third metacarpal, the long bone in
the hand leading to the middle finger. It tells
us about the compactness or potential collapse
of the carpus, perfmore imam. And related to
that is the carpal ratio. This simply compares
the carpal height to the length of that third
metacarpal. It gives us a proportional measure,
which is useful because it adjusts for the child's
overall hand size. Okay, so those are mostly
from the front on view, perfmore imam. Those
first six, yes, are primarily from the PA view.
Then on the lateral, the side view, we assessed
volar tilt, sometimes called palmar tilt. This
measures the forward tilt of the end surface
of the radius, so how much it slopes towards
the palm side. Very important for wrist flexion
and stability. Profmo imam. Then we looked at
the relationship between two key carpal bones,
the scaphoid and the lunate. The scapholunate
angle measures the angle between the axes of
these two bones. Changes here can indicate instability.
Prophemo imam. Similarly, the capital lunate
angle measures the angle between the lunate and
the capitate, which is the large central carpal
bone. Again, it's assessing the alignment within
the carpus itself, Prophemo imam. And finally,
the scaphelinate distance. This is simply the
gap measured between the scaphoid and the lunate.
In adults, a widening of this gap is a classic
sign of a ligament tear. So you see, each parameter
gives us a unique piece of the developmental
puzzle alignment proportion angles. Together,
they build that comprehensive geometric profile
we needed. Vital for understanding both normal
growth and spotting subtle problems. That is
incredibly detailed. Ten different measurements
across multiple centers over 20 years. Which
brings me to the question of consistency. How
could you be absolutely sure that these measurements
were accurate and reliable? How did you ensure
that precision? A critical question indeed. And
ensuring reliability was a major focus. All the
radiographs, regardless of when or where they
were taken over that two -decade span, were rigorously
checked for quality and adequacy. This was done
first by a senior radiologist and then independently
by the two orthopedic investigators involved,
Prof. Mor Imam. we adhered to a very strict preferred
imaging protocol. This meant consistent patient
positioning was paramount. For example, the patient
always had to be seated, forearm resting flat,
specific hand and finger positioning for both
the PA and lateral views. This standardization
was absolutely key to minimizing variability
right from the start. So the way the x -ray was
taken was standardized as much as possible. Prof.
Mo 'imam, exactly. But beyond that, we rigorously
tested the reliability of the measurements themselves.
We calculated what are known as interclass correlation
coefficients, or ICCs. These statistical measures
assess agreement. Prophemo imam. And our study
demonstrated excellent reliability, with ICCs
consistently above .85 for all 10 parameters.
This covered both interobserver reliability,
meaning the same person measuring the same x
-ray at different times got consistent results,
and interobserver reliability, meaning different
people measuring the same x -ray also got consistent
results. Above .85, that sounds very high. Prophemo
imam. It is considered excellent in this context.
This high level of consistency is absolutely
vital for clinical usefulness. It means the reference
values we've established are trustworthy. Clinicians
in different hospitals using these guidelines
can be confident they will arrive at similar
reliable conclusions when assessing a child's
wrist. It provides a shared objective standard
that really does solidify the findings. Knowing
the measurements are so reproducible gives immense
confidence. Okay so professor we have the what
and the how. Now for the really fascinating part
the what did you find? Yeah. What did this incredibly
detailed data actually reveal about the dynamic
journey of a child's wrist as it grows and matures?
Right, this is where the developmental picture
really comes alive. We found very clear age milestones
for when different parameters actually become
reliably measurable on these standard x -rays.
Profmo imam. For instance, four key measurements,
ulnar variance, radial height, carpal height,
and the carpal ratio, these were all consistently
definable and measurable right from the first
year of life. That's quite significant because
it means cornitions can start assessing these
fundamental relationships very early on using
objective data. So even in a one -year -old,
you can reliably measure those four things. Yes,
with the standardized methods we used. Then,
as children get a bit older, more features become
clear enough to major accurately. From around
age 4, radial inclination, the radiocarpal angle,
and the capital lunet angle became reliably measurable.
Prof mo imam. This timing makes sense biologically
because their accurate assessment really depends
on the epithesis, the end part of the bone being
sufficiently calcified, hardened into bone, to
show up clearly on the x -ray. Before age 4,
these areas are mostly cartilage, still developing
essentially. Prof mo imam, precisely. Then, a
bit later, from age 6 onwards, we found that
the scaphalunid angle and the scaphalunid distance
could only be reliably measured. This timing
correlates directly with when the ossific centers
of the lunate and scaphoid bones themselves typically
appear as visible bone, usually around ages four
and five respectively. So you need both bones
to be sufficiently ossified to measure the relationship
between them accurately. Okay, so different timings
for different measurements based on when the
bones actually develop enough to be seen clearly.
Prophmo imam, exactly. And what a final example,
the palmar tilt or voller tilt measured on the
side view. We found this wasn't really developed
or consistently measurable until about age 11.
After that point, it started to gradually increase.
This relies on the development of the distal
radius's voller inclination, which typically
occurs around age 10, so it really underscores
the dynamic nature of growth. You can't just
apply one standard measurement technique across
all ages. Our findings pin down precisely when
these different parts of the wrist become sufficiently
ossified and geometrically stable enough for
accurate radiographic assessment. That's such
a crucial point. It's not just what you measure,
but when you can measure it reliably. Beyond
that timing, what were the most striking growth
trends or patterns you observed? How did these
parameters change as children got older? Any
surprises? Profmo imam. Yes, several really interesting
clinically important patterns emerged. Let's
take ulnar variance again. We confirmed a clear
predominance of what we call ulna minus variance
in children throughout most of their growth,
meaning the ulna is shorter than the radius of
the wrist. Profmo imam. Correct. On average.
And what was fascinating was that this characteristic
remained remarkably stable. It didn't consistently
change from birth right up until about age 14.
But then, quite abruptly, it showed a rapid increase
around ages 15 or 16. It typically moved towards
a neutral variance, or sometimes even a positive
variance, where the ulna becomes longer than
the radius as the child nears skeletal maturity.
That's a really distinct shift. Does that have
clinical implications, profimo imam? We think
it does. This predominant ulna minus variance
during childhood could, hypothetically, be a
natural protective feature. It might help explain
why certain conditions common in adults, like
injuries to the TFCC—that's the triangular fibrocartilage
complex—a key stabilizer or ulnar impaction syndrome,
are relatively rare in children. The anatomy
itself might be protective during those years.
Interesting. What about the other measurements?
A prof mot imam? Radial height, radial inclination,
and the radial carpal angle all showed a very
consistent pattern, a steady, predictable increase
throughout the growth period. They generally
reach their adult values right around the onset
of the pubertal growth spurt. This clearly reflects
the gradual expansion and specific shaping of
the end of the radius bone as it matures. Prof
Mo Imam. For carpal height, as you'd expect,
it showed a constant increase with growth, reflecting
the lengthening of the carpal bones. But the
carpal ratio comparing carpal height to the third
metacarpal length showed no obvious increasing
or decreasing trend. This suggests the proportions
within the wrist and hand remain remarkably consistent
relative to each other throughout growth, even
as the absolute size increases. So the overall
shape stays proportional. Prof. Mol Imam seems
so, yes. Now, a particularly important finding,
especially for avoiding misdiagnosis, relates
to the scaphoid and lunate. We observed a significantly
wider scaphelunit distance in younger children,
and this gap gradually narrowed as they grew
older, profmo imam. Similarly, the scaphelunit
and capitalunit angles were found to be larger
in children compared to adults, and they showed
a downward trend, becoming smaller as growth
progressed, generally stabilizing around 12 to
13 years of age. Why is this so important? Because
in adults, a wide gap or abnormal angles here
are signs of instability, often requiring surgery.
But in children, our data shows this is just
a normal part of development. As those carpal
bones ossify, changing from cartilage to solid
bone, the space between them naturally tightens
and the angles change. It's crucial not to misinterpret
this normal developmental phase as pathology.
And finally, the Palmer radial tilt, once it
became measurable around age 11, it increased
gradually, reaching adult values by the time
puberty finished, finalizing the wrist -adult
configuration. So if you put it all together,
these predictable, reproducible anatomical changes
map out a clear developmental pathway. They establish
that vital baseline needed to distinguish normal
variation from true pathology at different ages.
The consistency we found really strengthens the
clinical utility that is incredibly clear. The
pattern seems so distinct. Now, one thing that
often comes up in development is differences
between sexes. One might naturally assume boys
and girls bones might grow differently, maybe
at different rates. or reaching different final
configurations. Did your research find significant
sex differences in these risk parameters? Prof
mo imam. That's a very common assumption, and
it's one of the areas where our findings were
particularly significant, and perhaps, yes, a
little surprising for clinical practice. Prof
mo imam. Despite analyzing data for 471 boys
and 425 girls across 16 age groups, our extensive
analysis revealed no significant sex differences
across any of the 10 measured radiographic parameters.
None at all. It's quite definitive. prof mo imam.
It was a very clear and consistent finding. When
we performed the statistical analysis, age was
the only significant predictor for the changes
we observed in these measurements. Neither the
child's sex nor even their hand dominance, whether
they were right or left handed, were found to
be significant factors influencing these specific
wrist parameters. That's really fascinating and
incredibly practical for clinicians, I imagine.
It simplifies things considerably. Prof mo imam.
It does indeed. It means one less variable to
factor in when a sentiment child's wrist radiograph
against these norms. Before this research, without
this definitive pediatric data, there might have
been, perhaps, a subtle bias or an underlying
assumption that growth patterns would differ
between boys and girls, leading to maybe uncertainty
in diagnosis. Profmoemum? Potentially, yes. A
clinician might have seen similar measurements
in a boy and girl of the same age and wondered
if it meant something different for each, perhaps
leading to unnecessary follow -up, extra imaging,
or maybe even just diagnostic uncertainty. Proph
mo imam. Our finding that, for these specific
wrist measurements, there are no significant
sex differences provides a single unified age
-specific reference range. It streamlines the
assessment. Clinicians don't need separate charts
for boys and girls for these parameters. They
can confidently apply the same age -matched normal
values regardless of the child's sex. That removes
a layer of complexity, then, Prof. Moima. Exactly.
It allows the focus to be purely on the objective
measurements compared against the established
norm for that child's chronological and skeletal
age. It's a powerful message of biological uniformity
in the specific anatomical context, at least
concerning these widely used radiographic parameters.
That clarity is so valuable. Okay, so professor,
let's bring all these threads together. We have
the precise measurements, the clear age -related
changes, the lack of sex differences, the rigorous
methodology. What does this all mean in practice?
How did these detailed findings directly benefit
the orthopedic professionals on the ground, and
ultimately, the children they're treating? What's
the real so -what here? Prof Moemem. Right? The
clinical application is the ultimate goal. Essentially,
the study's findings collectively provide a unique
and frankly long overdue template of pediatric
normal values. This acts as an invaluable practical
guide for ham surgeons, pediatric orthopedic
surgeons, even radiologists and pediatricians
when they're managing children with wrist problems.
Proth -mo -emome. The core benefit is the ability
to compare a child's specific risk measurements
against these robust age -specific normal values.
This allows for much earlier and more precise
identification of any deviations from the expected
normal growth pattern. So, better diagnosis,
essentially. Prof. Mo 'imam. Better and earlier
diagnosis, yes, but it goes beyond that. This
evidence is also crucial for guiding treatment,
particularly after trauma. For instance, when
reducing a distal radius fracture, these values
provide objective targets to aim for, helping
ensure the fracture heals in the best possible
anatomical position for long -term function and
minimizing the risk of later problems like stiffness
or arthritis. Before, judging the adequacy of
reduction was often more subjective. That makes
sense. Can you give some specific examples of
how these values help differentiate normal from
abnormal or act as predictive tools? Prophemo
imam, certainly. Let's look at ulnar variances.
The reference values we established are now critical
for distinguishing truly impaired ulnar growth,
which you might see in conditions like juvenile
arthritis or certain genetic conditions, like
hereditary multiple -exhaustoses from an ulnar
variance that, while maybe appearing short or
long, still falls within the normal developmental
range for that specific age. It prevents overdiagnosis
of pathology. Prof Moimim. Furthermore, tracking
ulnar variance over time using these norms can
become a useful prognostic tool. For children
with known progressive bone or joint diseases,
monitoring this value can help identify those
at higher risk for developing secondary problems
like instability or subluxation of the carpus,
allowing for early intervention if needed. So
it helps monitor ongoing conditions too. Profmo
imim. Absolutely. Then consider carpal height.
Our study reinforces its value not just for diagnosis,
but also for assessing disease severity and tracking
the progression of what's turned carpal collapse.
For example, we know that reduced carpal height
can be seen in conditions like multiple epiphyseal
dysplasia or Turner syndrome. Conversely, an
increased carpal height can be a feature of achondroplasia.
Profmo imam. And perhaps even more powerfully,
subtle early changes in carpal height can actually
predict poorer long -term outcomes in children
with juvenile idiopathic arthritis. That's invaluable
information for managing treatment and counseling
families. That's a very direct link to predicting
outcomes. Profmo imam. It is. And similarly for
radial height and inclination, we confirmed that
loss of radial height or significant changes
in radial inclination after a fracture are strong
predictors of a less favorable outcome, both
in children and adults. Knowing this helps guide
how aggressively we might need to intervene to
restore the anatomy after certain types of distal
radius fractures. Prophemo imam. The radiocarpal
angle also proved useful. It aids in diagnosing
certain congenital anomalies, like the characteristic
hand shape seen in Hurler syndrome, and it's
instrumental when we're creating growth plate
injuries, physial arrests, to assess if we've
restored the normal alignment. Prof Moimum. So
taken together, these findings really allow clinicians
to be more proactive. We can anticipate potential
issues, intervene more precisely, monitor progress
objectively, all guided by these evidence -based
measurements. It leads to better, more tailored
care. That's a clear shift towards more precise
proactive care. What about those very young children,
though, where the bones, as you said, aren't
fully ossified and might be hard to see clearly
on an x -ray? How does this research help navigate
that challenge and avoid misdiagnosis? Crofmo
Imam. That's a profoundly important application
because managing injuries in very young children,
say under four or five, presents unique challenges
precisely because of that incomplete ossification.
Crofmo Imam. In situations where the distal radius
epiphysis isn't yet fully visible on the x -ray,
the combined measurements of the parameters we
can see reliably from age 1 ulnar variance, radial
height, and carpal height become the only reliable
objective guide for assessing the reduction and
monitoring the healing of distal radius fractures.
So you use the relationships you can measure
to infer the position of the parts you can't
see clearly. Prophmo Imum. Essentially, yes.
These established normal values for the measurable
parameters give us the necessary reference points.
They provide objective data to guide treatment
even when the key bone ends are still largely
invisible cartilage. It allows for accurate management
where previously it was much more difficult,
profmoemum. And linked to avoiding misdiagnosis,
I must re -emphasize the point about the scapulunate
relationship. It is absolutely crucial that clinicians
understand the naturally wider scapulunate distance
and the larger scapulunate and capillunate angles
seen in children are normal development. features.
Prof mo imam. They should absolutely not be mistaken
for carpal instability, which is a significant
adult pathology often requiring surgery. Our
study provides the biological explanation the
gap narrows and angles decrease naturally as
the cartilage ossifies, so a child's x -ray might
look alarming if judged by adult standards. Prof
mo imam. Exactly. Without this knowledge, a child
with perfectly normal developing risks could
easily be misdiagnosed with instability. This
could lead to unnecessary anxiety, further investigations,
maybe even inappropriate treatment for what is
simply healthy growth. It really raises the question
how often might this have happened in the past?
Our data helps prevent these critical misdiagnoses.
That impact alone preventing misdiagnosis and
unnecessary interventions is huge. Now, shifting
gears slightly, for surgeons planning more complex
procedures like correcting deformities, time
Dreaming is everything. Does this research offer
guidance on when it might be safest or most appropriate
to perform procedures like corrective osteotomies?
Prophemo imam. Yes, it does offer a very practical
guideline for surgical planning. Our findings
indicate that corrective osteotomies procedures
where we cut and realign bone to correct a deformity
can generally be safely performed from the age
of 12 years onwards without jeopardizing the
child's remaining normal wrist development. From
age 12. Why that specific age? Prophmo, Imum.
The reasoning comes directly from our data. We
observe that most of the key radiologic parameters
demonstrate only minimal changes from the 12
-year -old time point through to skeletal maturity.
This suggests that by age 12, the wrist has achieved
a significant degree of anatomical stability
and maturity. The major developmental changes
have largely occurred. Prophemo imam. Performing
the surgery after this point is less likely to
interfere with unpredictable growth spurts or
significantly alter the final outcome due to
ongoing natural development. It provides a clear
evidence -based window for surgical planning.
offering clinicians, and importantly parents,
greater confidence about the timing of such interventions.
It helps ensure we choose the optimal time for
the best possible long -term result. That's incredibly
helpful, providing that objective marker for
surgical decision -making. Professor, as with
any research, it's important to understand the
context. Are there any nuances or limitations
to this study that clinicians should bear in
mind when applying these findings? Prophemo imam.
That's a very fair point, and acknowledging limitations
is always crucial in science. Firstly, while
it was extensive, this was primarily a radiological
analysis based on existing X -rays. Retrospective
studies like this always carry an inherent, though
hopefully small, risk of certain biases, perhaps
in patient selection over the years, or potential
under -representation of some very specific demographic
groups. Prof. Mo Imam, however, we believe the
study's rigorous design, the multi -center nature,
the large sample size with at least 50 children
per age group, Adding two decades significantly
mitigates these concerns and makes the data highly
robust and broadly applicable. What about the
lack of sex difference? Could there be very subtle
differences the study missed? Procmo imum. It's
possible. While we found no statistically significant
sex differences, which is the key message for
clinical practice, we do acknowledge that the
study might theoretically have been underpowered
to detect extremely subtle differences related
to sex, or perhaps even handedness, if they exist
at a very minor level. Our focus was on identifying
clinically relevant significant trends and differences,
which we did with high confidence. Prof Mo Imam.
Also, we did have to exclude a small percentage
of radiographs due to technical errors or suboptimal
positioning. This was necessary to maintain the
quality of the data used for measurements. Given
the huge overall number of images analyzed, it's
highly unlikely this skewed the results, but
it's a factor to note. And what about the fact
that x -rays mainly show bone, not cartilage?
Prof Mo Imam. That's a fundamental point about
the imaging modality itself. Plane radiographs
primarily visualize ossified bone. They can't
definitively tell us about the precise shape,
position, or motion of the parts that are still
cartilage, especially in very young children.
So we can't say for certain if the angle and
intervals we measured perfectly reflect the cartilaginous
structure, or if they partly reflect asymmetries
in how the bone itself is forming within that
cartilage. profmo imam. However, the study's
core aim wasn't necessarily to map the cartilage,
but to map the developmental array of the wrist
as seen on standard clinical imaging to define
what is consistently visible and reliably measurable
using the most common tool, the plane radiograph.
And that... it achieves successfully. So while
it's important to be transparent about these
natural boundaries of the technique, the practical
reliability and clinical utility of the developmental
map we've created remain exceptionally high.
That transparency is really helpful. And it does
raise that question with advanced imaging like
MRI available now, which shows cartilage well.
Why focus a foundational study like this on plane
x -rays? What's their enduring value here? Pro,
mo, ima? That's an excellent practical question.
MRI certainly offers incredibly detailed anatomical
information, including cartilage. And it definitely
has its place for specific diagnostic questions.
However, plain radiographs remain the absolute
cornerstone of musculoskeletal imaging for several
very good reasons. Prof mo imam. Firstly, they
are simple, quick, and remarkably inexpensive
compared to MRI. Secondly, they are highly feasible
to perform on young children who might struggle
to stay still for the length of time required
for an MRI scan. Prof mo imam. Thirdly, they
provide an excellent immediate overview of the
wrist's overall geometry, bony alignment, fracture
patterns, and the stage of skeletal development.
This makes them the most practical and accessible
tool for broad clinical application, particularly
in high -volume settings like A &E or busy outpatient
clinics. For establishing these fundamental,
widely applicable normal reference values across
diverse healthcare systems, plain radiography
was, and remains, the ideal tool, profmo imam.
So, in essence, this research provides that age
-stratified reference for normal wrist development
using the most commonly available imaging. By
doing so, it truly empowers clinicians, giving
them the knowledge needed to provide superior,
more confident care, leading to better outcomes
for countless children with wrist injuries and
conditions. It's about building a more evidence
-based foundation for pediatric orthopedics.
Professor Mo Imam, thank you so much. That was
an incredibly insightful journey through the
intricacies of the growing wrist. It's absolutely
clear how this work reshapes understanding and
provides such practical tools for clinicians.
And for you, our listener, we've really taken
a deep dive today, haven't we? Into how a child's
wrist develops, why adult measurements just don't
cut it, and how this groundbreaking research
offers that essential map for doctors and surgeons.
We've seen how understanding normal growth allows
for early diagnosis, more precise treatment,
and crucially helps avoid those misinterpretations
of normal development as something pathological.
If you found this deep dive valuable, please
do take a moment to rate and share the show.
It genuinely helps more professionals like you
discover these crucial insights. And finally,
as we reflect on the detailed age -specific changes
within something like a child's wrist, it really
makes you wonder, doesn't it? What other seemingly
fundamental parts of our anatomy hold similarly
complex developmental secrets just waiting to
be unlocked to improve health care for everyone
at every age?