Latest / Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast. / Normal Wrist Growth: A Radiographic Analysis in Children

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Normal Wrist Growth: A Radiographic Analysis in Children · Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast.

• 0:00
  Welcome to the Deep Dive. Today we're getting
• 0:02
  into something that seems, well, quite simple
• 0:04
  on the surface, how bones grow, specifically
• 0:06
  a child's wrist. But, you know, for something
• 0:09
  so fundamental, it's actually quite surprising
• 0:11
  there's been this, um... real lack of clear age
• 0:15
  -specific guidelines for what's normal. So our
• 0:18
  mission today is to explore some really groundbreaking
• 0:20
  research that's managed to map out normal risk
• 0:23
  development in children. Think of it as a vital
• 0:25
  compass for doctors and surgeons. It's really
• 0:28
  a shortcut to getting properly informed on a
• 0:30
  critical orthopedic topic because understanding
• 0:32
  what's normal, well, that's always the first
• 0:34
  step, isn't it? It's absolutely key for spotting
• 0:36
  problems early and treating them effectively,
• 0:38
  especially when you think about common things
• 0:40
  like fractures in kids or perhaps more complex
• 0:42
  congenital. conditions. And we're incredibly
• 0:45
  fortunate today. We have one of the leading minds
• 0:47
  behind this pivotal research right here with
• 0:49
  us. He's a true pioneer in this area of orthopedic
• 0:52
  surgery. A very warm welcome to Professor Mohi
• 0:54
  Imam, Prof Mohi Imam. Thank you. It's a real
• 0:57
  pleasure to be here and talk about this work.
• 0:59
  Great. Okay. Let's dive right in then. Professor,
• 1:01
  perhaps you could start by explaining why understanding
• 1:04
  this normal development pathway in children's
• 1:06
  wrists is just so important for conditions. It
• 1:08
  sounds basic, but clearly it wasn't straightforward.
• 1:11
  Prof Mohi Imam. Well, it's fundamentally important.
• 1:14
  And the numbers, actually, they really highlight
• 1:16
  why. Wrist fractures, we're talking specifically
• 1:18
  about the distal radius, that's the big forearm
• 1:20
  bone near the wrist. And the carpal bones, the
• 1:23
  small ones in the wrist itself, they're incredibly
• 1:25
  common in children. Prof. Moimam, they account
• 1:27
  for roughly about a quarter of all fractures
• 1:30
  in pediatrics. And what's also quite concerning
• 1:33
  is that the incidence, the rate, of these injuries
• 1:36
  seems to be on the rise. So it's a growing public
• 1:38
  health issue. A quarter. That's a huge proportion,
• 1:41
  Crofmo Eumum. It is. And it's not just injuries,
• 1:44
  not just trauma. We also deal quite frequently
• 1:46
  with various other conditions. Congenital malformations,
• 1:49
  for example, that can significantly impair the
• 1:51
  natural growth and development of those forearm
• 1:53
  bones, the radius and ulna, and the carpal bones
• 1:55
  too, right through childhood and adolescence,
• 1:58
  Crofmo Eumum. So... without having a really precise
• 2:01
  age -specific picture of what normal actually
• 2:04
  looks like at each stage, managing these conditions
• 2:06
  becomes, well, incredibly complex, often relying
• 2:10
  more on, shall we say, educated guesswork than
• 2:13
  hard data. It's a high volume of cases covering
• 2:16
  everything from playground falls to perhaps more
• 2:18
  complex developmental issues. And you mentioned
• 2:20
  this knowledge gap. Can you unpack that a bit?
• 2:22
  What exactly was missing historically? Why was
• 2:24
  it so hard to get this data for kids? Exactly.
• 2:30
  The core challenge historically was that the
• 2:32
  medical literature just lacked standardized measurements.
• 2:35
  There weren't precise radiological indices specifically
• 2:37
  designed for children's wrists, Prophemo imam.
• 2:40
  This meant clinicians Well, they often had little
• 2:42
  choice but to fall back on adult reference values.
• 2:45
  And that's obviously problematic, because adult
• 2:46
  bones are fully formed, presumably, Prof. Mari
• 2:48
  Mimmo. Precisely. Those previously known adult
• 2:51
  values for these anatomical parameters, they're
• 2:53
  often quite far from accurate when you apply
• 2:55
  them to a growing child. And the main reason
• 2:57
  for that is because getting accurate, reliable
• 3:00
  measurements is inherently difficult in very
• 3:02
  young children. Prof mo imam. It's down to the
• 3:05
  developing ossification centers. These are the
• 3:07
  parts of the bone that are still cartilage, still
• 3:09
  hardening into bone. They just aren't consistently
• 3:11
  visible or fully formed on a standard x -ray
• 3:14
  in the same way they are in adults. I see. So
• 3:17
  you're trying to measure something that isn't
• 3:18
  fully there yet on the image. Prof mo imam. In
• 3:23
  essence, yes. It's like trying to restore a painting
• 3:28
  without the original blueprint. You're making
• 3:29
  your best estimate. And that's where this research
• 3:31
  really comes in, profmoemom. What's fascinating
• 3:33
  here, and what we really wanted to address, is
• 3:36
  that without that clear template of normal growth
• 3:38
  stage by stage, it's genuinely like navigating
• 3:40
  in the dark for orthopedic pediatric surgeons,
• 3:42
  for hand surgeons, profmoemom. It becomes incredibly
• 3:45
  challenging to confidently differentiate between
• 3:47
  what's just normal physiological growth variation
• 3:49
  and what's an actual pathological deviation that
• 3:52
  needs treatment. This research provides that
• 3:54
  much needed map effectively. It shines a light.
• 3:57
  That's a powerful analogy navigating in the dark.
• 3:59
  It really highlights the clinical need. So faced
• 4:02
  with this gap, what were the specific goals?
• 4:04
  What did this extensive research actually set
• 4:06
  out to achieve? Prof. Mo Imam. Well, given that
• 4:09
  critical need, we designed the study with two
• 4:11
  very clear interlinked goals. The first was to
• 4:14
  identify, carefully considering the natural ossification
• 4:16
  pattern, precisely when it becomes valid and
• 4:19
  reliable to measure 10 specific radiographic
• 4:21
  parameters of a growing wrist. Prof. Mo Imam.
• 4:24
  Using a reliable standardized method, of course,
• 4:27
  this directly tackles that issue of the varying
• 4:29
  ossification stages we just talked about. Essentially
• 4:31
  pinning down at what age you can actually see
• 4:33
  and measure each feature accurately and consistently
• 4:36
  on a standard x -ray. Finding the window of measurability,
• 4:39
  if you like, right? So step one is figuring out
• 4:41
  when you can actually measure things reliably.
• 4:43
  Prof Mo Imam, exactly. And then secondly, and
• 4:46
  just as importantly, we aim to establish yearly
• 4:48
  -based normal reference values for these 10 measurements
• 4:51
  for both boys and girls right across that development.
• 4:53
  mental span from age 1 to 16, Prof Mo Imam. The
• 4:57
  idea was to provide an indispensable evidence
• 4:59
  -based guide for all clinicians involved in treating
• 5:02
  children with risk problems, be it fractures
• 5:04
  or other pathologies. Prof Mo Imam. If you connect
• 5:08
  this to the bigger picture, I mean, these goals
• 5:10
  are fundamental. They empower clinicians to make
• 5:12
  much more informed, much more precise decisions.
• 5:15
  Whether that's planning the best way to fix a
• 5:17
  fracture or diagnosing a subtle developmental
• 5:19
  issue accurately, it shifts us away from guesswork,
• 5:23
  often based on adult norms, towards precise,
• 5:26
  age -specific, evidence -based pediatric care.
• 5:29
  That sounds incredibly thorough. And you mentioned
• 5:31
  it was extensive research. This wasn't just looking
• 5:33
  at a few x -rays, was it? Can you give us a sense
• 5:36
  of the scale and the methodological rigor involved?
• 5:38
  Because that's what gives the findings their
• 5:40
  weight, isn't it, Prof. Moriamum? Absolutely.
• 5:43
  The scale was, well, it was significant. And
• 5:46
  the methodology had to be meticulous to ensure
• 5:49
  the findings were robust. We conducted what's
• 5:51
  called a retrospective multi -center analysis.
• 5:54
  profmoemum. That means we gather data from several
• 5:56
  different hospitals or clinical centers. This
• 5:59
  automatically helps make the findings more generalizable,
• 6:01
  more applicable across different settings. So
• 6:03
  not just one hospital's patient group, profmoemum.
• 6:07
  Correct. The study analyzed radiographs x -rays
• 6:10
  from 896 children. Specifically, we looked at
• 6:13
  896 posterior anterior views, that's the front
• 6:15
  to back view, and 896 lateral or side views.
• 6:20
  Crucially, all these children had normal, healthy
• 6:22
  wrists, prof mo imam. And this data wasn't elected
• 6:25
  over a short period, it spanned two full decades,
• 6:27
  from January 1996 right up until April 2016.
• 6:31
  That long timeframe was quite deliberate. It
• 6:33
  allowed us to capture a really wide and representative
• 6:35
  range of developmental stages and natural variations
• 6:37
  over time. Two decades worth of data, that's
• 6:40
  quite something. And how did you group the children?
• 6:42
  Prophemo imam. To make sure we had a good understanding
• 6:44
  across the whole growth period, the children
• 6:46
  were meticulously stratified into 16 distinct
• 6:49
  yearly age groups. So from age 1, age 2, all
• 6:51
  the way up to age 16. Prophemo imam. And within
• 6:53
  each S group, they were further divided by sex.
• 6:55
  We had 471 males and 425 females. So a pretty
• 6:58
  even split. And importantly, each single age
• 7:00
  group included a minimum of 50 children. 50 per
• 7:03
  group. Why that number specifically? Prophemo
• 7:05
  imam. That minimum number wasn't arbitrary. It
• 7:09
  came from a power analysis we did before even
• 7:11
  starting the main data collection. It ensured
• 7:13
  we had enough statistical power within each age
• 7:15
  bracket to detect differences that were not just
• 7:18
  statistically significant but also clinically
• 7:20
  meaningful. That makes sense. And I imagine defining
• 7:23
  normal for inclusion must have been incredibly
• 7:25
  strict for a study like this. How did you ensure
• 7:27
  you were really looking at healthy risks? Prof.
• 7:29
  Moimam, oh, absolutely rigorous. We had a very
• 7:32
  strict inclusion and exclusion process. Firstly,
• 7:35
  only x -rays that had been officially reported
• 7:37
  as normal by a specialist radiologist were even
• 7:40
  considered. Profmoimom. But we didn't stop there.
• 7:44
  These normal images then underwent a second,
• 7:46
  independent check by two experienced orthopedic
• 7:49
  investigators, myself included. This two -stage
• 7:51
  process meant we could systematically filter
• 7:53
  out any images showing obvious fractures, of
• 7:55
  course, but also any subtle abnormalities or
• 7:58
  even minor technical errors in how the x -ray
• 8:00
  was taken that could affect measurements. So
• 8:02
  double -checking everything. Profmoimom. And
• 8:04
  we also excluded children if they had any relevant
• 8:07
  medical history, things like congenital problems,
• 8:10
  systemic diseases that affect growth, or even
• 8:13
  previous fractures in that wrist, anything that
• 8:15
  could potentially skew the growth pattern away
• 8:17
  from normal. Prof mo imam. This focus on normal
• 8:21
  is just so critical, you simply can't define
• 8:23
  what's abnormal without a crystal clear robust
• 8:26
  baseline of what normal development looks like
• 8:28
  at every single age. Prof mo imam. The sheer
• 8:32
  number of children involved, combined with this
• 8:34
  very careful selection and double validation
• 8:36
  process, gave us that highly robust baseline.
• 8:39
  It really is the foundation upon which all the
• 8:41
  subsequent findings are built. Getting that right
• 8:43
  was paramount. I can tell you, sifting through
• 8:45
  thousands upon thousands of images, cross -referencing
• 8:48
  clinical histories, it was a huge undertaking,
• 8:50
  but absolutely necessary. That level of scrutiny
• 8:52
  is really impressive. It certainly builds confidence
• 8:54
  in the baseline. So once you had this vast, carefully
• 8:58
  curated dataset of normal wrists, what were the
• 9:00
  specific things you were measuring? These 10
• 9:02
  key radiographic parameters, could you walk us
• 9:05
  through them? What does each one tell you? These
• 9:07
  10 parameters, when taken together, they give
• 9:09
  us a very comprehensive geometric profile of
• 9:12
  the developing wrist. We measured them meticulously,
• 9:15
  but always dependent on the wrist's ossification
• 9:17
  pattern. meaning only when that specific feature
• 9:20
  was clearly visible and reliably measurable on
• 9:22
  the x -ray for that age group. Prophmo imam.
• 9:26
  Okay, so first we looked at ulnar variance. This
• 9:28
  measures the difference in length between the
• 9:30
  two forearm bones, the radius and ulna, right
• 9:32
  at the wrist joint. It's measured as the perpendicular
• 9:35
  distance between their end lines, essentially
• 9:37
  telling us if the ulna is shorter, longer, or
• 9:39
  the same length as the radius at that point.
• 9:41
  Important for load distribution, how they line
• 9:43
  up. Right. Prophemol imam, exactly. Then radial
• 9:46
  height. This is the height of the radius bone
• 9:48
  at the wrist end, measured from its main shaft
• 9:50
  line up to the tip of the radial styloid, the
• 9:52
  bony prominence on the thumb side. It relates
• 9:55
  to the space available for the carpal bones.
• 9:57
  Prophmo Imum. Next is radial inclination. This
• 10:01
  is an angle. It measures the sideways tilt of
• 10:03
  the end surface of the radio. Think of it like
• 10:04
  the slope on the end of the radius where the
• 10:06
  wrist bones sit. It's crucial for how the wrist
• 10:08
  moves side to side, like a ramp. Prophmo Imum.
• 10:12
  Sort of, yes. Then the radial carpal angle. Another
• 10:16
  angle, this one assesses the overall alignment
• 10:18
  of that first row of carpal bones relative to
• 10:20
  the radius. It gives an indication of how well
• 10:22
  the hand is seated on the forearm. prof mo imam.
• 10:26
  Moving to the carpal bones themselves, we measured
• 10:28
  carpal height. This is the overall height of
• 10:30
  that block of small carpal bones measured along
• 10:32
  the line of third metacarpal, the long bone in
• 10:35
  the hand leading to the middle finger. It tells
• 10:37
  us about the compactness or potential collapse
• 10:39
  of the carpus, perfmore imam. And related to
• 10:42
  that is the carpal ratio. This simply compares
• 10:44
  the carpal height to the length of that third
• 10:46
  metacarpal. It gives us a proportional measure,
• 10:48
  which is useful because it adjusts for the child's
• 10:51
  overall hand size. Okay, so those are mostly
• 10:53
  from the front on view, perfmore imam. Those
• 10:55
  first six, yes, are primarily from the PA view.
• 10:59
  Then on the lateral, the side view, we assessed
• 11:01
  volar tilt, sometimes called palmar tilt. This
• 11:04
  measures the forward tilt of the end surface
• 11:06
  of the radius, so how much it slopes towards
• 11:07
  the palm side. Very important for wrist flexion
• 11:09
  and stability. Profmo imam. Then we looked at
• 11:12
  the relationship between two key carpal bones,
• 11:14
  the scaphoid and the lunate. The scapholunate
• 11:17
  angle measures the angle between the axes of
• 11:19
  these two bones. Changes here can indicate instability.
• 11:22
  Prophemo imam. Similarly, the capital lunate
• 11:25
  angle measures the angle between the lunate and
• 11:27
  the capitate, which is the large central carpal
• 11:29
  bone. Again, it's assessing the alignment within
• 11:31
  the carpus itself, Prophemo imam. And finally,
• 11:34
  the scaphelinate distance. This is simply the
• 11:36
  gap measured between the scaphoid and the lunate.
• 11:39
  In adults, a widening of this gap is a classic
• 11:42
  sign of a ligament tear. So you see, each parameter
• 11:46
  gives us a unique piece of the developmental
• 11:48
  puzzle alignment proportion angles. Together,
• 11:51
  they build that comprehensive geometric profile
• 11:53
  we needed. Vital for understanding both normal
• 11:55
  growth and spotting subtle problems. That is
• 11:57
  incredibly detailed. Ten different measurements
• 11:59
  across multiple centers over 20 years. Which
• 12:02
  brings me to the question of consistency. How
• 12:04
  could you be absolutely sure that these measurements
• 12:06
  were accurate and reliable? How did you ensure
• 12:08
  that precision? A critical question indeed. And
• 12:13
  ensuring reliability was a major focus. All the
• 12:17
  radiographs, regardless of when or where they
• 12:19
  were taken over that two -decade span, were rigorously
• 12:21
  checked for quality and adequacy. This was done
• 12:24
  first by a senior radiologist and then independently
• 12:27
  by the two orthopedic investigators involved,
• 12:29
  Prof. Mor Imam. we adhered to a very strict preferred
• 12:33
  imaging protocol. This meant consistent patient
• 12:36
  positioning was paramount. For example, the patient
• 12:39
  always had to be seated, forearm resting flat,
• 12:42
  specific hand and finger positioning for both
• 12:44
  the PA and lateral views. This standardization
• 12:46
  was absolutely key to minimizing variability
• 12:49
  right from the start. So the way the x -ray was
• 12:51
  taken was standardized as much as possible. Prof.
• 12:53
  Mo 'imam, exactly. But beyond that, we rigorously
• 12:57
  tested the reliability of the measurements themselves.
• 12:59
  We calculated what are known as interclass correlation
• 13:02
  coefficients, or ICCs. These statistical measures
• 13:04
  assess agreement. Prophemo imam. And our study
• 13:07
  demonstrated excellent reliability, with ICCs
• 13:09
  consistently above .85 for all 10 parameters.
• 13:12
  This covered both interobserver reliability,
• 13:15
  meaning the same person measuring the same x
• 13:17
  -ray at different times got consistent results,
• 13:19
  and interobserver reliability, meaning different
• 13:21
  people measuring the same x -ray also got consistent
• 13:24
  results. Above .85, that sounds very high. Prophemo
• 13:27
  imam. It is considered excellent in this context.
• 13:31
  This high level of consistency is absolutely
• 13:33
  vital for clinical usefulness. It means the reference
• 13:37
  values we've established are trustworthy. Clinicians
• 13:39
  in different hospitals using these guidelines
• 13:41
  can be confident they will arrive at similar
• 13:43
  reliable conclusions when assessing a child's
• 13:45
  wrist. It provides a shared objective standard
• 13:48
  that really does solidify the findings. Knowing
• 13:51
  the measurements are so reproducible gives immense
• 13:53
  confidence. Okay so professor we have the what
• 13:56
  and the how. Now for the really fascinating part
• 13:58
  the what did you find? Yeah. What did this incredibly
• 14:01
  detailed data actually reveal about the dynamic
• 14:04
  journey of a child's wrist as it grows and matures?
• 14:07
  Right, this is where the developmental picture
• 14:09
  really comes alive. We found very clear age milestones
• 14:12
  for when different parameters actually become
• 14:13
  reliably measurable on these standard x -rays.
• 14:16
  Profmo imam. For instance, four key measurements,
• 14:19
  ulnar variance, radial height, carpal height,
• 14:21
  and the carpal ratio, these were all consistently
• 14:24
  definable and measurable right from the first
• 14:26
  year of life. That's quite significant because
• 14:28
  it means cornitions can start assessing these
• 14:30
  fundamental relationships very early on using
• 14:33
  objective data. So even in a one -year -old,
• 14:35
  you can reliably measure those four things. Yes,
• 14:39
  with the standardized methods we used. Then,
• 14:42
  as children get a bit older, more features become
• 14:44
  clear enough to major accurately. From around
• 14:46
  age 4, radial inclination, the radiocarpal angle,
• 14:50
  and the capital lunet angle became reliably measurable.
• 14:52
  Prof mo imam. This timing makes sense biologically
• 14:55
  because their accurate assessment really depends
• 14:56
  on the epithesis, the end part of the bone being
• 14:59
  sufficiently calcified, hardened into bone, to
• 15:01
  show up clearly on the x -ray. Before age 4,
• 15:04
  these areas are mostly cartilage, still developing
• 15:06
  essentially. Prof mo imam, precisely. Then, a
• 15:09
  bit later, from age 6 onwards, we found that
• 15:10
  the scaphalunid angle and the scaphalunid distance
• 15:13
  could only be reliably measured. This timing
• 15:15
  correlates directly with when the ossific centers
• 15:18
  of the lunate and scaphoid bones themselves typically
• 15:21
  appear as visible bone, usually around ages four
• 15:23
  and five respectively. So you need both bones
• 15:25
  to be sufficiently ossified to measure the relationship
• 15:28
  between them accurately. Okay, so different timings
• 15:30
  for different measurements based on when the
• 15:32
  bones actually develop enough to be seen clearly.
• 15:35
  Prophmo imam, exactly. And what a final example,
• 15:38
  the palmar tilt or voller tilt measured on the
• 15:41
  side view. We found this wasn't really developed
• 15:43
  or consistently measurable until about age 11.
• 15:46
  After that point, it started to gradually increase.
• 15:49
  This relies on the development of the distal
• 15:51
  radius's voller inclination, which typically
• 15:53
  occurs around age 10, so it really underscores
• 15:57
  the dynamic nature of growth. You can't just
• 15:59
  apply one standard measurement technique across
• 16:01
  all ages. Our findings pin down precisely when
• 16:04
  these different parts of the wrist become sufficiently
• 16:06
  ossified and geometrically stable enough for
• 16:09
  accurate radiographic assessment. That's such
• 16:11
  a crucial point. It's not just what you measure,
• 16:13
  but when you can measure it reliably. Beyond
• 16:16
  that timing, what were the most striking growth
• 16:18
  trends or patterns you observed? How did these
• 16:20
  parameters change as children got older? Any
• 16:22
  surprises? Profmo imam. Yes, several really interesting
• 16:25
  clinically important patterns emerged. Let's
• 16:27
  take ulnar variance again. We confirmed a clear
• 16:29
  predominance of what we call ulna minus variance
• 16:32
  in children throughout most of their growth,
• 16:34
  meaning the ulna is shorter than the radius of
• 16:36
  the wrist. Profmo imam. Correct. On average.
• 16:40
  And what was fascinating was that this characteristic
• 16:42
  remained remarkably stable. It didn't consistently
• 16:45
  change from birth right up until about age 14.
• 16:48
  But then, quite abruptly, it showed a rapid increase
• 16:51
  around ages 15 or 16. It typically moved towards
• 16:53
  a neutral variance, or sometimes even a positive
• 16:55
  variance, where the ulna becomes longer than
• 16:57
  the radius as the child nears skeletal maturity.
• 17:00
  That's a really distinct shift. Does that have
• 17:03
  clinical implications, profimo imam? We think
• 17:05
  it does. This predominant ulna minus variance
• 17:08
  during childhood could, hypothetically, be a
• 17:11
  natural protective feature. It might help explain
• 17:13
  why certain conditions common in adults, like
• 17:15
  injuries to the TFCC—that's the triangular fibrocartilage
• 17:19
  complex—a key stabilizer or ulnar impaction syndrome,
• 17:23
  are relatively rare in children. The anatomy
• 17:25
  itself might be protective during those years.
• 17:29
  Interesting. What about the other measurements?
• 17:31
  A prof mot imam? Radial height, radial inclination,
• 17:34
  and the radial carpal angle all showed a very
• 17:36
  consistent pattern, a steady, predictable increase
• 17:39
  throughout the growth period. They generally
• 17:41
  reach their adult values right around the onset
• 17:43
  of the pubertal growth spurt. This clearly reflects
• 17:46
  the gradual expansion and specific shaping of
• 17:48
  the end of the radius bone as it matures. Prof
• 17:51
  Mo Imam. For carpal height, as you'd expect,
• 17:54
  it showed a constant increase with growth, reflecting
• 17:56
  the lengthening of the carpal bones. But the
• 17:59
  carpal ratio comparing carpal height to the third
• 18:01
  metacarpal length showed no obvious increasing
• 18:03
  or decreasing trend. This suggests the proportions
• 18:06
  within the wrist and hand remain remarkably consistent
• 18:08
  relative to each other throughout growth, even
• 18:10
  as the absolute size increases. So the overall
• 18:13
  shape stays proportional. Prof. Mol Imam seems
• 18:15
  so, yes. Now, a particularly important finding,
• 18:18
  especially for avoiding misdiagnosis, relates
• 18:20
  to the scaphoid and lunate. We observed a significantly
• 18:23
  wider scaphelunit distance in younger children,
• 18:26
  and this gap gradually narrowed as they grew
• 18:28
  older, profmo imam. Similarly, the scaphelunit
• 18:31
  and capitalunit angles were found to be larger
• 18:33
  in children compared to adults, and they showed
• 18:36
  a downward trend, becoming smaller as growth
• 18:38
  progressed, generally stabilizing around 12 to
• 18:40
  13 years of age. Why is this so important? Because
• 18:44
  in adults, a wide gap or abnormal angles here
• 18:47
  are signs of instability, often requiring surgery.
• 18:50
  But in children, our data shows this is just
• 18:52
  a normal part of development. As those carpal
• 18:54
  bones ossify, changing from cartilage to solid
• 18:57
  bone, the space between them naturally tightens
• 18:59
  and the angles change. It's crucial not to misinterpret
• 19:02
  this normal developmental phase as pathology.
• 19:06
  And finally, the Palmer radial tilt, once it
• 19:09
  became measurable around age 11, it increased
• 19:11
  gradually, reaching adult values by the time
• 19:13
  puberty finished, finalizing the wrist -adult
• 19:15
  configuration. So if you put it all together,
• 19:18
  these predictable, reproducible anatomical changes
• 19:22
  map out a clear developmental pathway. They establish
• 19:25
  that vital baseline needed to distinguish normal
• 19:28
  variation from true pathology at different ages.
• 19:31
  The consistency we found really strengthens the
• 19:33
  clinical utility that is incredibly clear. The
• 19:36
  pattern seems so distinct. Now, one thing that
• 19:39
  often comes up in development is differences
• 19:40
  between sexes. One might naturally assume boys
• 19:43
  and girls bones might grow differently, maybe
• 19:45
  at different rates. or reaching different final
• 19:46
  configurations. Did your research find significant
• 19:49
  sex differences in these risk parameters? Prof
• 19:52
  mo imam. That's a very common assumption, and
• 19:55
  it's one of the areas where our findings were
• 19:57
  particularly significant, and perhaps, yes, a
• 19:59
  little surprising for clinical practice. Prof
• 20:01
  mo imam. Despite analyzing data for 471 boys
• 20:05
  and 425 girls across 16 age groups, our extensive
• 20:08
  analysis revealed no significant sex differences
• 20:11
  across any of the 10 measured radiographic parameters.
• 20:14
  None at all. It's quite definitive. prof mo imam.
• 20:16
  It was a very clear and consistent finding. When
• 20:18
  we performed the statistical analysis, age was
• 20:21
  the only significant predictor for the changes
• 20:23
  we observed in these measurements. Neither the
• 20:25
  child's sex nor even their hand dominance, whether
• 20:28
  they were right or left handed, were found to
• 20:30
  be significant factors influencing these specific
• 20:32
  wrist parameters. That's really fascinating and
• 20:36
  incredibly practical for clinicians, I imagine.
• 20:38
  It simplifies things considerably. Prof mo imam.
• 20:41
  It does indeed. It means one less variable to
• 20:44
  factor in when a sentiment child's wrist radiograph
• 20:46
  against these norms. Before this research, without
• 20:49
  this definitive pediatric data, there might have
• 20:52
  been, perhaps, a subtle bias or an underlying
• 20:54
  assumption that growth patterns would differ
• 20:55
  between boys and girls, leading to maybe uncertainty
• 20:58
  in diagnosis. Profmoemum? Potentially, yes. A
• 21:02
  clinician might have seen similar measurements
• 21:04
  in a boy and girl of the same age and wondered
• 21:05
  if it meant something different for each, perhaps
• 21:08
  leading to unnecessary follow -up, extra imaging,
• 21:10
  or maybe even just diagnostic uncertainty. Proph
• 21:13
  mo imam. Our finding that, for these specific
• 21:16
  wrist measurements, there are no significant
• 21:18
  sex differences provides a single unified age
• 21:21
  -specific reference range. It streamlines the
• 21:23
  assessment. Clinicians don't need separate charts
• 21:26
  for boys and girls for these parameters. They
• 21:29
  can confidently apply the same age -matched normal
• 21:32
  values regardless of the child's sex. That removes
• 21:34
  a layer of complexity, then, Prof. Moima. Exactly.
• 21:37
  It allows the focus to be purely on the objective
• 21:40
  measurements compared against the established
• 21:42
  norm for that child's chronological and skeletal
• 21:44
  age. It's a powerful message of biological uniformity
• 21:47
  in the specific anatomical context, at least
• 21:50
  concerning these widely used radiographic parameters.
• 21:53
  That clarity is so valuable. Okay, so professor,
• 21:57
  let's bring all these threads together. We have
• 21:58
  the precise measurements, the clear age -related
• 22:01
  changes, the lack of sex differences, the rigorous
• 22:03
  methodology. What does this all mean in practice?
• 22:06
  How did these detailed findings directly benefit
• 22:08
  the orthopedic professionals on the ground, and
• 22:10
  ultimately, the children they're treating? What's
• 22:12
  the real so -what here? Prof Moemem. Right? The
• 22:15
  clinical application is the ultimate goal. Essentially,
• 22:17
  the study's findings collectively provide a unique
• 22:19
  and frankly long overdue template of pediatric
• 22:22
  normal values. This acts as an invaluable practical
• 22:26
  guide for ham surgeons, pediatric orthopedic
• 22:28
  surgeons, even radiologists and pediatricians
• 22:31
  when they're managing children with wrist problems.
• 22:34
  Proth -mo -emome. The core benefit is the ability
• 22:37
  to compare a child's specific risk measurements
• 22:39
  against these robust age -specific normal values.
• 22:43
  This allows for much earlier and more precise
• 22:45
  identification of any deviations from the expected
• 22:48
  normal growth pattern. So, better diagnosis,
• 22:51
  essentially. Prof. Mo 'imam. Better and earlier
• 22:54
  diagnosis, yes, but it goes beyond that. This
• 22:57
  evidence is also crucial for guiding treatment,
• 22:59
  particularly after trauma. For instance, when
• 23:01
  reducing a distal radius fracture, these values
• 23:04
  provide objective targets to aim for, helping
• 23:06
  ensure the fracture heals in the best possible
• 23:08
  anatomical position for long -term function and
• 23:11
  minimizing the risk of later problems like stiffness
• 23:13
  or arthritis. Before, judging the adequacy of
• 23:16
  reduction was often more subjective. That makes
• 23:18
  sense. Can you give some specific examples of
• 23:21
  how these values help differentiate normal from
• 23:23
  abnormal or act as predictive tools? Prophemo
• 23:25
  imam, certainly. Let's look at ulnar variances.
• 23:27
  The reference values we established are now critical
• 23:30
  for distinguishing truly impaired ulnar growth,
• 23:32
  which you might see in conditions like juvenile
• 23:34
  arthritis or certain genetic conditions, like
• 23:37
  hereditary multiple -exhaustoses from an ulnar
• 23:39
  variance that, while maybe appearing short or
• 23:41
  long, still falls within the normal developmental
• 23:43
  range for that specific age. It prevents overdiagnosis
• 23:47
  of pathology. Prof Moimim. Furthermore, tracking
• 23:50
  ulnar variance over time using these norms can
• 23:53
  become a useful prognostic tool. For children
• 23:56
  with known progressive bone or joint diseases,
• 23:58
  monitoring this value can help identify those
• 24:00
  at higher risk for developing secondary problems
• 24:02
  like instability or subluxation of the carpus,
• 24:05
  allowing for early intervention if needed. So
• 24:08
  it helps monitor ongoing conditions too. Profmo
• 24:10
  imim. Absolutely. Then consider carpal height.
• 24:13
  Our study reinforces its value not just for diagnosis,
• 24:16
  but also for assessing disease severity and tracking
• 24:19
  the progression of what's turned carpal collapse.
• 24:21
  For example, we know that reduced carpal height
• 24:23
  can be seen in conditions like multiple epiphyseal
• 24:26
  dysplasia or Turner syndrome. Conversely, an
• 24:29
  increased carpal height can be a feature of achondroplasia.
• 24:32
  Profmo imam. And perhaps even more powerfully,
• 24:35
  subtle early changes in carpal height can actually
• 24:37
  predict poorer long -term outcomes in children
• 24:40
  with juvenile idiopathic arthritis. That's invaluable
• 24:43
  information for managing treatment and counseling
• 24:45
  families. That's a very direct link to predicting
• 24:48
  outcomes. Profmo imam. It is. And similarly for
• 24:52
  radial height and inclination, we confirmed that
• 24:54
  loss of radial height or significant changes
• 24:56
  in radial inclination after a fracture are strong
• 24:58
  predictors of a less favorable outcome, both
• 25:01
  in children and adults. Knowing this helps guide
• 25:03
  how aggressively we might need to intervene to
• 25:05
  restore the anatomy after certain types of distal
• 25:07
  radius fractures. Prophemo imam. The radiocarpal
• 25:11
  angle also proved useful. It aids in diagnosing
• 25:14
  certain congenital anomalies, like the characteristic
• 25:16
  hand shape seen in Hurler syndrome, and it's
• 25:18
  instrumental when we're creating growth plate
• 25:19
  injuries, physial arrests, to assess if we've
• 25:22
  restored the normal alignment. Prof Moimum. So
• 25:25
  taken together, these findings really allow clinicians
• 25:28
  to be more proactive. We can anticipate potential
• 25:30
  issues, intervene more precisely, monitor progress
• 25:33
  objectively, all guided by these evidence -based
• 25:35
  measurements. It leads to better, more tailored
• 25:37
  care. That's a clear shift towards more precise
• 25:39
  proactive care. What about those very young children,
• 25:43
  though, where the bones, as you said, aren't
• 25:45
  fully ossified and might be hard to see clearly
• 25:47
  on an x -ray? How does this research help navigate
• 25:50
  that challenge and avoid misdiagnosis? Crofmo
• 25:53
  Imam. That's a profoundly important application
• 25:55
  because managing injuries in very young children,
• 25:58
  say under four or five, presents unique challenges
• 26:01
  precisely because of that incomplete ossification.
• 26:04
  Crofmo Imam. In situations where the distal radius
• 26:07
  epiphysis isn't yet fully visible on the x -ray,
• 26:10
  the combined measurements of the parameters we
• 26:12
  can see reliably from age 1 ulnar variance, radial
• 26:15
  height, and carpal height become the only reliable
• 26:17
  objective guide for assessing the reduction and
• 26:19
  monitoring the healing of distal radius fractures.
• 26:22
  So you use the relationships you can measure
• 26:23
  to infer the position of the parts you can't
• 26:26
  see clearly. Prophmo Imum. Essentially, yes.
• 26:29
  These established normal values for the measurable
• 26:31
  parameters give us the necessary reference points.
• 26:34
  They provide objective data to guide treatment
• 26:36
  even when the key bone ends are still largely
• 26:38
  invisible cartilage. It allows for accurate management
• 26:41
  where previously it was much more difficult,
• 26:43
  profmoemum. And linked to avoiding misdiagnosis,
• 26:46
  I must re -emphasize the point about the scapulunate
• 26:48
  relationship. It is absolutely crucial that clinicians
• 26:51
  understand the naturally wider scapulunate distance
• 26:54
  and the larger scapulunate and capillunate angles
• 26:56
  seen in children are normal development. features.
• 27:00
  Prof mo imam. They should absolutely not be mistaken
• 27:03
  for carpal instability, which is a significant
• 27:05
  adult pathology often requiring surgery. Our
• 27:08
  study provides the biological explanation the
• 27:10
  gap narrows and angles decrease naturally as
• 27:12
  the cartilage ossifies, so a child's x -ray might
• 27:15
  look alarming if judged by adult standards. Prof
• 27:17
  mo imam. Exactly. Without this knowledge, a child
• 27:21
  with perfectly normal developing risks could
• 27:23
  easily be misdiagnosed with instability. This
• 27:25
  could lead to unnecessary anxiety, further investigations,
• 27:28
  maybe even inappropriate treatment for what is
• 27:30
  simply healthy growth. It really raises the question
• 27:33
  how often might this have happened in the past?
• 27:35
  Our data helps prevent these critical misdiagnoses.
• 27:38
  That impact alone preventing misdiagnosis and
• 27:40
  unnecessary interventions is huge. Now, shifting
• 27:42
  gears slightly, for surgeons planning more complex
• 27:45
  procedures like correcting deformities, time
• 27:48
  Dreaming is everything. Does this research offer
• 27:51
  guidance on when it might be safest or most appropriate
• 27:53
  to perform procedures like corrective osteotomies?
• 27:56
  Prophemo imam. Yes, it does offer a very practical
• 28:00
  guideline for surgical planning. Our findings
• 28:02
  indicate that corrective osteotomies procedures
• 28:05
  where we cut and realign bone to correct a deformity
• 28:08
  can generally be safely performed from the age
• 28:10
  of 12 years onwards without jeopardizing the
• 28:13
  child's remaining normal wrist development. From
• 28:16
  age 12. Why that specific age? Prophmo, Imum.
• 28:20
  The reasoning comes directly from our data. We
• 28:22
  observe that most of the key radiologic parameters
• 28:25
  demonstrate only minimal changes from the 12
• 28:27
  -year -old time point through to skeletal maturity.
• 28:30
  This suggests that by age 12, the wrist has achieved
• 28:32
  a significant degree of anatomical stability
• 28:34
  and maturity. The major developmental changes
• 28:37
  have largely occurred. Prophemo imam. Performing
• 28:40
  the surgery after this point is less likely to
• 28:42
  interfere with unpredictable growth spurts or
• 28:44
  significantly alter the final outcome due to
• 28:46
  ongoing natural development. It provides a clear
• 28:49
  evidence -based window for surgical planning.
• 28:51
  offering clinicians, and importantly parents,
• 28:54
  greater confidence about the timing of such interventions.
• 28:57
  It helps ensure we choose the optimal time for
• 28:59
  the best possible long -term result. That's incredibly
• 29:02
  helpful, providing that objective marker for
• 29:05
  surgical decision -making. Professor, as with
• 29:07
  any research, it's important to understand the
• 29:09
  context. Are there any nuances or limitations
• 29:12
  to this study that clinicians should bear in
• 29:14
  mind when applying these findings? Prophemo imam.
• 29:17
  That's a very fair point, and acknowledging limitations
• 29:20
  is always crucial in science. Firstly, while
• 29:22
  it was extensive, this was primarily a radiological
• 29:25
  analysis based on existing X -rays. Retrospective
• 29:28
  studies like this always carry an inherent, though
• 29:30
  hopefully small, risk of certain biases, perhaps
• 29:33
  in patient selection over the years, or potential
• 29:35
  under -representation of some very specific demographic
• 29:38
  groups. Prof. Mo Imam, however, we believe the
• 29:41
  study's rigorous design, the multi -center nature,
• 29:43
  the large sample size with at least 50 children
• 29:45
  per age group, Adding two decades significantly
• 29:48
  mitigates these concerns and makes the data highly
• 29:50
  robust and broadly applicable. What about the
• 29:53
  lack of sex difference? Could there be very subtle
• 29:56
  differences the study missed? Procmo imum. It's
• 30:00
  possible. While we found no statistically significant
• 30:03
  sex differences, which is the key message for
• 30:06
  clinical practice, we do acknowledge that the
• 30:08
  study might theoretically have been underpowered
• 30:10
  to detect extremely subtle differences related
• 30:12
  to sex, or perhaps even handedness, if they exist
• 30:15
  at a very minor level. Our focus was on identifying
• 30:19
  clinically relevant significant trends and differences,
• 30:21
  which we did with high confidence. Prof Mo Imam.
• 30:25
  Also, we did have to exclude a small percentage
• 30:27
  of radiographs due to technical errors or suboptimal
• 30:30
  positioning. This was necessary to maintain the
• 30:32
  quality of the data used for measurements. Given
• 30:35
  the huge overall number of images analyzed, it's
• 30:38
  highly unlikely this skewed the results, but
• 30:39
  it's a factor to note. And what about the fact
• 30:42
  that x -rays mainly show bone, not cartilage?
• 30:45
  Prof Mo Imam. That's a fundamental point about
• 30:47
  the imaging modality itself. Plane radiographs
• 30:50
  primarily visualize ossified bone. They can't
• 30:52
  definitively tell us about the precise shape,
• 30:54
  position, or motion of the parts that are still
• 30:56
  cartilage, especially in very young children.
• 30:59
  So we can't say for certain if the angle and
• 31:01
  intervals we measured perfectly reflect the cartilaginous
• 31:03
  structure, or if they partly reflect asymmetries
• 31:06
  in how the bone itself is forming within that
• 31:08
  cartilage. profmo imam. However, the study's
• 31:12
  core aim wasn't necessarily to map the cartilage,
• 31:14
  but to map the developmental array of the wrist
• 31:16
  as seen on standard clinical imaging to define
• 31:19
  what is consistently visible and reliably measurable
• 31:21
  using the most common tool, the plane radiograph.
• 31:25
  And that... it achieves successfully. So while
• 31:28
  it's important to be transparent about these
• 31:30
  natural boundaries of the technique, the practical
• 31:32
  reliability and clinical utility of the developmental
• 31:34
  map we've created remain exceptionally high.
• 31:37
  That transparency is really helpful. And it does
• 31:39
  raise that question with advanced imaging like
• 31:42
  MRI available now, which shows cartilage well.
• 31:44
  Why focus a foundational study like this on plane
• 31:46
  x -rays? What's their enduring value here? Pro,
• 31:48
  mo, ima? That's an excellent practical question.
• 31:51
  MRI certainly offers incredibly detailed anatomical
• 31:54
  information, including cartilage. And it definitely
• 31:56
  has its place for specific diagnostic questions.
• 31:59
  However, plain radiographs remain the absolute
• 32:01
  cornerstone of musculoskeletal imaging for several
• 32:04
  very good reasons. Prof mo imam. Firstly, they
• 32:08
  are simple, quick, and remarkably inexpensive
• 32:10
  compared to MRI. Secondly, they are highly feasible
• 32:14
  to perform on young children who might struggle
• 32:16
  to stay still for the length of time required
• 32:18
  for an MRI scan. Prof mo imam. Thirdly, they
• 32:21
  provide an excellent immediate overview of the
• 32:24
  wrist's overall geometry, bony alignment, fracture
• 32:26
  patterns, and the stage of skeletal development.
• 32:29
  This makes them the most practical and accessible
• 32:31
  tool for broad clinical application, particularly
• 32:34
  in high -volume settings like A &E or busy outpatient
• 32:37
  clinics. For establishing these fundamental,
• 32:39
  widely applicable normal reference values across
• 32:41
  diverse healthcare systems, plain radiography
• 32:44
  was, and remains, the ideal tool, profmo imam.
• 32:47
  So, in essence, this research provides that age
• 32:50
  -stratified reference for normal wrist development
• 32:52
  using the most commonly available imaging. By
• 32:55
  doing so, it truly empowers clinicians, giving
• 32:57
  them the knowledge needed to provide superior,
• 32:59
  more confident care, leading to better outcomes
• 33:01
  for countless children with wrist injuries and
• 33:03
  conditions. It's about building a more evidence
• 33:06
  -based foundation for pediatric orthopedics.
• 33:09
  Professor Mo Imam, thank you so much. That was
• 33:12
  an incredibly insightful journey through the
• 33:14
  intricacies of the growing wrist. It's absolutely
• 33:17
  clear how this work reshapes understanding and
• 33:20
  provides such practical tools for clinicians.
• 33:22
  And for you, our listener, we've really taken
• 33:25
  a deep dive today, haven't we? Into how a child's
• 33:28
  wrist develops, why adult measurements just don't
• 33:30
  cut it, and how this groundbreaking research
• 33:32
  offers that essential map for doctors and surgeons.
• 33:35
  We've seen how understanding normal growth allows
• 33:37
  for early diagnosis, more precise treatment,
• 33:40
  and crucially helps avoid those misinterpretations
• 33:42
  of normal development as something pathological.
• 33:45
  If you found this deep dive valuable, please
• 33:47
  do take a moment to rate and share the show.
• 33:49
  It genuinely helps more professionals like you
• 33:51
  discover these crucial insights. And finally,
• 33:53
  as we reflect on the detailed age -specific changes
• 33:56
  within something like a child's wrist, it really
• 33:58
  makes you wonder, doesn't it? What other seemingly
• 34:00
  fundamental parts of our anatomy hold similarly
• 34:03
  complex developmental secrets just waiting to
• 34:06
  be unlocked to improve health care for everyone
• 34:08
  at every age?