Date of Award

January 2019

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)



First Advisor

Daniel R. Cooperman


Background: There are multiple skeletal maturity grading systems, but none of them utilizes the phalanges of the foot. To minimize radiation, it would be ideal if one could assess the skeletal maturity of a foot based on bones seen on routine foot x-rays, if guided growth is being considered as a treatment option, as in hallux valgus. We developed a system that in combination with the calcaneal system, can closely predict skeletal maturity and help with the timing of surgical interventions of the foot.

Methods: We selected 94 healthy children from the Bolton-Brush study, each with consecutive radiographs from age ten to fifteen years old. Using the AP view, we analyzed the ossification patterns of the phalanges and developed a six stage classification system. We then determined the Peak Height Velocity (PHV) for each subject and defined its relationship with our system. Our system was then compared to the previously established calcaneal system.

Results: We calculated an Intraclass correlation coefficient (ICC) range of 0.957-0.985 with an average of 0.975 and interclass reliability coefficient of 0.993 indicating that this method is reliable and consistent. Our system showed no significant difference between sexes, with respect to PHV, which makes it a reliable surrogate for determining bone age in pediatric and adolescent patients.

Conclusions: Our system has a strong association with the calcaneal system. It is reliable and correlated more strongly with PHV than chronological age. The system requires knowledge of the ossification markers used for each stage but is easily used in a clinical setting.


This is an Open Access Thesis.

Open Access

This Article is Open Access