OSTEOSYNTHESIS OF COMPLEX COMMINUTED HAND BONE FRACTURES BY APPLYING THE LACING METHOD (A CLINICAL CASE STUDY).

Complex comminuted hand injuries are an urgent medical and social problem of national health systems, which is especially sensitive for countries with a low level of socio-economic development. The work aims to substantiate the effectiveness and safety of the shoelace method of hand bone osteosynthesis in complex comminuted fractures (a clinical case study). Clinical case: A 42-year-old female patient was admitted to the clinic with complaints of the presence of a crushed wound on the 2nd finger of the left hand. The shoelace method was applied for hand bone osteosynthesis. The surgical intervention time was 24 minutes, and the time before returning to work or daily activities equaled 7.1 weeks. The time to bone fusion was less than 45 days. The shoelace osteosynthesis method in complex comminuted fractures of the hand bones has prospects for modern clinical practice with the possibility of improving the performance and safety indicators.

Traditional and New Methods of Bone Age Assessment-An Overview

Bone age is one of biological indicators of maturity used in clinical practice and it is a very important parameter of a child's assessment, especially in paediatric endocrinology. The most widely used method of bone age assessment is by performing a hand and wrist radiograph and its analysis with Greulich-Pyle or Tanner-Whitehouse atlases, although it has been about 60 years since they were published. Due to the progress in the area of Computer-Aided Diagnosis and application of artificial intelligence in medicine, lately, numerous programs for automatic bone age assessment have been created. Most of them have been verified in clinical studies in comparison to traditional methods, showing good precision while eliminating inter- and intra-rater variability and significantly reducing the time of assessment. Additionally, there are available methods for assessment of bone age which avoid X-ray exposure, using modalities such as ultrasound or magnetic resonance imaging.

Relationship between hand and wrist bone age assessment methods.

Assessment of skeletal maturity is crucial for managing growth related problems. Tanner and Whitehouse (TW) hand and wrist bone age assessment is an accurate method; however, it is complex and labor-intensive. Several simplified methods derived from the TW method were proposed, and each had its own character. The purpose of this study is to explore the relationship between these methods for accurate usage.Between 2018 and 2019, a cross-sectional study was performed with consecutive left hand and wrist x-rays obtained from a pediatric orthopedic clinic. Bone age assessments included the distal radius and ulna (DRU) classification, Sanders staging (S), thumb ossification composite index (T), and TW method. Somers delta correlation was conducted to determine the interchangeability of these stages. The mean bone age and standard deviation (SD) of each subgrade were compared and analyzed.Totally 103 films (92 girls) were analyzed with mean age of 12.1 years (range: 8.0-17.9 years). The radius (R) stages had good correlation with S, T, and U stages with a very high Somers delta correlation (P < .05). R5 had relatively large SD (1.5) and referred to T2 and T3; R6 and R7 had the smallest SD (0.3) with reference to T4 or S2; R8 referred to T5 or S3, S4, S5; R9 referred to S6 and S7.The internal relationship between the DRU and digital stages system was well proven. We also provided a simple and accurate way to assess the bone age by combination of some subgrades with smaller SD: 10y-proximal thumb covered without sesamoid (T2); 10.5y-sesamoid just appearing (T3); 11y-distal radial physis just covered (medial double joint line, R6); 11.5y-medial capping of distal radial physis (R7); 12y-bilateral capping of distal radial physis (R8) / phalangeal capping without fusion (S3); 12.5y-distal phalangeal physes start to fuse (S4); 13y-distal phalangeal physes fused (S5); 13.5y-proximal phalangeal physes start to fuse (S6); 14.5y-proximal phalangeal physes fused (S7); 15y-distal radial physis almost fused (R10).Level of Evidence: Diagnostic study, level III.

Forensic age assessment of living adolescents and young adults at the Institute of Legal Medicine, Münster, from 2009 to 2018.

Due to high migration inflows to Europe, forensic age assessment of living persons has clearly gained importance. If there is a legal justification for X-ray examinations without a medical indication, the Study Group on Forensic Age Diagnostics (AGFAD) recommends the combination of a physical examination with anamnesis, an X-ray examination of the hand and a dental examination with evaluation of an orthopantomogram for age assessments of adolescents and young adults. If the development of the hand skeleton has been completed, an additional CT examination of the clavicles is to be performed. To demonstrate the outcome of forensic age assessments according to AGFAD recommendations with regard to migrants of doubtful minority declaration, this study analyzes the expert reports carried out at the Institute of Legal Medicine, Münster, from 2009 to 2018. A total of 597 age assessments were performed during the study period. A total of 227 age assessments were issued on behalf of youth welfare offices in the legal area of social law, 282 in family law proceedings, 76 in criminal proceedings, and 12 age assessments in immigration law proceedings. In 211 out of 597 cases, the stated age was compatible with the findings of the age assessment. In the remaining 386 cases, the average difference between the stated age and the minimum age was 1.9 years. The average difference between stated age and most probable age was 5.1 years. Of the 521 age assessments carried out outside criminal proceedings, 197 unaccompanied minors with questionable age minority (37.8%) have reached the age of majority beyond doubt. A total of 388 unaccompanied minors (74.5%) have most probably reached the age of majority. Forensic age assessments with the AGFAD methodology make an important contribution to legal certainty, the welfare of the child, and the fair distribution of resources.

Applicability of two commonly used bone age assessment methods to twenty-first century UK children.

OBJECTIVES: To assess the effect of secular change on skeletal maturation and thus on the applicability of the Greulich and Pyle (G&P) and Tanner and Whitehouse (TW3) methods. METHODS: BoneXpert was used to assess bone age from 392 hand trauma radiographs (206 males, 257 left). The paired sample t test was performed to assess the difference between mean bone age (BA) and mean chronological age (CA). ANOVA was used to assess the differences between groups based on socioeconomic status (taken from the Index of Multiple Deprivation). RESULTS: CA ranged from 2 to 15 years for females and 2.5 to 15 years for males. Numbers of children living in low, average and high socioeconomic areas were 216 (55%), 74 (19%) and 102 (26%) respectively. We found no statistically significant difference between BA and CA when using G&P. However, using TW3, CA was underestimated in females beyond the age of 3 years, with significant differences between BA and CA (- 0.43 years, SD 1.05, p = < 0.001) but not in males (0.01 years, SD 0.97, p = 0.76). Of the difference in females, 17.8% was accounted for by socioeconomic status. CONCLUSION: No significant difference exists between BoneXpert-derived BA and CA when using the G&P atlas in our study population. There was a statistically significant underestimation of BoneXpert-derived BA compared with CA in females when using TW3, particularly in those from low and average socioeconomic backgrounds. Secular change has not led to significant advancement in skeletal maturation within our study population. KEY POINTS: • The Greulich and Pyle method can be applied to the present-day United Kingdom (UK) population. • The Tanner and Whitehouse (TW3) method consistently underestimates the age of twenty-first century UK females by an average of 5 months. • Secular change has not advanced skeletal maturity of present-day UK children compared with those of the mid-twentieth century.

Applicability of two bone age assessment methods to children from Saudi Arabia.

AIM: To assess the applicability of the Greulich & Pyle (G&P) and Tanner & Whitehouse (TW3) methods to children from Saudi Arabia using both subjective (manual) rating and BoneXpert software. MATERIALS AND METHODS: Bone age (BA) was assessed using the G&P and TW3 methods, firstly by independent manual rating of two observers, followed by a single observer using the BoneXpert software program. In total, 420 hand trauma radiographs for Saudi Arabians (220 males, 329 left, age range 1-18 years) performed in the period January 2012 to September 2016 were assessed. Paired sample t test was used to compare the difference between mean BA and mean chronological age (CA) and to compare the difference between manual and BoneXpert ratings. Statistical analysis was undertaken using SPSS v.25. RESULTS: A statistically significant difference was found between BA and CA in males when using the G&P (mean difference -0.36±1 years, p<0.01) and TW3 (mean difference -0.22±0.9 years, p=0.03) methods, but not in females for either G&P (mean difference 0.13±1.2 years) or TW3 (mean difference 0.08±1.1 years). In males, BoneXpert results conformed to the manual ratings for TW3, but not for G&P, for which the mean difference between manual and BoneXpert ratings was -0.27±0.5 years (p<0.01). DISCUSSION: The present results indicate that manual and BoneXpert-derived G&P and TW3 bone age assessment can be applied with no modification to Saudi Arabian females; however, only TW3 BoneXpert-derived BA can be applied without caution to Saudi Arabian males.

Regression Convolutional Neural Network for Automated Pediatric Bone Age Assessment From Hand Radiograph.

Skeletal bone age assessment is a common clinical practice to investigate endocrinology, and genetic and growth disorders of children. However, clinical interpretation and bone age analyses are time-consuming, labor intensive, and often subject to inter-observer variability. This advocates the need of a fully automated method for bone age assessment. We propose a regression convolutional neural network (CNN) to automatically assess the pediatric bone age from hand radiograph. Our network is specifically trained to place more attention to those bone age related regions in the X-ray images. Specifically, we first adopt the attention module to process all images and generate the coarse/fine attention maps as inputs for the regression network. Then, the regression CNN follows the supervision of the dynamic attention loss during training; thus, it can estimate the bone age of the hard (or "outlier") images more accurately. The experimental results show that our method achieves an average discrepancy of 5.2-5.3 months between clinical and automatic bone age evaluations on two large datasets. In conclusion, we propose a fully automated deep learning solution to process X-ray images of the hand for bone age assessment, with the accuracy comparable to human experts but with much better efficiency.

Automated Assessment of Bone Age Using Deep Learning and Gaussian Process Regression.

Bone age is an essential measure of skeletal maturity in children with growth disorders. It is typically assessed by a trained physician using radiographs of the hand and a reference model. However, it has been described that the reference models leave room for interpretation leading to a large inter-observer and intra-observer variation. In this work, we explore a novel method for automated bone age assessment to assist physicians with their estimation. It consists of a powerful combination of deep learning and Gaussian process regression. Using this combination, sensitivity of the deep learning model to rotations and flips of the input images can be exploited to increase overall predictive performance compared to only using the deep learning network. We validate our approach retrospectively on a set of 12611 radiographs of patients between 0 and 19 years of age.

An Abbreviated Scale for the Assessment of Skeletal Bone Age Using Radiographs of the Knee.

Hand and wrist radiographs are the most common means for estimating skeletal bone age. There is no widely used scale for estimating skeletal bone age using knee radiographs. Do skeletal bone age estimates from knee-maturity scales correlate sufficiently with both chronologic age and estimates from a hand-wrist scale to potentially substitute for estimates from the latter? The authors reviewed the records of 503 patients 6 to 19 years old who had hand and knee radiographs obtained within 30 days of each other. They analyzed radiographs using the O'Connor knee scale (based on 10 maturation markers) and a new, abbreviated version of the O'Connor scale (based on 7 markers). The authors also analyzed radiographs of the hands of boys 12.5 to 16 years old and girls 10 to 16 years old using the shorthand method. Multivariate linear regression was used for analysis. Inter- and intrarater reliabilities were assessed. Skeletal bone age derived from the O'Connor and abbreviated knee scales correlated with chronologic age (adjusted R2=0.88 and 0.90, respectively). Compared with estimates from the hand-wrist scale, estimates were lower by a mean of 0.91 years for boys and 0.38 years for girls when using the O'Connor scale and 0.96 years for boys and 0.52 years for girls when using the abbreviated scale. Inter- and intrarater reliabilities were very good (κ=0.82 and 0.90, respectively) and were substantial at each bony landmark measured. Knee radiographs can be used to estimate skeletal bone age using an abbreviated knee scale. [Orthopedics. 2018; 41(5):e676-e680.].

Cone-beam computed tomography, a new low-dose three-dimensional imaging technique for assessment of bone erosions in rheumatoid arthritis: reliability assessment and comparison with conventional radiography - a BARFOT study.

OBJECTIVES: To determine the intra- and inter-observer agreement of erosions detected and scored with cone-beam computed tomography (CBCT) of bones in the hands and feet, and to compare CBCT with conventional radiography (CR) for assessment of bone erosions in patients with long-standing rheumatoid arthritis (RA). METHOD: Thirty patients with long-standing RA from the Better Anti-Rheumatic PharmacOTherapy (BARFOT) cohort were examined with CBCT and CR of hands and feet at their 15 year follow-up. Intra- and inter-class correlation coefficients (ICCs) were calculated. Erosions were analysed with the total rheumatoid arthritis magnetic resonance imaging erosion score (RAMRIS erosion score) for ICCs with CBCT, and with the modified RAMRIS erosion score (RAMRIS-mod.) for the same locations as used in the Sharp van der Heijde score and Sharp van der Heijde erosion score for CR. RESULTS: All 30 patients showed erosions on CBCT and 26 on CR. The ICCs for both intra- and inter-observer reliability were 0.92-0.99. CBCT showed numerically more erosions than CR for all regions compared, although a statistically significant difference was found only for the metacarpophalangeal joints [median number of eroded joints 1.0 (range 0-14) with CBCT and 0.5 (0-13) with CR, p = 0.044]. CONCLUSION: CBCT has high reproducibility and is more sensitive than CR in detecting erosions in this cohort of patients with long-standing RA. CBCT has the potential to become an important tool in the detection and follow-up of erosions in patients with RA.

Wrong-Bone Excision in Hand Surgery.

BACKGROUND: The incidence of wrong-bone excision in hand surgery is not known. The wrist offers a unique challenge in that a single surgical incision yields access to multiple potential surgical sites, thus rendering site marking less effective. Mistaken identification of structures in the wrist is a real and potentially troublesome phenomenon. This study is designed to evaluate the occurrence of wrong-bone excision and to identify any risk factors and preventative measures that may help to prevent this complication in the future. METHODS: We designed an anonymous online survey to determine the occurrence, risk factors, medicolegal outcomes, and preventative measures of wrong-bone excision. We distributed the survey to 777 hand surgeons via email. RESULTS: Ninety-nine surgeons responded to our survey. Twenty-three respondents had participated in an excision of the incorrect bone in the wrist. The most common error was partial or complete excision of the scaphoid during a planned excision of the trapezium. Respondents indicated that inadequate visualization, inadequate localization, and teaching of a resident or fellow contributed to the error. There was only 1 case of legal action. CONCLUSIONS: The results of our survey indicate that there exists a non-zero incidence of wrong-bone excision in hand surgery. The most common mistake is incorrect excision of the scaphoid during a planned trapeziectomy. Most surgeons feel that their patients were pleased with their outcome despite this complication, and legal action is rare. Deliberate identification of known landmarks was identified as the most useful strategy in preventing wrong-bone excision.

Skeletal maturity of the hand in an East African group from Sudan.

OBJECTIVES: Studies of skeletal maturity from Africa indicate a delay, reflected in a negative relative skeletal age (RSA). This study aims to evaluate the influence of age, socioeconomic status (SES) and nutritional status on skeletal maturation in a large sample of children from North Sudan. MATERIALS: The sample consisted 665 males and 1018 females from 3-25 years from Khartoum. Height, weight, age of menarche and, SES were recorded of patients attending for dental treatment. METHODS: Skeletal age was assigned from hand-wrist radiographs using the Greulich-Pyle (GP) atlas (1952). RSA (difference between skeletal and chronological ages) was compared in groups divided by age, sex, height-for-age and body-mass-index z scores, and SES. Spearman's correlation and student t-test was used to compare groups. RESULTS: Delayed skeletal age was noted across all age in boys. In girls, a delay was observed between ages 6-10, while advancement occurred between ages 13-18. Maturity was delayed in low height groups (p < .05) and low SES groups. RSA was negatively associated with HAZ in low SES males (R = -0.0.27, p < .001) and low SES females (R = -0.32, p < .001). CONCLUSIONS: There were statistically significant skeletal delays in North Sudanese males and most pre-menarche females, low height and low SES groups. Post-menarche females were advanced relative to males and GP references. Low SES impacts were statistically correlated to skeletal delay.

Comparisons between skeletal and dental age assessment in unaccompanied asylum seeking children.

BACKGROUND: For children with disputed date of birth, age assessments based on skeletal and dental development are recommended. AIM: The aim of this retrospective study was to compare and contrast the results of age assessments from these two methods performed on unaccompanied asylum seeking children in Norway. In addition the aim of the analysis was to see if the skeletal age assessment from hand-wrist was operator sensitive. MATERIALS AND METHODS: Age assessments performed from January 2010 to December 2014 were analysed. Skeletal development of hand-wrist was graded according to Greulich and Pyle (1959). Dental development of the wisdom teeth was scored on orthopantomograms according to Moorrees, Fanning and Hunt (1963) and age assessed from tables published by Liversidge (2008) and Haavikko (1970). In the statistical analysis agreement between the two age assessments was defined according to the asylum seeker's age being assessed to be older or younger than 18 years. The statistical analysis included 3333 boys and 486 girls. RESULTS: The agreement was 83% for boys and 79% for girls. Approximately 70% of the boys and girls were 18 years or older by both methods. It was more common that the skeletal age was assessed older than 18 years and dental age younger than 18 years for both genders. It could be demonstrated that the age assessment based on skeletal maturation was not operator sensitive. CONCLUSION: The analyses demonstrate that there is good agreement between the two age assessments, but a method to combine the results would increase the reliability of the age assessments.

Modeling skeletal bone development with hidden Markov models.

This paper presents a tool for automatic assessment of skeletal bone age according to a modified version of the Tanner and Whitehouse (TW2) clinical method. The tool is able to provide an accurate bone age assessment in the range 0-6 years by processing epiphysial/metaphysial ROIs with image-processing techniques, and assigning TW2 stage to each ROI by means of hidden Markov models. The system was evaluated on a set of 360 X-rays (180 for males and 180 for females) achieving a high success rate in bone age evaluation (mean error rate of 0.41±0.33 years comparable to human error) as well as outperforming other effective methods. The paper also describes the graphical user interface of the tool, which is also released, thus to support and speed up clinicians' practices when dealing with bone age assessment.

A Dosimetry Study of Deuterium-Deuterium Neutron Generator-based In Vivo Neutron Activation Analysis.

A neutron irradiation cavity for in vivo neutron activation analysis (IVNAA) to detect manganese, aluminum, and other potentially toxic elements in human hand bone has been designed and its dosimetric specifications measured. The neutron source is a customized deuterium-deuterium neutron generator that produces neutrons at 2.45 MeV by the fusion reaction 2H(d, n)3He at a calculated flux of 7 × 10(8) ± 30% s(-1). A moderator/reflector/shielding [5 cm high density polyethylene (HDPE), 5.3 cm graphite and 5.7 cm borated (HDPE)] assembly has been designed and built to maximize the thermal neutron flux inside the hand irradiation cavity and to reduce the extremity dose and effective dose to the human subject. Lead sheets are used to attenuate bremsstrahlung x rays and activation gammas. A Monte Carlo simulation (MCNP6) was used to model the system and calculate extremity dose. The extremity dose was measured with neutron and photon sensitive film badges and Fuji electronic pocket dosimeters (EPD). The neutron ambient dose outside the shielding was measured by Fuji NSN3, and the photon dose was measured by a Bicron MicroREM scintillator. Neutron extremity dose was calculated to be 32.3 mSv using MCNP6 simulations given a 10-min IVNAA measurement of manganese. Measurements by EPD and film badge indicate hand dose to be 31.7 ± 0.8 mSv for neutrons and 4.2 ± 0.2 mSv for photons for 10 min; whole body effective dose was calculated conservatively to be 0.052 mSv. Experimental values closely match values obtained from MCNP6 simulations. These are acceptable doses to apply the technology for a manganese toxicity study in a human population.

Compact DD generator-based neutron activation analysis (NAA) system to determine fluorine in human bone in vivo: a feasibility study.

The subject of whether fluorine (F) is detrimental to human health has been controversial for many years. Much of the discussion focuses on the known benefits and detriments to dental care and problems that F causes in bone structure at high doses. It is therefore advantageous to have the means to monitor F concentrations in the human body as a method to directly assess exposure. F accumulates in the skeleton making bone a useful biomarker to assess long term cumulative exposure to F. This study presents work in the development of a non-invasive method for the monitoring of F in human bone. The work was based on the technique of in vivo neutron activation analysis (IVNAA). A compact deuterium-deuterium (DD) generator was used to produce neutrons. A moderator/reflector/shielding assembly was designed and built for human hand irradiation. The gamma rays emitted through the (19)F(n,γ)(20)F reaction were measured using a HPGe detector. This study was undertaken to (i) find the feasibility of using DD system to determine F in human bone, (ii) estimate the F minimum detection limit (MDL), and (iii) optimize the system using the Monte Carlo N-Particle eXtended (MCNPX) code in order to improve the MDL of the system. The F MDL was found to be 0.54 g experimentally with a neutron flux of 7 × 10(8) n s(-1) and an optimized irradiation, decay, and measurement time scheme. The numbers of F counts from the experiment were found to be close to the (MCNPX) simulation results with the same irradiation and detection parameters. The equivalent dose to the irradiated hand and the effective dose to the whole body were found to be 0.9 mSv and 0.33 µSv, respectively. Based on these results, it is feasible to develop a compact DD generator based IVNAA system to measure bone F in a population with moderate to high F exposure.

[Application possibilities and initial experience with digital volume tomography in hand and wrist imaging]. / Digitale Volumentomografie (DVT) des knöchernen Handskeletts: Erste Erfahrungen und Anwendungsmöglichkeiten.

During the last decade, DVT (digital volume tomography) imaging has become a widely used standard technique in head and neck imaging. Lower radiation exposure compared to conventional computed tomography (MDCT) has been described. Recently, DVT has been developed as an extremity scanner and as such represents a new imaging technique for hand surgery. We here describe the first 24 months experience with this new imaging modality in hand and wrist imaging by presenting representative cases and by describing the technical background. Furthermore, the method's advantages and disadvantages are discussed with reference to the given literature.

Lateral comparisons using Fishman's skeletal maturation assessment.

OBJECTIVE: To assess lateral differences between ossification events and stages of bone development in the hands and wrists utilizing Fishman's skeletal maturation indicators (SMIs). MATERIALS AND METHODS: The skeletal ages of 125 subjects, aged 8 to 20 years, were determined with left and right hand-wrist radiographs using Fishman's SMI assessment. Each subject was also given the Edinburgh Handedness Questionnaire to assess handedness. The skeletal ages of both hand-wrist radiographs were analyzed against each other, handedness, chronologic age, and gender. RESULTS: There were no significant differences overall in right and left SMI scores (P  =  .70); 79% of all patients showed no difference in right and left SMI scores, regardless of handedness, gender, or age. However, when patients were categorized based on clinical levels of SMI score for the right hand-wrist, there was a significant difference (P  =  .01) between the SMI 1-3 group and the SMI 11 group. Subjects in the SMI 1-3 group were more likely to show a left > right SMI score, while subjects in the SMI 11 group were likely to show a right > left SMI score. CONCLUSION: Although no significant overall lateral differences in SMI scores were noted, it may be advisable to obtain a left hand-wrist radiograph and/or additional diagnostic information to estimate completion of growth in young surgical patients.

New software for cervical vertebral geometry assessment and its relationship to skeletal maturation--a pilot study.

OBJECTIVES: In the present study, we developed new software for quantitative analysis of cervical vertebrae maturation, and we evaluated its applicability through a multinomial logistic regression model (MLRM). METHODS: Digitized images of the bodies of the second (C2), third (C3) and fourth (C4) cervical vertebrae were analysed in cephalometric radiographs of 236 subjects (116 boys and 120 girls) by using a software developed for digitized vertebrae analysis. The sample was initially distributed into 11 categories according to the Fishman's skeletal maturity indicators and were then grouped into four stages for quantitative cervical maturational changes (QCMC) analysis (QCMC I, II, III and IV). Seven variables of interest were measured and analysed to identify morphologic alterations of the vertebral bodies in each QCMC category. RESULTS: Statistically significant differences (p < 0.05) were observed among all QCMC categories for the variables analysed. The MLRM used to calculate the probability that an individual belonged to each of the four cervical vertebrae maturation categories was constructed by taking into account gender, chronological age and four variables determined by digitized vertebrae analysis (Ang_C3, MP_C3, MP_C4 and SP_C4). The MLRM presented a predictability of 81.4%. The weighted κ test showed almost perfect agreement (κ = 0.832) between the categories defined initially by the method of Fishman and those allocated by the MLRM. CONCLUSIONS: Significant alterations in the morphologies of the C2, C3 and C4 vertebral bodies that were analysed through the digitized vertebrae analysis software occur during the different stages of skeletal maturation. The model that combines the four parameters measured on the vertebral bodies, the age and the gender showed an excellent prediction.

Age assessment using the Greulich and Pyle method on a heterogeneous sample of 300 Italian healthy and pathologic subjects.

The exponential growth of the illegal immigration phenomenon, the requests for asylum, and the increasing number of migrant settlements on Italian territory have strong repercussions on the legal system. One important aspect of this problem is age assessment. In the case of living individuals, identification may be focused on ascertaining their age, more directly if they can attest their age but are not registered (foreigners who claim to be minors or under 14 years of age). These have entered our country as illegal immigrants and have an interest in declaring a younger age (as a minor or under 14) rather than their true age because they can obtain the benefits specifically provided by Italian law for such categories. Since the most frequently used method in age assessment is the Greulich and Pyle Atlas, the objective of this study was to evaluate the consistency and accuracy of the method on a sample of Italian teenagers, in order to ascertain whether or not the Atlas is suitable for the purpose, especially in the critical threshold between 14 and 18 years of age. A total of 300 radiographs of the left wrist and hand of individuals between 10 and 20 years of age were obtained from the outpatient Pediatric Radiology Department of the Papa Giovanni XXIII Hospital in Bari. The results showed that the Greulich and Pyle Atlas, used on the Italian population, provide a good match with the chronological age, showing no statistically significant differences. The Greulich and Pyle Atlas is usable on the Italian population since there were no significant differences in skeletal age determination with this method as compared to the chronological age; however, one must allow for a possible standard deviation equal to more or less 13 months.