——— MS Se SS SS SS ua ea APPENDIX 1 The Rating System Radiographic Technique \¢ correct positioning of the hand and wrist is shown in Appendix Fig. 1. It is of great importance since faulty posing causes some bones to have appearances different from those described below. The radiographer must be brought to look on this technique as an attempt to be quantitative, and the anode-film distance should be exact. The left hand is used. ‘The palm faces downwards, in contact with the cassette, with the axis of the middle finger in direct line with the axis of the forearm; the upper arm and fore-arm should be in the sime horizontal plane }ot touching and the thumb is placed in the comfortable, natural degree of rotation with its axis making an angle of about 30 degrees with the first finger. The palm is pressed lightly downwards on the film cassette by the subject; or if the child is too young to follow th ban he fingersareju instructions the hand is secured in this position with The tube is centred above the head of the 3rd metacarpa inches or 76 cm. High definition se ‘essential. The skin dose is lead-material apron is atta the gonads at a tube-film distance of 30 ens should be used since high quality definition is 10 millirads. The X-ray table is topped with lead sheeting and a to its edge and is pulled well up into the child’s lap to shield n radiation. The developmer f the film should preferably be rather light.= = = = = = = = = = = = = SISTEMA DE VALORACION ‘Técnica radiografica. Fig. Al Se usa la mano izquierda, la palma hacia abajo en contacto con el chasis, con el eje del dedo medio en linea recta con el eje del antebrazo. Los dedos no deben tocarse entre si y el pulgar debe estar colocado en una posicién confortable, el Angulo natural de rotacién del dedo pulgar es de 30° con el primer dedo. El tubo del aparato se centra en el 3er metacarpal a una distancia de 30 pulgadas © 76 cms. Deben usarse peliculas de alta definicién, la dosis usada es de 8 a 10 milirads. Asignacién de los valores. Fig. A2 Los huesos estan clasificados en orden, empezando de izquierda a derecha: radio, cubito, metacarpal 1, 3, 5; falanges proximales 1, 3, 5; falanges media 3,5; falanges distales 1,3,5; hueso grande, ganchoso, pisiforme, semilunar, escafoide, trapecio y trapezoide. Observando la figura de frente, el lado lateral esta a la derecha del observador, el lado medio a su izquierda, el lado distal hacia arriba y el lado proximal hacia abajo. Los valores son asignados mediante la comparacién del hueso con la descripcién y diagramas. La nomenciatura de la region epifisial estan en la Fig. 3. Si no existen sefiales del hueso se asigna la letra A. Las sefiales visibles se describen con la letra Hol, En las siguientes paginas se anexa una descripcién del criterio de cada estadio con un diagrama donde se observa la apariencia tipica. Inevitablemente ocurren variaciones en forma de individuo a individuo y no siempre coinciden los diagramas con la realidad. Por cada estadio hay dos o tres criterios marcados con (i), (ii) y (lil), con que uno 0 dos criterios coincidan con el diagrama es suficiente. Algunos huesos muestran grandes variaciones entre una persona y otra. Puede haber fusiones prematuras o ausencias de algunas zonas del hueso. Se anexan tablas con medidas de: Edad ésea (RUS, Carpal, 20 huesos) Maduracién dsea (A4-A9) Edad ésea en nifios (A10-A11) Tablas de coeficientes de prediccién para altura de adultos.2 SKELETAL MATURITY AND HEIGHT PREDICTION Assigning the Ratings ‘The bones are shown in Appendix Fig. 2. They are rated in the order radius, ulna, meta carpals 1, 3, 5; proximal phalanges 1, 3, 3; middle phalanges 3, 5; distal phalinges 1, 3, 3; capitate, hamate, triquetral, lunate, scaphoid, trapezium, trapezoid, It is convenient to use 1 standard form for recording. In ‘ll drawings the hand is seen with the fingers pointing upward with the thumb on the right hand side of the viewer. Thus, the lateral side is to the viewer's right always, the medial side to his left, distal away from him (or upwards), proximal towards him (or downwards). Reference is frequently made to dorsal and palmer margins oor surfaces. It is important to remember that the appearance on the film is 4 plan in ewo dimensions of a structure built in three with the added and helpful complication that two superimposed surfaces both penetrated by the X-rays produce a greater degree of whiteness than either of the surfaces penetrated alone, In general the word ‘‘margin” or “border” is ‘used where a single line, or edge, is visible on the film: when dorsal and palmer lips become visible the wording has been changed to “surface”. The only apparatus required for reading the films is a pair of dividers; these are used for making a rough comparison of diameters of bones in the cases where a criterion requires one bone to he a half or more the width of another. Finer comparisons are not required. Fig, AZ Bones of the han nd weit, Ratings are assigned by comparing the bone in question with the descriptions and diagrams which follow: the nomenclature of the epiphyseal regions is shown in Appendix Fig. 3. If no sign of the bone is present the rating A is given. Appearances corresponding to the descriptions given of H plusor [ plus should be rated Hor I respectively (they are the old I and J ratings for capitate, triquetral, lunate and trapezoid bones in system TW) ‘We give on pp. 44-75 a written description of the criteria for each stage together with a dia ‘gram of the typical appearance. In all cases of doubt itis the written description that should be