Aim: The aim was to identify, evaluate, and summarize the findings of relevant individual studies on the precision and accuracy of radiological BA assessment procedures among children from different ethnic groups. Materials and Methods: A qualitative systematic review was carried out following the MOOSE statement and previously registered in PROSPERO (CRD42023449512). A search was performed in MEDLINE (PubMed) (n = 561), the Cochrane Library (n = 261), CINAHL (n = 103), Web of Science (WOS) (n = 181), and institutional repositories (n = 37) using MeSH and free terms combined with the Booleans “AND” and “OR”. NOS and ROBINS-E were used to assess the methodological quality and the risk of bias of the included studies, respectively. Results: A total of 51 articles (n = 20,100) on radiological BA assessment procedures were precise in terms of intra-observer and inter-observer reliability for all ethnic groups. In Caucasian and Hispanic children, the Greulich–Pyle Atlas (GPA) was accurate at all ages, but in youths, Tanner–Whitehouse radius–ulna–short bones 3 (TW3-RUS) could be an alternative. In Asian and Arab subjects, GPA and Tanner–Whitehouse 3 (TW3) overestimated the BA in adolescents near adulthood. In African youths, GPA overestimated the BA while TW3 was more accurate. Conclusion: GPA and TW3 radiological BA assessment procedures are both precise but their accuracy in estimating CA among children of different ethnic groups can be altered by racial bias.

Bone age assessments measure the growth and development of children and adolescents by evaluating their skeletal maturity, which is influenced by various factors like heredity, ethnicity, culture, and nutrition. The clinical standards for this assessment should be up to date and appropriate for the specific population being studied. This study validates the GP-Canary Atlas for accurately predicting bone age by analyzing posteroanterior left hand and wrist radiographs of healthy children (80 females and 134 males) from the Canary Islands across various developmental stages and genders. We found strong intra-rater reliability among all three raters, with Raters 1 and 2 indicating very high consistency (intra-class coefficients = 0.990 to 0.996) and Rater 3 displaying slightly lower but still strong reliability (intra-class coefficients = 0.921 to 0.976). The inter-rater agreement was excellent between Raters 1 and 2 but significantly lower between Rater 3 and the other two raters, with intra-class coefficients of 0.408 and 0.463 for Rater 1 and 0.327 and 0.509 for Rater 2. The accuracy analysis revealed a substantial underestimation of bone age compared to chronological age for preschool- (mean difference = 17.036 months; p < 0.001) and school-age males (mean difference = 13.298 months; p < 0.001). However, this was not observed in females, where the mean difference was minimal (3.949 months; p < 0.239). In contrast, the Atlas showed greater accuracy for teenagers, showing only a slight overestimation (mean difference = 3.159 months; p = 0.823). In conclusion, the GP-Canary Atlas demonstrates overall precision but requires caution as it underestimates the BA in preschool children and overestimates it in school-age girls and adolescents.

Background/Objectives: Bone age assessments are essential for evaluating the growth and skeletal development of children and adolescents, influenced by factors such as genetics, ethnicity, culture, and nutrition. Clinical standards for these assessments must be adapted to the specific populations under study. This study validates the use of the Tanner–Whitehouse 3 method for determining bone age in pediatric and adolescent populations in the Canary Islands. Methods: This cross-sectional study analyzed 214 posteroanterior radiographs of the left hand and wrist from 80 females and 134 males, aged between 5 and 18 years. The radiographs were independently evaluated by three raters: a Radiologist Specialist (Rater 1), a General Practitioner (Rater 2), and a Medical Student (Rater 3). Intra- and inter-rater reliability were assessed using intraclass correlation coefficients (ICCs). Accuracy was evaluated by comparing estimated bone age with chronological age, stratified by sex and developmental stage. Results: Strong intra-rater reliability was observed across all raters. Raters 1 and 2 demonstrated excellent consistency (ICCs: 0.990–0.996), while Rater 3 exhibited slightly lower yet robust reliability (ICCs: 0.921–0.976). Inter-rater agreement was high between Raters 1 and 2 but decreased with Rater 3, reflecting the influence of experience (ICCs: 0.812–0.912). Bone age was underestimated in preschool children (mean difference: 3.712 mos.; 95% CI: 1.290–6.130; p = 0.199) and school-age males (mean difference: 3.978 mos.; 95% CI: −12.550 to 4.590; p = 0.926), with minimal discrepancies in females. In teenagers, the Tanner–Whitehouse 3 method slightly overestimated bone age (mean difference: −0.360 mos.; 95% CI: −0.770 to −0.954; p = 0.299). Conclusions: In conclusion, the Tanner–Whitehouse 3 method demonstrates overall precision and reliability but requires caution, as it underestimates bone age in preschool children and school-age males, while slightly overestimating it in adolescents.

Introduction: Determination of radiological bone age (BA) is a diagnostic method that consists of estimating chronological age (CA) from the bone maturation of children. Although environmental and hormonal factors can interfere with bone ossification, the process is essentially dependent on ancestral inheritance. These ethnic backgrounds are not usually considered, which can lead to biased interpretations and inadequate decision-making by pediatricians or forensic experts. The objective of this study was to determine the precision and accuracy of these radiological procedures among different ethnic groups. Methods: A qualitative systematic review carried out following MOOSE statement and previously registered in the International Prospective Registry of Systematic Reviews PROSPERO (CRD42023449512). Search was performed in MEDLINE (PubMed) (n=561), Cochrane Library (n=261), CINAHL (n=103), Web of Science (WOS) (n=181) and public institutional repositories (n=37) from inception to 31st December 2022 using Mesh as “Diagnostic Techniques and Procedures”, “Diagnostic imaging”, “Radiography”, “Age Determination by Skeleton” and free terms combining with booleans “AND” and “OR”. PEDro scale, and Risk of Bias in non-randomized Studies of Exposure (ROBINS-E) were used to assess methodological quality and risk of bias of included studies respectively. Results: 51 articles (n=19,531) were included according to the inclusion criteria previously established. There was a good to moderate methodological quality and a high to very high risk of bias. Skeletal methods for determining BA were precised in terms of intra-observer and inter-observer reliability in all ethnic groups. Regarding to accuracy of Skeletal methods in Caucasians and Hispanic children, GPA was accurate at all ages, but in youths, TW3 RUS could be a consistent alternative. In Asian and Arab, GPA and TW3 overestimated BA in adolescents near adulthood. In African youths, GPA overestimated BA while TW3 was more accurate in estimating CA. Dental and Cervical radiographic methods are equally precise but lesser accurate than Skeletal BA determination. Conclusion: Skeletal radiographic methods GPA and TW3 are both precise for BA determination among all ethnical groups, but their accuracy in estimating CA can be altered by racial bias.

Accurate assessment of bone age (BA) is crucial for pediatric clinical practice. This study validated the Radiological Reference Atlas for Bone Age in the Canary Islands Population with a total of 203 anteroposterior left hand and wrist radiographs from healthy children (91 females, 112 males) across preschool, school-age, and adolescent stages. Intra-observer agreement, assessed by intraclass correlation coefficients (BAA1: ICC = 1.000, BAA2: ICC = 0.995, BAA3: ICC = 0.943), showed differing levels of precision among assessors. Inter-observer agreement was high (Pearson’s r = 0.905 - 0.951), suggesting consistent evaluations across different expertise levels. Accuracy analysis revealed significant BA underestimation compared to chronological age (CA) in preschool (MD = -17.036 months, p < 0.001) and school-age (MD = -8.165 months, p < 0.001) groups, but closer agreement in teenagers (MD = -0.33 months, p = 0.550). Furthermore, a relevant underestimation in the teenage stage for girls compared to boys was also noted. These findings underscore the atlas's precision; however, its accuracy for BA assessment in younger children and adolescent girls needs to be approached with caution.

Background: Central precocious puberty (CPP), defined as the onset of secondary sexual characteristics before age 8 in girls, is increasingly prevalent worldwide. CPP is often caused by early activation of the HPG axis, leading to accelerated growth and bone maturation. However, the diagnostic accuracy of standard bone age (BA) methods remains uncertain in this context. Objective: To compare the diagnostic accuracy of the Greulich–Pyle atlas (GPA) and Tanner–Whitehouse 3 (TW3) methods in estimating skeletal age in girls with CPP and to assess the predictive value of serum hormone levels for estimating chronological age (CA). Methods: An observational, cross-sectional diagnostic study was conducted, involving n = 109 girls aged 6–12 years with confirmed CPP (Ethics Committee approval: CHUC_2023_86; 13 July 2023). Left posteroanterior hand–wrist (PA–HW) radiographs were assessed using the GPA and TW3 methods. Anthropometric measurements were recorded, and serum concentrations of estradiol, LH, FSH, DHEA-S, cortisol, TSH, and free T4 were obtained. Comparisons between CA and BA estimates were conducted using repeated-measures ANOVA, and ANCOVA was applied to examine the hormonal predictors of CA. Results: Both GPA and TW3 overestimated CA between 7 and 12 years, with the GPA showing larger deviations (up to 4.8 months). The TW3 method provided more accurate estimations, particularly at advanced pubertal stages. Estradiol (η²_p = 0.188–0.197), LH (η²_p = 0.061–0.068), and FSH (η²_p = 0.008–0.023) emerged as the strongest endocrine predictors of CA, significantly enhancing the explanatory power of both radiological methods. Conclusions: The TW3 method demonstrated superior diagnostic accuracy over GPA in girls with CPP, especially between 7 and 12 years. Integrating estradiol, LH, and FSH into BA assessment significantly improved the accuracy, supporting a more individualized and physiologically grounded diagnostic approach.