Bone Age, Delayed
Catherine C. Roberts, MD
DIFFERENTIAL DIAGNOSIS
Common
Constitutional Delay of Puberty (Normal Variant)
Chronic Disease
Chronic Liver Disease
Renal Osteodystrophy
Congenital Heart Disease
Rickets
Juvenile Idiopathic Arthritis
Thalassemia
Cerebral Palsy
Excessive Exercise
Malnutrition
Anorexia
Malabsorption Conditions
Complications of Steroids
Fetal Alcohol Syndrome
Less Common
Lead Poisoning
Down Syndrome (Trisomy 21)
Cushing Disease
Hypopituitarism
Pseudohypoparathyroidism
Craniopharyngioma
Rare but Important
HIV-AIDS: MSK Complications
Growth Hormone Deficiency
Hypogonadism
Hypothyroidism
Warfarin Embryopathy
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
Skeletal maturation more than 2 standard deviations below mean
Formally evaluated with serial PA radiographs of left hand
Standards of Greulich and Pyle classically used for comparison
Helpful Clues for Common Diagnoses
Majority of common diagnoses cause delayed bone age due to delay of puberty
Identifiable by clinical history
Helpful Clues for Less Common Diagnoses
Lead Poisoning
Widened metaphyses, dense metaphyseal lines
Down Syndrome (Trisomy 21)
Additional findings: Flared iliac wing, flat acetabular roof, clinodactyly, microcephaly, atlantoaxial instability
Helpful Clues for Rare Diagnoses
Hypogonadism
Results in long limbs with disproportionally short trunk
Alternative Differential Approaches
Stippled epiphyses: Hypothyroidism, warfarin embryopathy, chondrodysplasia punctata, multiple epiphyseal dysplasia, trisomy 21, trisomy 18, prenatal infection, Morquio syndrome
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