Journal of Pediatric Orthopaedics

21:549–555 © 2001 Lippincott Williams & Wilkins, Inc., Philadelphia

Current Issues
Edited by Carl L. Stanitski, M.D.

Growth in Pediatric Orthopaedics

Alain Dimeglio, M.D.

The mature musculoskeletal system is the end result of How tall is the child?
a highly ordered, coordinated sequence of cellular and What is their sitting height?
extracellular matrix events initiated early in embryonic What is their subischial leg length?
life and continued to skeletal maturity. These events in- What are their chronological and bone ages?
clude transformation of undifferentiated mesenchymal What is their annual growth?
tissue into bone, cartilage, synovium, tendon, ligaments, What is the growth remaining in the trunk and lower
and muscle, and integration of these tissues to form the limbs?
musculoskeletal system (7). Where is the child in their normal development?
Growth is a consequence of microgrowth at the cellu- Where is the child on their pubertal path?
lar level in the growth plate. Although the histologic Are the proportions of the child normal?
structure is the same, each physis has its own character- What is the child’s weight?
istics and dynamics. The study of growth as height,
weight, and body proportions considers macrogrowth,
BIOMETRIC MEASUREMENTS
the culmination of the effects of microgrowth of various
body segments and the total individual. One must not Limited growth data is obtained from a single mea-
loose sight of other aspects of growth, such as the impact surement. Birthdays are a convenient reminder for an-
of the nervous system. Growth assessment provides a nual longitudinal growth evaluations. In some cases,
reference for the orthopaedist for normal development evaluating the child every 6 months allows easy assess-
and, in abnormal states, a guideline for treatment (13,14). ment of growth velocity of the child and different body
Growth is a volumetric revolution. From birth on- segments. These measurements provide a real-time im-
wards, height increases 350% and weight, 20-fold. age of growth and generate charts that make decisions
Growth involves changes in proportion. At birth, the easier. An excellent example of this is growth velocity,
lower limbs make up 30% of the standing height in con- because it provides the best indicator of the beginning of
trast to 48% at skeletal maturity. The infant head makes puberty onset upon which so many decisions rest. The
up 25% of the standing height and only 13% at skeletal first pubertal skeletal sign is an increase in height of
maturity. Growth reflects a succession of accelerations more than 0.5 cm per month or 6 cm a year.
and decelerations. Because growth does not occur simul-
taneously in the same magnitude or rate in varied body Standing height
segments, it is synchronized to maintain limb and spine In children less than 5 years of age, it is recommended
relationships (20,34–36). A change in direction of pa- that height be measured with the child supine because in
rameters that alters synchronization with other param- this age group, it is easier and more reliable.
eters may signal an abnormality, a return to normal, or Between birth and maturity, the body will grow ap-
the onset of a normal phase of growth. For this reason, a proximately 1.2 to 1.3 m. At 5 years of age, standing
sequence of measurements of the important parameters is height is 60% of the adult height, reaching 80% of the
far superior to a single measurement. Simple measure- final height by the age of 9. Arm span is an indirect way
ment tools are required at the time of evaluation: height to evaluate standing height. Excellent correlation exists
gauge, weight scales, measuring tape, and bone age atlas. between arm span and the standing height (9,21). In 77%
Ten simple questions will guide the orthopaedist to the of normal children, arm span is less than 5 cm of the
information that is required. standing height; in 22% of healthy children, arm span is
between 5 and 10 cm; and in 1%, it is greater than 10 cm.
Arm span is routinely used in any child who has a
Address correspondence to Pr. Alain Dimeglio, Professor à la faculté spine significant deformity to calculate the normal pul-
de medecine, Hôpital Lapeyronie, 371, Avenue Gaston Giraud 34965,
Montpellier Cedex, France. monary function values. This relationship is also useful
From the Faculté de Medecine, Hôpital Lapeyronie, Montpellier Ce- to diagnose disorders characterized by a limb-trunk dis-
dex, France. proportion, e.g., Marfan’s syndrome.

549
550 CURRENT ISSUES

Sitting height maturity. By the age of 5 years, the standing height has
In children less than 2 years of age, sitting height is doubled and is 60% of the final height. Height gain in the
measured with the child supine for the same reasons that first year is as great as it is during the entire growth surge
standing height is measured with the child supine in this during puberty. At the age of 1 year, growth rate slows,
age group. The child should always be measured under with the child growing 10 cm between the ages of 1 and
the same conditions using the same measuring instru- 2 years and 7 cm between the ages of 3 and 4 years. At
ments. Measurement of sitting height can be useful in birth, sitting height is approximately two thirds of stand-
anticipating the onset of puberty. In an average popula- ing height and 37% of the final sitting height. By the age
tion, puberty starts at approximately 75 cm sitting height of 5 years, sitting height is approximately 66% of the
in girls and 78 cm sitting height in boys. At 84 cm of final sitting height with an additional 30 cm to grow.
sitting height, 80% of girls have menarche. Growth in the subischial leg length follows a pattern
Subischial leg length almost identical to that for sitting height. At birth, the
The body segment made up by the lower extremities is lower limbs are relatively small compared with the trunk.
known as the subischial leg length. It is measured by By the age of 5 years, subischial leg length has increased
subtracting sitting height from standing height. At birth, to more than 50% of the final length.
subischial leg length averages 19 cm. At the completion
of growth, it averages 81 cm in boys and 74.5 cm in girls. From 5 years to 10 years
This 62 cm of growth in boys and the 55.5 cm in girls Between 5 and 10 years of age, there is a marked
contribute a far greater percentage of growth in height deceleration in growth, with standing height increasing
than does the trunk and account for the changing body approximately 5.5 cm per year. Two thirds (3.5 cm) of
proportions during growth (Fig. 1). this growth occurs in the lower limb and one third (2 cm)
in the sitting height. The trunk grows at a slower rate
CHRONOLOGY than the lower limbs and body proportions change.
Intrauterine development
By the time of birth, the infant’s weight is 6 million Puberty
times that of the original egg. Length increases steadily Beyond the age of 10 years, the growth patterns of
and rapidly during the first 6 months in utero; weight boys and girls diverge. On average, girls experience the
gain is the most rapid during the final 3 months of ges- onset of puberty at the age of 11, boys at the age of 13.
tation. At the end of the second trimester of gestation, the Acceleration in the velocity of growth best characterizes
fetus has reached 70% of its final predelivery length, the onset of puberty (6,12,13). Four main characteristics
measuring 30 cm, but it has achieved no more than 20% dominate puberty: dramatic increase in stature; change of
of birth weight. During the third trimester, the fetus gains upper and lower body segment proportions; change in
weight at the highest rate (700 g per month). overall morphology; and sexual characteristic develop-
ment. There are wide individual variations in onset and
Birth to 5 years duration of puberty (36). The ultimate standing height
After birth, not only does the overall rate of growth depends on unpredictable factors: onset, tempo, and du-
vary at different ages, the rate at which various segments ration of puberty (9,12,17).
of the body grow also differs. During the first 5 years of During puberty, standing height increases by approxi-
life, sitting height and subischial length grow about the mately 1 cm per month. At the onset of puberty, boys
same. From age 5 years to puberty, sitting height ac- have 14% (± 1%) of their remaining standing height to
counts for one third of the gain, whereas subischial leg grow. This is approximately 22.5 cm (± 1 cm) made up
length accounts for two thirds. From puberty to maturity, of 13 cm in sitting height and 9.5 cm in subischial leg
the ratio is reversed. length. Girls have 12% (± 1%) of their standing height to
Standing neonate height is 30% of the final height at grow. This is approximately 20.5 cm (± 1 cm) made up
of 12 cm in sitting height and 8.5 cm in subischial leg
length (12,34–36) (Figs. 2,3).
Growth rate peaks during puberty between 13 and 15
years of bone age in boys and 11 and 13 years of bone
age in girls. By the time girls and boys pass bone ages of
13 and 15, respectively, lower limb growth comes virtu-
ally to a standstill, with all remaining growth (4.5 cm)
taking place in sitting height (12,34–36). These figures,
ratios, and rates provide only a partial reflection of the
growth phenomena. Precise evaluation of the character-
FIG. 1. Proportion in percentage of the lower limb and sitting istics of puberty, using the Tanner classification, the on-
height: at birth, standing height makes up 70% of sitting height; at set of menstruation, and Risser’s sign needs to be under-
skeletal maturity, 52%. Reproduced with permission from Mor-
rissy RT, Weinstein SL. Lovell and Winter’s Pediatric Orthopae- taken with great care. A major problem with using the
dics. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins, onset of menarche or Risser sign is that they occur after
2001. the pubertal growth rate has begun to slow.

J Pediatr Orthop, Vol. 21, No. 4, 2001

 CURRENT ISSUES 551

Pubertal diagram
Using these landmarks, it is possible to construct a
diagram relating all of the events occurring during pu-
berty. Even when one indicator is missing or does not
match the other, it is still possible to have a good idea
where the child is on their way through puberty (12,13).
The first phase of the pubertal growth spurt corre-
sponds to the acceleration in the velocity of growth and
is the major portion of the pubertal growth spurt. This
phase lasts 2 years from approximately 11 to 13 years of
bone age in girls and 13 to 15 years of bone age in boys.
The gain in standing height for girls during this phase is
approximately 14.5 cm, made up of 6.5 cm in sitting
FIG. 2. Growth in sitting height (top bars) and subischial leg height and 7 cm in subischial leg length. The gain in
length at various ages in girls. Reproduced with permission from standing height for boys during this phase is approxi-
Morrissy RT, Weinstein SL. Lovell and Winter’s Pediatric Ortho-
paedics. 5th ed. Philadelphia, PA: Lippincott Williams and mately 16.5 cm, made up of 8.5 cm in sitting height and
Wilkins, 2001. 8 cm in subischial leg length (12,13).
Triradiate cartilage closure occurs approximately half-
way on the ascending limb of the pubertal curve and
Secondary sexual characteristics corresponds to an approximate bone age of 12 years for
Secondary sexual characteristics develop throughout girls and 14 years for boys. After closure of the triradiate
the course of puberty. The first physical sign of puberty cartilage, there remains a significant amount of remain-
in boys (testicular growth in 77%) occurs on average 1.7 ing growth—greater than 12 cm of standing height for
years before the peak height velocity and 3.5 years be- girls and more than 14 cm for boys.
fore attaining adult height (6,34–36). Bone age will be The second phase of the pubertal growth spurt is a
approximately 13 years at the onset of puberty. Risser period of deceleration in the rate of growth, which lasts
sign is zero and the triradiate cartilage is open. At this 2.5 years from 13 to 15.5 years of bone age in girls and
age, girls have well-developed secondary sexual charac- from 15 to 17.5 years of bone age in boys. During this
teristics, and their rate of growth is decelerating. In 93% phase, boys and girls gain approximately 6 cm in stand-
of girls, breast budding occurs about one year before ing height with 4.5 cm coming from an increase in sitting
peak height velocity (6,34–36). This averages 11 years in height and 1.5 cm coming from an increase in the subis-
bone age. Risser sign is still zero and the triradiate car- chial leg length. During this phase, the increase in sitting
tilage is open at the onset of puberty. Menarche occurs height contributes 80% of the gain in the standing height
approximately 2 years after breast budding and final (12,13).
height is usually achieved 2.5 to 3 years after menarche. Menarche most often occurs when the rate of growth
After menarche, girls gain the final 5% of their standing is slowing, usually between bone age of 13 and 13.5
height, approximately 3 to 5 cm. The appearance of ax- years and corresponds to Risser I on the iliac apophysis.
illary hair, though variable, often signals the peak of the At this stage, the average girl will gain an additional 4
pubertal growth curve. cm of sitting height and 0.6 cm of subischial leg length.
Menarche is not a precise indicator of puberty. Forty-two
percent of girls have menarche before Risser I, 31% at
Risser I, 13% at Risser II, 8% at Risser III, and 5% at
Risser IV (13).

FIG. 4. The pubertal peak is made up of three peaks on the

FIG. 3. Growth in sitting height (top bars) and subischial leg ascending side: first = lower limb peak; second = sitting height
length at various ages in boys. Reproduced with permission from (trunk); third = chest growth. Reproduced with permission from
Morrissy RT, Weinstein SL. Lovell and Winter’s Pediatric Ortho- Morrissy RT, Weinstein SL. Lovell and Winter’s Pediatric Ortho-
paedics. 5th ed. Philadelphia, PA: Lippincott Williams and paedics. 5th ed. Philadelphia, PA: Lippincott Williams and
Wilkins, 2001. Wilkins, 2001.

J Pediatr Orthop, Vol. 21, No. 4, 2001

552 CURRENT ISSUES

No significant difference was seen between data in these

atlases. The Tanner and Whitehouse method (36), though
accurate, is very time consuming and difficult, making it
impractical in daily practice. The Greulich and Pyle atlas
is sufficient for clinical decision making in orthopaedic
practice when used by physicians knowledgeable in this
method. A weakness of the Greulich and Pyle atlas is that
there are few changes in the hand during the critical time
of puberty. For this reason, I find the Sauvegrain method
to be of more value during puberty (30). It shows good
correlation with the Greulich and Pyle atlas but is easier
FIG. 5. The pubertal growth curve in girls. The fusion of the distal
phalanx of thumb occurs at the same period as elbow closure. to use.
Risser 1 occurs on the descending side about six months after At the beginning of puberty, growth centers of the
elbow closure. Usually menarche occurs at this period. Tanner elbow are wide open, but 2 years later, when the peak
signs: Breast 1, Breast 2 and Breast 3 on the ascending side. velocity of the pubertal growth spurt is reached and
Axillary hairs are poor indicators. Reproduced with permission
from Morrissy RT, Weinstein SL. Lovell and Winter’s Pediatric
growth begins to slow, they are all completely closed.
Orthopaedics. 5th ed. Philadelphia, PA: Lippincott Williams and This complete closure occurs 6 months before Risser I.
Wilkins, 2001. There is great value in analysis of olecranon ossification.
At the start of puberty (bone age 11 for girls and 13 for
Puberty peak boys), two olecranon ossification centers appear. Six
The puberty peak is a juxtaposition of three micro- months later, the centers merge in a crescentic shape. By
peaks (Fig. 4). The first peak is marked by lower limb bone age 12 years for girls and 14 years for boys, the
growth at the very beginning of puberty; the second peak olecranon apophysis is rectangular and 6 months later,
is marked by trunk growth; the third peak is marked by the olecranon apophysis begins to fuse with the ulna, and
chest growth. The lower limb peak takes place between in another 6 months, fusion is complete (17) (Figs. 5, 6).
P1 and P2 Tanner signs for boys and Breast 1 and Breast The Risser sign is a commonly used marker of skeletal
2 for girls. The trunk peak happens between P2 and P3 maturation, especially in the treatment of scoliosis. The
for boys and Breast 2 and Breast 3 for girls. The chest duration of excursion of Risser sign is variable and
growth peak occurs on the descending side of pubertal ranges from 1 to 3 years (4,11). Little and Sussman con-
growth. cluded that it is better to rely on chronologic age (25). I
do not agree with their conclusions. The Risser sign
should be augmented with the bone age as determined by
IMAGING ASSESSMENT OF GROWTH
the method of Greulich and Pyle.
Accurate assessment of bone age is not easy. The The Risser sign is zero for the first two thirds of the
younger the child, the more difficult it is to determine pubertal growth spurt. The child is Risser 0 before the
future growth and the more likely errors are committed ascending limb of the growth acceleration curve and it
(22). Children are often a bone age mosaic. Bone age gives little information other than to indicate that the
determinations for the hands, elbows, pelvis, and knees peak of the growth velocity curve has not been reached.
do not always agree coincidentally. Bone age determi- I recommend dividing this time characterized by Risser 0
nation is often made too quickly and with too little in- into two periods based on the triradiate cartilage and its
formation. When using a reference method (e.g., the closure: triradiate cartilage open, triradiate cartilage
Greulich and Pyle atlas), it is important to understand
what to look for and know the standard error and not
simply compare radiographs (19). Where a major deci-
sion is to be made, it is better to have two interpretations
of the child’s bone age by experienced observers.
Cundy (10) demonstrated that four radiologists’ inter-
pretations of skeletal age of sample radiographs differed
by more than 2 years in 10% of the patients. Carpenter
(8) evaluated bone age in children less than 10 years of
age and showed that separate readings of the distal radius
and ulna, tarsal bones, metacarpals, and phalanxes could
magnify these errors. The bone ages of carpal bones and
distal radius and ulna often lagged behind the bone ages FIG. 6. The pubertal growth curve in boys. The fusion of the
of the metacarpals and phalanges. Haste in bone age distal phalanx of thumb occurs at the same period as elbow clo-
determinations can result in major strategic errors. sure. Risser 1 occurs on the descending side about six months
There are several methods to evaluate bone age (1,17, after elbow closure. Tanner signs: P1, P2, P3 occurs on the
ascending side. Axillary hairs are poor indicators. Reproduced
19,31). Knowledge of these methods and their limita- with permission from Morrissy RT, Weinstein SL. Lovell and Win-
tions is important. We compared the Greulich and Pyle ter’s Pediatric Orthopaedics. 5th ed. Philadelphia, PA: Lippincott
atlas with its French counterpart, the Sempe atlas (31). Williams and Wilkins, 2001.

J Pediatr Orthop, Vol. 21, No. 4, 2001

 CURRENT ISSUES 553

closed (12,13,17). The estimation of bone maturation in GROWTH AND SCOLIOSIS

children is a problem that can at first seem complex but, Sitting height evaluation plays an essential part in the
in practice, it can be easily resolved. The following treatment of scoliosis (13,14). Unfortunately, it is not
method is proposed. recorded often enough. Change in sitting height always
Risser I heralds the beginning of the descending slope needs to be compared with angular spinal changes. Any
of the pubertal growth peak. It generally appears after the spinal curve increasing by 1° each month (12° per year)
olecranon apophysis is united to the ulna. By Risser II, during the ascending phase of the pubertal peak is likely
the greater trochanteric apophysis is united to the femur. to be a progressive curve that will require treatment.
This corresponds to a bone age of 14 years in girls and 16 Curves increasing by 0.5° each month during this phase
years in boys. At Risser III, there is 1 year of growth must be monitored closely. Curves gaining less than 0.5°
remaining. This corresponds to bone age of 14.5 years each month during this phase can be considered mild (13).
for girls and 16.5 for boys. Risser IV corresponds to a However, imprecise and approximate Risser’s sign
bone age of 15 years for girls and 17 years for boys. may be, it is widely used as a deciding factor in scoliosis
Risser V is very much like Risser 0. It is a long period treatment. It can be very useful if its limitations are un-
that does not provide much information to the clinician. derstood. As noted above, two thirds of the pubertal
The iliac apophysis may fuse as late as age 22 or 23, and growth spurt has occurred before the appearance of Ris-
sometimes, it never fuses. It would be futile, if not naive, ser I (24). Bone age, growth rate, and secondary sexual
to wait until the iliac crest is completely ossified before characteristic onset are more reliable parameters. Risser
discontinuing the treatment of scoliosis. stages must be considered as only one factor in the treat-
In our institution, 322 children (245 girls and 77 boys) ment equation (33).
were evaluated during their pubertal period by assessing The “crankshaft” effect on the spine after posterior
standing height, sitting height, Tanner signs, bone age, spinal arthrodesis for scoliosis was described by Dubous-
Riser sign, triradiate cartilage closure, and greater tro- set (18) and analyzed by others (17,28,29,32). The crank-
chanter apophysis closure. In girls, closure of the trira- shaft phenomenon occurs when there is a solid posterior
diate cartilage occurred at 12 years of bone age and arthrodesis with sufficient anterior growth remaining to
closure of the apophysis of the greater trochanter oc- produce a rotation of the spine and trunk with progres-
curred at 14.6 years, between Risser II and III. Fifty-one sion of the curve. The best method to prevent crankshaft
percent of the girls had chronologic age in phase with phenomenon is to perform a perivertebral arthrodesis
their bone age; 33% had an advanced bone age; and 16% that eliminates all the growth plates of the vertebra
had delayed bone age. In boys, closure of the triradiate (13,14). This is especially recommended when the trira-
cartilage occurred at 14 years of bone age and closure of diate cartilages are still open (29).
the great trochanter occurred at 16 years of bone age.
Bone age was in phase with their chronologic age in LOWER LIMB GROWTH
46%, advanced in 30%, and delayed in 24%. The lower limb grows more than the trunk (2,15). The
We drew the following conclusions from our study. cycle of growth in the lower limb is very predictable.
Risser 0 must be split in two periods: triradiate cartilage There is a rapid increase in growth during the first 5
open or triradiate cartilage closed. The apophysis closure years of age, followed by a steady but slower growth
of the greater trochanter is a good landmark to split Ris- from 5 years of age to the onset of the puberty. A slight
ser I to Risser V period in two parts: Risser I–II and growth spurt occurs during the accelerated velocity of
Risser IV–V. There are four zones in the pubertal phase. growth at the beginning of puberty, and finally, early ces-
Zone I: Risser 0, triradiate cartilage open (ascending sation of growth after the velocity peak. The femur grows
side). Zone II: Risser 0, triradiate cartilage closed (as- more than the tibia with a constant relationship between the
cending side). Zone III: Risser I to II, olecranon closed, femur and the tibia throughout growth. Their proportions
great trochanter open (descending side). Zone IV: Risser are set as early as age 5 years. Tibial length is 80% of
IV to V, greater trochanter closed (descending side). It femoral length. Fibular length is 98% of tibial length.
should be noted that bone age was coincident with
chronologic age in only 50% of the patients. Advanced Femoral growth
bone age is more frequent than delayed bone age (17). The proximal femoral physis of the femur accounts for
30% of the femoral growth or approximately 10 cm. The
SPINAL COLUMN GROWTH distal and proximal femoral growth plates grow approxi-
Measurement of sitting height provides an indirect re- mately 1 cm and 0.7 cm, respectively, each year. During
flection of spinal growth. The spine makes up 60% of the puberty, this rate of growth increases to approximately
sitting height, whereas the head represents 20% and the 1.2 cm for the distal femur and 0.8 cm for the proximal
pelvis 20% (12,13,16). The height of the spine will femur (15).
nearly triple from birth to adulthood. Growth of the tho- Tibial growth
rax represents the spine’s fourth dimension (13). The The tibial and femoral growth profiles are almost iden-
thoracic circumference equals 96% of sitting height. The tical with rapid growth during the first 5 years of life,
combined values of the transverse and anteroposterior which then slows to approximately 1.3 cm each year
(AP) diameters (as measured by calipers) of the thorax until puberty, when growth increases to 1.6 cm per year.
should equal 50% or more of the sitting height. Growth of the tibia and the fibula are interdependent (15).

J Pediatr Orthop, Vol. 21, No. 4, 2001

554 CURRENT ISSUES

Knee growth valuable and objective tool for evaluating residual

Growth around the knee is the largest growth site of growth, particularly with respect to the proportions be-
all. The knee accounts for about two thirds of growth in tween the length of various limb segments and between
the lower limb, 37% for the distal femoral physis and the limbs and the trunk. However diverse the ethnic ori-
28% for the tibia (2,15). gins and even though stature has increased in succeeding
generations over the centuries, boys of all generations
Foot growth and ethnic backgrounds have approximately 14% of out-
The length of the foot is relatively large during intra- standing growth in standing height and 10% of length of
uterine life with relative diminution throughout growth the femur and tibia remaining at the beginning of puberty
(5). At birth, the foot is approximately 40% of its final (3,12,17). The percentages, proportions, and ratios are
size. The foot is the first segment of the musculoskeletal stable. The humerus makes up about 20% of sitting
system to show pubertal growth change. The growth height and 38% of standing height (17). Whatever the
spurt of the foot occurs a few months before the start of race, the lower limbs double in length at age 2 years, and
puberty. The foot is also the first musculoskeletal seg- there remains 50% of growth in the lower limbs at the
ment that stops growing at maturity. Foot growth stops age of 4 years (12). Despite the diversity of races, ve-
about 3 years before the end of skeletal maturation. Ar- locity of the standing height always has the same pattern.
throdesis of the foot at the beginning of puberty will have It is extremely rapid during intrauterine life, rapid during
no significant impact on the length of the foot. The foot the first 5 years after birth, slows after 5 years of age, and
represents 15% of the standing height in both girls and followed by acceleration at puberty.
boys at skeletal maturity, an amount which must be taken All the changes are gradual. Puberty is a short period
into consideration during lower limb length assessment, of approximately 2 years with rapid growth changes. The
especially in conditions that have foot manifestations, milestones that mark the path during this period must be
e.g., fibular hemimelia. noted and understood by the orthopaedic surgeon. The
best way to understand growth is to follow its patterns.
UPPER LIMB GROWTH One must embrace its rhythms and its cadences in order
Upper limb growth follows the same pattern of devel- to control it. This is best done by perceptive, repetitive
opment as the lower limb. The first 5 years are charac- collection of measurements. The more accurate and fre-
terized by rapid growth. Between 5 years and the begin- quent the data, the more sensitive and precise is the treat-
ning of puberty, there is a plateau and, in the very be- ment. Rigorous analysis and flexibility in the interpreta-
ginning of the puberty, a slight spurt in growth (12,27). tions are the keys for success.
The maturity gradient in the upper limbs is similar to that
in the lower limbs. The hand shows its relatively slight REFERENCES
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amongst the various bones of the upper and lower limbs growth in the lower extremities. J Bone Joint Surg Am 1963;45A:
1–14.
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