RADIOLOGIC EVALUATION OF THE DISTAL RADIUS INDICES
IN EARLY AND LATE CHILDHOOD
Pooya Hosseinzadeh, MD1, Douglas Olson, MD2, Ryan Eads, MD3,
Ashley Jaglowicz, DO4, Charles A Goldfarb, MD5, Scott A Riley, MD6
ABSTRACT
The osseous anatomy of the distal radius is well
documented in adults. Three commonly discussed
variables are the volar tilt (also known as palmar
tilt or palmar inclination), radial inclination, and
radial height. These values are not well defined in
the growing skeleton. We studied the radiographic
measurements of normal distal radius osseous
anatomy in children and identified how these
values change with age. 372 patients (215 males
and 157 females) between the ages of 8 and 16
were included in the study. Normal values of volar
tilt, radial inclination, and radial epiphyseal height
were defined for each age group. Regression analy-
sis showed that volar tilt increased significantly by
increase in age (P <0.001). Radial inclination and
radial epiphyseal height both showed significant
increase with increase in age (P<0.001). This is
the first study to define these radiographic values
in children and their change with age.
Keywords: volar tilt, distal radius, radial inclina-
tion, epiphysis
1.
Pooya Hosseinzadeh, MD (Corresponding author)
Washington University Orthopaedics at St. Louis Children’s Hospital
1 Children’s Place, Suite 4S60
St. Louis, MO 63110
Email: hosseinzadehp@wustl.edu
2.
Douglas Olson, MD
Email: olsonds25@gmail.com
Shriners Hospital for Children, Lexington, KY
3.
Ryan Eads, MD
Shriners Hospital for Children, Lexington, KY
4.
Ashley Jaglowicz, DO
Shriners Hospital for Children, Lexington, KY
5.
Charles A Goldfarb, MD
Department of Orthopedics, Washington University School of
Medicine
St Louis, MO
6.
Scott A Riley, MD
Email: sariley@shrinenet.org
Shriners Hospital for Children, Lexington, KY
We have no conflicts of interest to disclose. This study was not
funded.
INTRODUCTION
The osseous anatomy of the distal radius is well docu-
mented in adults. This knowledge has helped us guide
clinical treatment of pathologies involving the wrist and
distal radius. Three commonly discussed variables are
the volar tilt (also known as palmar tilt or palmar inclina-
tion), radial inclination, and radial height. These values
are not well defined in the growing skeleton. Previous
radiographic studies using pediatric patients have identi-
fied the distal radius growth plate-shaft angle as the angle
between a line drawn down the long axis of the radius
and a line drawn across the distal radius physis, with a
normal of 90 degrees on the AP and lateral radiographs1-4.
To our knowledge, there has been no study identifying
the age based values of volar tilt, radial inclination, and
radial height in the pediatric population. We studied
the radiographic measurements of normal distal radius
osseous anatomy in children and identified how these
values change with age.
METHODS
We performed a retrospective review of wrist radio-
graphs performed at our center from 2009 to 2013. We
identified all patients ages 8-16 who had wrist radio-
graphs taken during that time period. We chose our
cut off age of 16 because by that age both males and
females will presumably have reached skeletal matu-
rity. We systematically reviewed every radiograph and
excluded all patients who had any evidence of trauma
(acute or chronic) to the distal radius. The PA and lateral
radiographs were used to obtain our measurements.
Only true lateral radiographs were included in the study
which was defined as having the ulnar head completely
superimposed behind the radius2-4. Johnson showed that
on a conventional lateral wrist radiograph, a 5 degree
rotational change produces a 1.6 degree change in volar
tilt, where an increase in supination causes an increase
in volar tilt5. The volar tilt was measured on the lateral
view. It was defined as the angle between a line drawn
perpendicular to the long axis of the radius and a tan-
gent line drawn along the slope of the dorsal-to-palmar
surface of the radius. We chose to use the Cobb angle
technique to get the volar tilt. A normal adult volar tilt
angle has been identified as 10-25 degrees6-8. An example
of volar tilt measurement is shown in figure 1. Radial
Volume 38   137
P. Hosseinzadeh, D. Olson, R. Eads, A. Jaglowicz, C.A. Goldfarb, S.A. Riley
Figure 1: Measurement of volar tilt Figure 2: Measurement of radial inclination
inclination is measured on PA view as the angle between
a line drawn perpendicular to the long axis of the radius
along the articular surface of the distal radius and a line
drawn down from the tip of the radial styloid. A normal
adult radial inclination is 15-25 degrees6,7. An example
of this measurement is seen in figure 2. Traditionally in
adults radial height is measured as the distance between
two parallel lines. One line perpendicular to the long
axis of the radius is drawn along the ulnar aspect of the
articular surface and the other line is drawn at the tip of
the radial styloid. A normal radial height in adults is 9.9-
17.3 mm9. However, in children the distal radius physis
complicates the measurement of radial height. We chose
to measure the height of the distal radial epiphysis as
the measurement of radial height. An example of distal
radial epiphysis measurement in children is shown in
figure 3. All of the data collection was performed by one
senior orthopedic surgery resident. Skeletal age was also
measured using Greulich and Pyle’s Radiographic Atlas
of Skeletal Development of the Hand and Wrist. Average
values of all these measurements were calculated for 4
age groups (8-9, 10-11, 12-13, and 14-16 years of age).
138   The Iowa Orthopedic Journal
Figure 3: Measurement of radial
epiphyseal height
The total number of wrist radiographs examined for each
age group includes 74 for the 8-9 year old age group, 122
for the 10-11 year old group, 77 for the 12-13 year old
group, and 99 for the 14-16 year old age group. A regres-
sion analysis was performed to determine the statistical
significance of change in radiographic measurements
(volar tilt, radial inclination, and radial epiphyseal height)
with regards to chronologic age and skeletal age.
RESULTS
372 patients (215 males and 157 females) between the
ages of 8 and 16 were included in the study. Normal val-
ues of volar tilt, radial inclination, and radial epiphyseal
height were defined for each age group. The age based
values of volar tilt, radial inclination, and radial epiphy-
seal height are summarized in tables 1-3. Regression
analysis showed that volar tilt increased significantly by
increase in age (P <0.001). Volar tilt values correlated
both with skeletal age (R= 0.5) and chronological age
(R=0.4) which is shown in table 4. Radial inclination and
radial epiphyseal height both showed significant increase
with increase in age (P<0.001). Radial inclination values
 Radiologic Evaluation of the Distal Radius Indices in Early and Late Childhood

Table I: Average values of volar tilt for each

age group; VT: Volar tilt
Combined Male
Age Female VT Male VT
and Female VT
8-9 10.15 9.23 9.96

10-11 10.63 10.18 10.43

12-13 12.89 12.22 12.56

14-16 14.21 12.35 13.57

Table II: Average values of radial inclination Table 4: Change in volar tilt in males and females based on chrono-
logical age (R: 0.4)
for each age group; RI: Radial inclination
Combined male
Age Female RI Male RI
and female RI
8-9 19.85 18.3 19.66

10-11 21.75 20.36 21.14

12-13 24.73 23.61 24.17

14-16 24.99 24.4 24.79

Table III: Average values of radial epiphyseal

for each age group; REH: Radial epiphyseal
height
Combined male Table 5: Change in radial inclination in males and females based on
Age Female REH Male REH
and female REH chronological age (R: 0.6)
8-9 8.62 8.86 8.73

10-11 10.93 10.33 10.66

12-13 13 13.32 13.16

14-16 13.36 15.25 14.01

correlated
A both with skeletal age(R=0.6) and chrono-
logical age (R=0.6) which is shown in table 5. Radial
epiphyseal height also showed strong correlation with
skeletal (R=0.8) and chronological age (R=0.8) which is
shown in table 6.

DISCUSSION
Table 6: Change in REH in males and females based on chronological
The cumulative risk of fracture from age 0-16 is 27% age (R: 0.8), RH: Radial Epiphyseal Height
in girls and 42% in boys10. The distal end of the forearm
is one of the most commonly fractured sites of a child’s
body10. Fortunately it is well accepted that most distal
radial height. Average values of these three measure-
radius fractures in children that are properly reduced
ments are known for adults, but not for the pediatric
and treated will heal without any clinical consequences.
population.
Even though this is a very common injury there has
Our study identified the normal values of volar tilt,
been no radiographic study of the distal radius anatomy
radial inclination, and radial height in children in dif-
correlated with the child’s age. Three values commonly
ferent age groups. All these values showed to increase
used to determine need for surgery as well as quality of
significantly with increase in age and showed correlation
correction in adults are volar tilt, radial inclination, and

Volume 38   139

P. Hosseinzadeh, D. Olson, R. Eads, A. Jaglowicz, C.A. Goldfarb, S.A. Riley
with both chronological and skeletal age in children. The
highest correlation was seen between radial epiphyseal
height and age. We have identified that the radiographic
anatomy of the distal radius in children is different than
that of the mature skeleton and changes with age.
Our study has its limitations. The error in the
measurements and potential unknown metabolic bone
disease or fully remodeled previous fractures in some
children may have affected our results. Also, one must
realize that the periarticular osseous anatomy in children
is very different from that of adults due to the significant
cartilaginous epiphyseal component. Our study only fo-
cused on ossified anatomy visible on plain radiographs.
MR imaging would greatly improve visualization of this
cartilaginous component, but becomes impractical when
A
trying to get a large volume of patientsB included in the
study, as it is cost prohibitive to perform MR screening
of all wrist injuries. We also realize that the general eth-
nicity statistics provided may not be indicative of those
patients who show up to the Emergency Room with
complaints of wrist pain, and that this information would
change the anthropometric data. Lastly, we note that it is
a widely accepted fact that girls reach skeletal maturity
earlier than boys, typically at age 14 for girls and at age
16 for boys. However there are age ranges for each of the
different stages of skeletal development. For instance,
Gruelich and Pyle in their extensive atlas on hand bone
age note an age range for “Early and Mid-Puberty” for
females to be 7-13 years of age and for males to be 9-14
years of age. This does illustrate that in general females
develop skeletal anatomy at a younger age than males,
but it also illustrates that these are broad ranges of ages.
In our study both boys and girls had an increase in the
indices studied at the same 11-13 age range. This could
be because we chose narrower age ranges, or it could
also indicate that a larger patient population should be
studied in this age range to see if this equivalent increase
in indices holds true.
The shape of the epiphysis and/or pattern of the
physeal line, as well as the ratio of the radial height,
i.e., height of the epiphysis in relation to the total length
of the radius, was not evaluated in the study, although
these would be interesting values to pursue further with
follow up studies.
Another limitation of the study is the lack of data
about the ethnicity of the subjects. The study was
performed at a large teaching hospital in Kentucky.
Although the ethnicity of each patient was not noted
for this study, results of the 2010 census reveal that in
the state of Kentucky, particularly, for Fayette County
(where the study was performed), the population con-
sists of 75.7% Caucasian, 14.5% African American, 6.9%
Hispanic/Latino, 3.2% Asian and 0.3% American Indian
140   The Iowa Orthopedic Journal
and Alaska Native11. Based on the population, we expect
our study results to mostly represent normal values in
Caucasians.
In summary, we have identified normal age based
values for distal radius anatomy in children and have
shown how they change with growth.
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