Is the Greulich and Pyle atlas applicable to all ethnicities? A systematic review and meta-analysis.

Objective: To determine whether the Greulich and Pyle (G&P) atlas is applicable when applied to populations of different ethnicity. Methods: A systematic review of studies published between 1959 and 15th February 2017 identified from the Embase, MEDLINE and Cochrane databases was undertaken. Quality of the studies was assessed using the National Institute for Health and Care Excellence tool. Meta-analysis used mean differences and standard deviations as summary statistics for the difference between bone age (BA) and chronological age (CA). Results: A total of 49 studies were included of which 27 (55%) were related to Caucasian populations. Of the 49 eligible studies, 35 were appropriate for further meta-analysis. In African females, meta-analysis showed a significant mean difference between BA and CA of 0.37 years (95% CI 0.04, 0.69). In Asian males, meta-analysis showed significant differences between BA and CA of -1.08, -1.35, -1.07, -0.80 and 0.50 years for chronological ages of 6, 7, 8, 9 and 17 years, respectively. Meta-analysis showed no significant differences between BA and CA in African males, Asian females, Caucasians and Hispanics. Conclusions: The G&P standard is imprecise and should be used with caution when applied to Asian male and African female populations, particularly when aiming to determine chronological age for forensic/legal purposes. Key Points: • In African females, bone age is significantly advanced when compared to the G&P standard. • In Asian males, bone age is significantly delayed between 6 and 9 years old inclusive and significantly advanced at 17 years old when compared to the G&P standard. • The G&P atlas should be used with caution when applied to Asian and African populations, particularly when aiming to determine chronological age for forensic/legal purposes.