Assessment of the skeletal maturity in Libyan preschool children

Assessment of the skeletal maturity in Libyan preschool children | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of the skeletal maturity in Libyan preschool children Fathy Ahmed Fetouh, Youssef Ahmad Trunba, Adel Kerfa This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9611066/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Introduction: Bone age assessment is one of the commonly used methods in pediatric practice for detection of discrepancies between bone age and chronological age, which may point at problems with normal skeletal development and be helpful in diagnosing endocrinological or growth disorders. Material and Methods: This retrospective cross-sectional study was conducted using wrist and hand radiographs of Libyan preschool children aged 3 to less than 6 years. Study participants were grouped by age as follows: 3 years (58 boys, 62 girls), 4 years (46 boys, 62 girls), and 5 years (70 boys, 42 girls). Evaluation of carpal bone age was done according to Tanner-Whitehouse 3 (TW3) method. Comparisons of chronological age and carpal bone age according to sex and age were statistically analyzed. Results: A statistically significant sex difference in carpal age was observed only in the first age group, where males showed a higher mean carpal age compared to females. No significant sex differences were identified in the second and third groups. Furthermore, a significant difference between chronological age and carpal age was found only among males in the youngest age group, where carpal age exceeded chronological age. In contrast, no significant differences were detected among females or in either sex within the older age groups. Conclusion: Carpal bone age is generally consistent with chronological age in Libyan preschool children. However, early sex differences were observed in younger males, suggesting age-dependent variation in skeletal maturation. Bone age Carpal bone age Skeletal maturation TW3 Libyan children Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Chronological age and bone age are two different but interconnected measures of growth. The chronological age refers to the period of time passed since birth up to the current moment measured in years. On the contrary, bone age describes the level of maturity of bones expressed in years as well [ 1 – 5 ]. The assessment of bone age is a frequently applied measure in pediatric practice, as it allows for the detection of inconsistencies between skeletal and chronological age. These inconsistencies might suggest problems with the process of skeleton maturation in children and become an essential indicator for the treatment of various endocrine disorders [ 6 – 8 ]. Bone age (BA) is accomplished by using some bones such as pharyngeal, radius, ulna and carpal bones. Examination of the carpal bones to determine the age of bone is widely used because it is much easier than other bones. Specifically, the carpal bones have minimal exposure to radiation and have various ossification centers, which helps to evaluate bone development better [ 9 ]. Additionally, in children under six years old, carpal bones provide the highest reliability of bone age results, before overlapping of these bones occurs [ 10 ]. The most common methods for the assessment of bone age on radiographs of hands and wrists are the Greulich and Pyle (GP) method and Tanner and Whitehouse (TW2) technique. Using the GP method, bone age is estimated through comparison of a child's radiographs with those presented in an atlas of reference radiographs to find the closest one [ 1 ]. The TW2 method evaluates the maturity of individual bones in the hand and wrist using a scoring system from A to I. The method implies evaluation of 20 bones, and the cumulative score is used to determine overall skeletal maturity. Sex differences are taken into account in the assessment [ 6 , 11 ]. Despite the TW2 method is more time-consuming, it is generally believed to be more accurate and reliable compared to the GP method [ 12 ]. In 2001, Tanner et al. [ 8 ] introduced updated reference standards based on American and European samples, known as the TW3 method. This updated method places greater emphasis on the radius, ulna, and short bones (RUS score), rather than the carpal score or the combined scores. Recent clinical studies prove that TW3 is the most appropriate method showing the highest degree of accuracy in 3–6-year old and can be regarded as the most reliable method with the highest accuracy compared to the other methods [ 13 – 16 ]. Although there is a rising need for accurate skeletal age estimation in a clinical practice, there is still a lack of data on skeletal maturity among Libyan children. A considerable percentage of the children in Libya in the preschool age category are within critical periods of their growth and development (3–5 years old). This study focuses on describing the growth pattern of skeletal maturity among Libyan preschool children by sex and developing standard growth curves for the skeletal maturity based on the TW3 carpal score. Materials and Methods The current retrospective cross-sectional study was approved by the Biosafety and Bioethics Committee of the Libyan Medical Research Center (Approval No. NBC:018.H.26.109 ), and is in accordance with ethical principles stated in the Declaration of Helsinki. The study was carried out utilizing hand and wrist radiographs of children seen in the emergency or outpatient departments at Zawia Educational Hospital, Zawia, Libya, as suspected bone fractures from December 1, 2024, to October 1, 2025. Informed consent was waived since the study was conducted retrospectively, and the anonymity of all data was maintained. All radiographs were acquired based on a standardized procedure. The child sits at the edge of the radiography table, placing his/her examined hand on the radiographic film cassette. In the case of anteroposterior hand, all fingers should be fully extended and slightly separated. Carpal and metacarpal areas must contact the image plate. The X-ray focus should be positioned over the third metacarpal bone. Hand radiographs of preschool children aged 3–6 years were included in the study. Whenever possible, left-hand radiographs were taken. In cases where left-hand radiographs were unavailable, right-hand radiographs were taken because there is no difference in the skeletal ossification process between two sides [ 17 ]. Chronological age (CA) was determined as the difference between the X-ray date and the date of birth of each participant. Three age groups (3-, 4-, and 5-year-old children) were involved in the study. Male and female subjects were present in each age group. The age range for each group extended from the exact age to one day before the next year (e.g., the age range of the 5-year group was exactly 5 years to 5 years, 11 months, and 29 days). The sample distribution was as follows: the 3-year-old group included 58 boys and 62 girls; the 4-year-old group included 46 boys and 62 girls; the 5-year-old group included 70 boys and 42 girls. Exclusion Criteria Children under 3 years or older than 6 years were not included in the study. Besides, those suffering from chronic disease affecting bone age (e.g., diabetes mellitus, sickle cell anemia, rickets), having experienced trauma to the carpal bones, suffering from congenital or endocrine diseases, or having poor-quality radiographs with incomplete demographic information (i.e., age or gender) were excluded. Bone Age Evaluation Bone age was evaluated based on the Tanner–Whitehouse 3 (TW3) method applied to carpal bones (Tanner et al. 2001). These carpal bones include the capitate, hamate, triquetrum, lunate, scaphoid, trapezium, and trapezoid. (The pisiform appears around 11 years of age.). Maturity stages A-I are assigned to each bone by comparing with the standard reference radiograph. Each stage has its specific score value, and the summation of all these values provides a score indicating maturity. Maturity score is translated to the age using reference tables for boys and girls. Evaluation of each radiograph was performed independently by two investigators. Excellent inter-observer agreement is achieved with a standard error of measurement equal to 0.10 years. Radiographs for each age-sex combination were arranged based on their maturity score in ascending order. The middle radiograph was selected as the standard representative of each group. Statistical Analysis Statistical analysis was conducted using the Statistical Package for the Social Sciences (SPSS), version 21 (IBM Corp., USA). The difference between mean bone age (BA) and mean chronological age (CA) were compared across different age groups and sexes using the independent samples t-test. A p-value of less than 0.05 was considered statistically significant. . Results Comparison of Males and Females The comparison of males and females in terms of their CA and BA has been presented in Table 1 and Fig. 1 for all three study groups. No statistically significant difference was noted between males and females in terms of their CA (p = 0.62) in the first group. In this study group, however, a statistically significant difference was noted between males and females in terms of BA (p = 0.024). In the second and third groups, no statistically significant difference was noted between males and females in both CA and CBA (p > 0.05). In conclusion, sex-related differences were only evident in BA among males and females in the first group. Table 1 Comparison between males and females regarding chronological age and carpal age in the studied group Group Variable Sex N Mean SD t-value p-value 1st group Chronological age M 58 3.50 0.60 0.49 0.62 F 62 3.45 0.50 Carpal age M 58 3.90 0.89 2.28 0.024* F 62 3.50 1.03 2nd group Chronological age M 46 4.40 0.40 1.05 0.30 F 62 4.50 0.60 Carpal age M 46 4.75 1.85 0.34 0.72 F 62 4.60 2.70 3rd group Chronological age M 70 5.50 0.70 0.00 1.00 F 42 5.50 0.60 Carpal age M 70 5.30 2.20 0.78 0.44 F 42 5.55 1.20 Notes: Data are presented as Mean ± SD. Independent samples t-test was used. Statistically significant at p < 0.05. Comparative Analysis of Chronological and Carpal Bone Ages As seen in Table 2 and Figs. 2 and 3 , the comparison of chronological and carpal bone ages for both sexes was conducted using data from the study groups. A significant difference was observed between chronological age and carpal bone age among males of the first group; that is, carpal bone age was greater (p < 0.01), whereas there were no differences for females. In the case of the second and third groups, there were no statistically significant differences between the chronological age and carpal bone age for males and females (p > 0.05). Consequently, a difference between chronological and carpal bone ages was seen only in males of the first group. Table 2 Comparison between chronological age and carpal age across study groups Group Sex N Chronological Age (Mean ± SD) Carpal Age (Mean ± SD) t p Significance 1st M 58 3.50 ± 0.60 3.90 ± 0.89 -2.84 0.005 Significant 1st F 62 3.45 ± 0.50 3.50 ± 1.03 -0.34 0.730 NS 2nd M 46 4.40 ± 0.40 4.75 ± 1.85 -1.25 0.210 NS 2nd F 62 4.50 ± 0.60 4.60 ± 2.70 -0.28 0.780 NS 3rd M 70 5.50 ± 0.70 5.30 ± 2.20 0.72 0.470 NS 3rd F 42 5.50 ± 0.60 5.55 ± 1.20 -0.24 0.810 NS Notes: Test used: Paired samples t-test Level of significance set at p ≤ 0.05 Only males in the 1st group showed a statistically significant difference Standard Carpal Bone Age Tables 3 and Figs. 4 present the descriptive analysis for standard carpal bone age in the different study groups. In the first and second groups, males exhibited higher average values than females. On the other hand, in the third group, the average carpal bone age was found to be higher in females than males. Table 3 Standard carpal bone age across age groups in males and females Standard carpal bone age 1st group 2nd group 3rd group Male Female Male Female Male Female 3.80 3.40 4.82 4.62 5.40 5.80 Discussion The present study showed a significant sex difference concerning carpal bone age in the first group of children, whereby boys exhibited higher values of skeletal maturity compared to girls. Contrary to these results, Greulich & Pyle [ 1 ] and Marshall & Tanner [ 18 , 19 ] reported that females are characterized by greater skeletal maturation than males in general. The reason for these contradictory results can be found in individual differences related to genetic, environmental, and nutritional factors influencing the process of bone formation [ 20 ]. Additionally, it has been established that ossification pattern differences vary with sex among various populations and age groups [ 21 ]. The lack of significant differences concerning the second and third age groups is also in accordance with earlier studies [ 22 , 23 ] stating that boys and girls differ little regarding skeletal maturation in comparable age categories. It is possible to suggest that with age, these differences become insignificant owing to the progressive ossification process. In addition, hormonal regulation of growth might be associated with these results since growth hormone and thyroid hormones are important regulators of skeletal maturation [ 24 ]. It was shown that carpal bone age in the first age group exceeded chronological age only in males. This suggests that boys demonstrate relatively advanced bone maturation at an early age probably due to biological factors associated with genetics and environment. Such results coincide with those of earlier studies demonstrating that in some cases, skeletal age differs from chronological age in preschool boys and girls [ 22 , 25 ]. Carpal bones serve as valid criteria to estimate skeletal maturity since they have a definite pattern of ossification [ 26 , 27 ]. They are particularly useful in early childhood before overlapping of structures occurs [ 28 ]. The absence of significant differences in older groups suggests that chronological age and skeletal age tend to converge with increasing age. Such finding is supported by Zhang et al. [ 28 ] who reported that the discrepancies between carpal bone age and chronological age may vary with age due to differences in the speed of ossification. In addition, methodological aspects can be involved in the occurrence of the obtained results. Previously, it was shown that TW3 method can underestimate bone age in preschool children [ 29 , 30 ]. Thus, the data obtained show that discrepancies between skeletal and chronological ages exist in preschoolers, while with age, they become less pronounced. These findings emphasize the necessity to consider age and sex when estimating skeletal maturity. It is suggested to conduct further longitudinal studies involving large-scale sampling to prove and explore the factors of skeletal maturation. Limitations and Future Recommendations It is necessary to take into consideration several methodological factors that could have influenced the findings of the current study. First, its cross-sectional design made it impossible to trace personal growth trajectories, which is why the use of longitudinal designs is required in order to determine the dynamics of the examined process. Second, this study is limited by the use of only one criterion to estimate skeletal age. While carpal bones were chosen for this purpose due to their high validity and reliability, the inclusion of other skeletal elements in the examination is proposed for the further study. Third, the lack of controlling for potentially interfering factors, such as nutritional status, social and economic aspects, and hormonal regulation, makes it possible to recommend their further consideration. Finally, the study was conducted within a single population, which may limit the generalizability of the findings. Thus, it would be beneficial to carry out a comparative analysis in several other populations. Conclusion Carpal bone age was largely consistent with chronological age across the studied groups, with a significant advancement observed only in younger males. This indicates early sex-related variation in skeletal maturation that appears to diminish with increasing age. Overall, chronological age remains a reliable indicator of skeletal maturity in preschool children; however, caution is advised when interpreting skeletal maturity in younger age groups. Declarations Ethics Approval declaration The study was approved by the Biosafety and Bioethics Committee of the Libyan Medical Research Center (Approval No. NBC:018.H.26.109 ). Funding Declaration No funding was received for this study Competing interests The authors declare no competing interests. Author Contribution Fathy ahmed Fetouh; Concept, Initiate the study design, and outline and a major contributor in writing the manuscript. and Youssef Ahmad Trunba, Adel Kerfa collect and analyze the patient data and review the radiological images with interpretation of the all X ray films. All authors read, review and approved the final manuscript. Data Availability Included in the paper or Supplementary Information References Greulich WW, Pyle SI (1959) Radiographic atlas of skeletal development of the hand and wrist. Stanford University Press, Stanford. https://doi.org/10.1097/00000441-195909000-00030 Tanner JM (1962) Growth at adolescence. 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J Clin Endocrinol Metab 94(5):1638–1643. https://doi.org/10.1210/jc.2008-1522 Plotkin LI, Bruzzaniti A, Pianeta R (2024) Sexual dimorphism in the musculoskeletal system. J Endocr Soc 8(10):bvae153. https://doi.org/10.1210/jendso/bvae153 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 09 May, 2026 Reviewers agreed at journal 05 May, 2026 Reviewers invited by journal 05 May, 2026 Editor assigned by journal 05 May, 2026 Submission checks completed at journal 05 May, 2026 First submitted to journal 04 May, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9611066","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":637886639,"identity":"b339683c-39d9-4bf7-b93d-ef252ae60b85","order_by":0,"name":"Fathy Ahmed Fetouh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYBAC9gYGNgYeBgsZEAsImIFCBLTwHABrkeABsSBamInWIpFArBYG5mcP3tRI8PDPfP5MgqHCOrGBmceAgBY2c8M5xyR4JG4npEkwnEknrMWegcFMmocN6LDbCcckGNsOE2ML+zdpnn8SPPI3D7ZJMP4jSguPmTRvmwSPwQ1mNgnGBmK0MPOUG87tk+AxPJPGbJFwLN24jZmtAL8W9vZtD958s5GTO3784Y0PNday/ezNG/BqQY2FBCBmY+DA7zBsgP0ByVpGwSgYBaNgWAMApqM3jrgft6UAAAAASUVORK5CYII=","orcid":"","institution":"University of Zawia","correspondingAuthor":true,"prefix":"","firstName":"Fathy","middleName":"Ahmed","lastName":"Fetouh","suffix":""},{"id":637886640,"identity":"bec99cd2-9fb9-4433-8305-cf9b2d8b4af6","order_by":1,"name":"Youssef Ahmad Trunba","email":"","orcid":"","institution":"University of Zawia","correspondingAuthor":false,"prefix":"","firstName":"Youssef","middleName":"Ahmad","lastName":"Trunba","suffix":""},{"id":637886641,"identity":"ba3fa65b-a8b2-4139-bad7-cd10c415b45b","order_by":2,"name":"Adel Kerfa","email":"","orcid":"","institution":"University of Zawia","correspondingAuthor":false,"prefix":"","firstName":"Adel","middleName":"","lastName":"Kerfa","suffix":""}],"badges":[],"createdAt":"2026-05-04 17:53:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9611066/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9611066/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109222290,"identity":"2656baf5-d466-4e70-b2db-b1382e1a190c","added_by":"auto","created_at":"2026-05-13 21:06:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":16889,"visible":true,"origin":"","legend":"\u003cp\u003ecomparison between male and female regarding mean carpal age\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9611066/v1/dca1e5475d07cd83d4675435.png"},{"id":109215836,"identity":"28bb3853-72bf-4fae-98eb-b891fd254dc7","added_by":"auto","created_at":"2026-05-13 17:56:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":22672,"visible":true,"origin":"","legend":"\u003cp\u003eComparison between chronological age and carpal bone age across groups in females\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9611066/v1/25964b28b87efc9c7e4e0784.png"},{"id":109215838,"identity":"c2b29a5a-76e4-4c2d-88e1-e561fc37dbd4","added_by":"auto","created_at":"2026-05-13 17:56:59","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":20120,"visible":true,"origin":"","legend":"\u003cp\u003eComparison between chronological age and carpal bone age across groups in males\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9611066/v1/50dc8e6052131783a5429185.png"},{"id":109215839,"identity":"287fdca8-ffc7-45a7-a600-a70c96fcb638","added_by":"auto","created_at":"2026-05-13 17:56:59","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":13747,"visible":true,"origin":"","legend":"\u003cp\u003eStandard carpal bone age in male and female Libyan preschool children\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9611066/v1/ab9517313b224221799ea3c8.png"},{"id":109252472,"identity":"4ddb2854-7ab8-45de-8e3a-72ffcf60ab7a","added_by":"auto","created_at":"2026-05-14 09:26:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":302768,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9611066/v1/e2e4b4a0-5c27-40a2-8120-2d3c69beec95.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of the skeletal maturity in Libyan preschool children","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronological age and bone age are two different but interconnected measures of growth. The chronological age refers to the period of time passed since birth up to the current moment measured in years. On the contrary, bone age describes the level of maturity of bones expressed in years as well [\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The assessment of bone age is a frequently applied measure in pediatric practice, as it allows for the detection of inconsistencies between skeletal and chronological age. These inconsistencies might suggest problems with the process of skeleton maturation in children and become an essential indicator for the treatment of various endocrine disorders [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBone age (BA) is accomplished by using some bones such as pharyngeal, radius, ulna and carpal bones. Examination of the carpal bones to determine the age of bone is widely used because it is much easier than other bones. Specifically, the carpal bones have minimal exposure to radiation and have various ossification centers, which helps to evaluate bone development better [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Additionally, in children under six years old, carpal bones provide the highest reliability of bone age results, before overlapping of these bones occurs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe most common methods for the assessment of bone age on radiographs of hands and wrists are the Greulich and Pyle (GP) method and Tanner and Whitehouse (TW2) technique. Using the GP method, bone age is estimated through comparison of a child's radiographs with those presented in an atlas of reference radiographs to find the closest one [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The TW2 method evaluates the maturity of individual bones in the hand and wrist using a scoring system from A to I. The method implies evaluation of 20 bones, and the cumulative score is used to determine overall skeletal maturity. Sex differences are taken into account in the assessment [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the TW2 method is more time-consuming, it is generally believed to be more accurate and reliable compared to the GP method [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In 2001, Tanner et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] introduced updated reference standards based on American and European samples, known as the TW3 method. This updated method places greater emphasis on the radius, ulna, and short bones (RUS score), rather than the carpal score or the combined scores. Recent clinical studies prove that TW3 is the most appropriate method showing the highest degree of accuracy in 3\u0026ndash;6-year old and can be regarded as the most reliable method with the highest accuracy compared to the other methods [\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough there is a rising need for accurate skeletal age estimation in a clinical practice, there is still a lack of data on skeletal maturity among Libyan children. A considerable percentage of the children in Libya in the preschool age category are within critical periods of their growth and development (3\u0026ndash;5 years old). This study focuses on describing the growth pattern of skeletal maturity among Libyan preschool children by sex and developing standard growth curves for the skeletal maturity based on the TW3 carpal score.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThe current retrospective cross-sectional study was approved by the \u003cb\u003eBiosafety and Bioethics Committee\u003c/b\u003e of the Libyan Medical Research Center (Approval No. \u003cb\u003eNBC:018.H.26.109\u003c/b\u003e), and is in accordance with ethical principles stated in the Declaration of Helsinki. The study was carried out utilizing hand and wrist radiographs of children seen in the emergency or outpatient departments at Zawia Educational Hospital, Zawia, Libya, as suspected bone fractures from December 1, 2024, to October 1, 2025. Informed consent was waived since the study was conducted retrospectively, and the anonymity of all data was maintained.\u003c/p\u003e \u003cp\u003eAll radiographs were acquired based on a standardized procedure. The child sits at the edge of the radiography table, placing his/her examined hand on the radiographic film cassette. In the case of anteroposterior hand, all fingers should be fully extended and slightly separated. Carpal and metacarpal areas must contact the image plate. The X-ray focus should be positioned over the third metacarpal bone.\u003c/p\u003e \u003cp\u003eHand radiographs of preschool children aged 3\u0026ndash;6 years were included in the study. Whenever possible, left-hand radiographs were taken. In cases where left-hand radiographs were unavailable, right-hand radiographs were taken because there is no difference in the skeletal ossification process between two sides [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eChronological age (CA) was determined as the difference between the X-ray date and the date of birth of each participant. Three age groups (3-, 4-, and 5-year-old children) were involved in the study. Male and female subjects were present in each age group. The age range for each group extended from the exact age to one day before the next year (e.g., the age range of the 5-year group was exactly 5 years to 5 years, 11 months, and 29 days). The sample distribution was as follows: the 3-year-old group included 58 boys and 62 girls; the 4-year-old group included 46 boys and 62 girls; the 5-year-old group included 70 boys and 42 girls.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eExclusion Criteria\u003c/h2\u003e \u003cp\u003eChildren under 3 years or older than 6 years were not included in the study. Besides, those suffering from chronic disease affecting bone age (e.g., diabetes mellitus, sickle cell anemia, rickets), having experienced trauma to the carpal bones, suffering from congenital or endocrine diseases, or having poor-quality radiographs with incomplete demographic information (i.e., age or gender) were excluded.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eBone Age Evaluation\u003c/h3\u003e\n\u003cp\u003eBone age was evaluated based on the Tanner\u0026ndash;Whitehouse 3 (TW3) method applied to carpal bones (Tanner et al. 2001). These carpal bones include the capitate, hamate, triquetrum, lunate, scaphoid, trapezium, and trapezoid. (The pisiform appears around 11 years of age.).\u003c/p\u003e \u003cp\u003eMaturity stages A-I are assigned to each bone by comparing with the standard reference radiograph. Each stage has its specific score value, and the summation of all these values provides a score indicating maturity. Maturity score is translated to the age using reference tables for boys and girls. Evaluation of each radiograph was performed independently by two investigators. Excellent inter-observer agreement is achieved with a standard error of measurement equal to 0.10 years. Radiographs for each age-sex combination were arranged based on their maturity score in ascending order. The middle radiograph was selected as the standard representative of each group.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was conducted using the Statistical Package for the Social Sciences (SPSS), version 21 (IBM Corp., USA). The difference between mean bone age (BA) and mean chronological age (CA) were compared across different age groups and sexes using the independent samples t-test. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e \u003cp\u003e.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eComparison of Males and Females\u003c/h2\u003e \u003cp\u003eThe comparison of males and females in terms of their CA and BA has been presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for all three study groups. No statistically significant difference was noted between males and females in terms of their CA (p\u0026thinsp;=\u0026thinsp;0.62) in the first group. In this study group, however, a statistically significant difference was noted between males and females in terms of BA (p\u0026thinsp;=\u0026thinsp;0.024).\u003c/p\u003e \u003cp\u003eIn the second and third groups, no statistically significant difference was noted between males and females in both CA and CBA (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In conclusion, sex-related differences were only evident in BA among males and females in the first group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison between males and females regarding chronological age and carpal age in the studied group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003et-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1st group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChronological age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCarpal age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.024*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2nd group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChronological age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCarpal age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3rd group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChronological age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCarpal age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eNotes:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eData are presented as Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIndependent samples t-test was used.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eStatistically significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/em\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eComparative Analysis of Chronological and Carpal Bone Ages\u003c/h3\u003e\n\u003cp\u003eAs seen in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the comparison of chronological and carpal bone ages for both sexes was conducted using data from the study groups. A significant difference was observed between chronological age and carpal bone age among males of the first group; that is, carpal bone age was greater (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), whereas there were no differences for females. In the case of the second and third groups, there were no statistically significant differences between the chronological age and carpal bone age for males and females (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Consequently, a difference between chronological and carpal bone ages was seen only in males of the first group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison between chronological age and carpal age across study groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChronological Age\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCarpal Age\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSignificance\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e3.90\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-2.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eSignificant\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e3.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.730\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e4.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.210\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e4.60\u0026thinsp;\u0026plusmn;\u0026thinsp;2.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.780\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e5.30\u0026thinsp;\u0026plusmn;\u0026thinsp;2.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.470\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e5.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.810\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eNotes:\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eTest used: Paired samples t-test\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLevel of significance set at p\u0026thinsp;\u0026le;\u0026thinsp;0.05\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOnly males in the 1st group showed a statistically significant difference\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStandard Carpal Bone Age\u003c/h2\u003e \u003cp\u003eTables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Figs.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e present the descriptive analysis for standard carpal bone age in the different study groups. In the first and second groups, males exhibited higher average values than females. On the other hand, in the third group, the average carpal bone age was found to be higher in females than males.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStandard carpal bone age across age groups in males and females\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStandard carpal bone age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1st group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2nd group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e3rd group\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study showed a significant sex difference concerning carpal bone age in the first group of children, whereby boys exhibited higher values of skeletal maturity compared to girls. Contrary to these results, Greulich \u0026amp; Pyle [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and Marshall \u0026amp; Tanner [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] reported that females are characterized by greater skeletal maturation than males in general. The reason for these contradictory results can be found in individual differences related to genetic, environmental, and nutritional factors influencing the process of bone formation [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Additionally, it has been established that ossification pattern differences vary with sex among various populations and age groups [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe lack of significant differences concerning the second and third age groups is also in accordance with earlier studies [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] stating that boys and girls differ little regarding skeletal maturation in comparable age categories. It is possible to suggest that with age, these differences become insignificant owing to the progressive ossification process. In addition, hormonal regulation of growth might be associated with these results since growth hormone and thyroid hormones are important regulators of skeletal maturation [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt was shown that carpal bone age in the first age group exceeded chronological age only in males. This suggests that boys demonstrate relatively advanced bone maturation at an early age probably due to biological factors associated with genetics and environment. Such results coincide with those of earlier studies demonstrating that in some cases, skeletal age differs from chronological age in preschool boys and girls [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCarpal bones serve as valid criteria to estimate skeletal maturity since they have a definite pattern of ossification [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. They are particularly useful in early childhood before overlapping of structures occurs [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The absence of significant differences in older groups suggests that chronological age and skeletal age tend to converge with increasing age. Such finding is supported by Zhang et al. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] who reported that the discrepancies between carpal bone age and chronological age may vary with age due to differences in the speed of ossification. In addition, methodological aspects can be involved in the occurrence of the obtained results. Previously, it was shown that TW3 method can underestimate bone age in preschool children [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus, the data obtained show that discrepancies between skeletal and chronological ages exist in preschoolers, while with age, they become less pronounced. These findings emphasize the necessity to consider age and sex when estimating skeletal maturity. It is suggested to conduct further longitudinal studies involving large-scale sampling to prove and explore the factors of skeletal maturation.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Future Recommendations\u003c/h2\u003e \u003cp\u003eIt is necessary to take into consideration several methodological factors that could have influenced the findings of the current study. First, its cross-sectional design made it impossible to trace personal growth trajectories, which is why the use of longitudinal designs is required in order to determine the dynamics of the examined process. Second, this study is limited by the use of only one criterion to estimate skeletal age. While carpal bones were chosen for this purpose due to their high validity and reliability, the inclusion of other skeletal elements in the examination is proposed for the further study. Third, the lack of controlling for potentially interfering factors, such as nutritional status, social and economic aspects, and hormonal regulation, makes it possible to recommend their further consideration. Finally, the study was conducted within a single population, which may limit the generalizability of the findings. Thus, it would be beneficial to carry out a comparative analysis in several other populations.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCarpal bone age was largely consistent with chronological age across the studied groups, with a significant advancement observed only in younger males. This indicates early sex-related variation in skeletal maturation that appears to diminish with increasing age. Overall, chronological age remains a reliable indicator of skeletal maturity in preschool children; however, caution is advised when interpreting skeletal maturity in younger age groups.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eEthics Approval declaration\u003c/h2\u003e \u003cp\u003eThe study was approved by the \u003cb\u003eBiosafety and Bioethics Committee\u003c/b\u003e of the Libyan Medical Research Center (Approval No. \u003cb\u003eNBC:018.H.26.109\u003c/b\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFunding Declaration\u003c/b\u003e \u003c/p\u003e \u003cp\u003eNo funding was received for this study\u003c/p\u003e \u003c/div\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eFathy ahmed Fetouh; Concept, Initiate the study design, and outline and a major contributor in writing the manuscript. and Youssef Ahmad Trunba, Adel Kerfa collect and analyze the patient data and review the radiological images with interpretation of the all X ray films. All authors read, review and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eIncluded in the paper or Supplementary Information\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGreulich WW, Pyle SI (1959) Radiographic atlas of skeletal development of the hand and wrist. Stanford University Press, Stanford. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/00000441-195909000-00030\u003c/span\u003e\u003cspan address=\"10.1097/00000441-195909000-00030\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanner JM (1962) Growth at adolescence. Blackwell Scientific, Oxford\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanner J, Oshman D, Bahhage F, Healy M (1997) Tanner-Whitehouse bone age reference values. 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J Endocr Soc 8(10):bvae153. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1210/jendso/bvae153\u003c/span\u003e\u003cspan address=\"10.1210/jendso/bvae153\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"egyptian-pediatric-association-gazette","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"epag","sideBox":"Learn more about [Egyptian Pediatric Association Gazette](https://epag.springeropen.com)","snPcode":"43054","submissionUrl":"https://submission.springernature.com/new-submission/43054/3?","title":"Egyptian Pediatric Association Gazette","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Bone age, Carpal bone age, Skeletal maturation, TW3, Libyan children","lastPublishedDoi":"10.21203/rs.3.rs-9611066/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9611066/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eBone age assessment is one of the commonly used methods in pediatric practice for detection of discrepancies between bone age and chronological age, which may point at problems with normal skeletal development and be helpful in diagnosing endocrinological or growth disorders.\u003c/p\u003e\u003ch2\u003eMaterial and Methods:\u003c/h2\u003e \u003cp\u003eThis retrospective cross-sectional study was conducted using wrist and hand radiographs of Libyan preschool children aged 3 to less than 6 years. Study participants were grouped by age as follows: 3 years (58 boys, 62 girls), 4 years (46 boys, 62 girls), and 5 years (70 boys, 42 girls). Evaluation of carpal bone age was done according to Tanner-Whitehouse 3 (TW3) method. Comparisons of chronological age and carpal bone age according to sex and age were statistically analyzed.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eA statistically significant sex difference in carpal age was observed only in the first age group, where males showed a higher mean carpal age compared to females. No significant sex differences were identified in the second and third groups. Furthermore, a significant difference between chronological age and carpal age was found only among males in the youngest age group, where carpal age exceeded chronological age. In contrast, no significant differences were detected among females or in either sex within the older age groups.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eCarpal bone age is generally consistent with chronological age in Libyan preschool children. However, early sex differences were observed in younger males, suggesting age-dependent variation in skeletal maturation.\u003c/p\u003e","manuscriptTitle":"Assessment of the skeletal maturity in Libyan preschool children","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-13 17:56:55","doi":"10.21203/rs.3.rs-9611066/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"265091298278934865427560838274802006120","date":"2026-05-09T10:22:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"12699120566724513269128316370269459650","date":"2026-05-05T23:39:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-05T04:46:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-05T04:34:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-05-05T04:33:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"Egyptian Pediatric Association Gazette","date":"2026-05-04T17:49:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"egyptian-pediatric-association-gazette","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"epag","sideBox":"Learn more about [Egyptian Pediatric Association Gazette](https://epag.springeropen.com)","snPcode":"43054","submissionUrl":"https://submission.springernature.com/new-submission/43054/3?","title":"Egyptian Pediatric Association Gazette","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b2e78bc7-9e19-4836-bff9-ad349e362019","owner":[],"postedDate":"May 13th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"265091298278934865427560838274802006120","date":"2026-05-09T10:22:48+00:00","index":52,"fulltext":""},{"type":"reviewerAgreed","content":"12699120566724513269128316370269459650","date":"2026-05-05T23:39:08+00:00","index":48,"fulltext":""},{"type":"reviewersInvited","content":"37","date":"2026-05-05T04:46:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-05T04:34:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-05-05T04:33:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"Egyptian Pediatric Association Gazette","date":"2026-05-04T17:49:58+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T17:56:55+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-13 17:56:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9611066","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9611066","identity":"rs-9611066","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}