Meinhard

William

Robinow,
Cameron

M.D.
Chumlea,

Ph.D.

Standards

for Limb Bone Length

Ratios in Chil dren1

Norms
have been developed
for the following
limb bone length
ratios:
middleto-proximal
segments
(radius/humerus
and tibia/femur)
and upper-to-lower
limb segments
(humerus/femur
and radius/tibia)
in individuals
aged 2 months
to maturity.
These
norms
were calculated
from serial
measurements
of limb radiographs
of 350 participants
in the Child
Research
Council
Study,
Denver,
Cobrado. The norms
provide
an objective
measure for assessing
disproportionate
growth
of the extremities.
Index
Bones,
normal
Radiology

terms:
Bones,
growth
measurement,
4(0)123
variants,
4[0.130)
143: 433-436,

May

and

development.
(Skeletal
system,

#{149}

are in use to describe

disproportionate
limb growth:
means
short
limbs
and relative
brachymelia
may
be
defined
as short limbs in relation
to stature.
Rhizomelic,
mesomelic,
and
acromelic
brachymelia
denote
special
types of short-limb
dwarfing.
Rhizomelic
brachymelia
is disproportionate
shortness
of proximal
segments
(upper
arms and thighs),
while
mesomelic
brachymelia
is
relative
shortness
of the middle
segments
(forearm
and calf), anji
acromelic
brachymelia
refers
to shortness
of the distal
segments
(hands
and feet). Strangely,
there
is no scientific
term
to describe
disproportion
between
upper
and lower
extremities.
Age- and sex-specific
standards
for limb bone lengths
and for the
ratios of the major limb bones
to stature
were developed
some years
ago by Maresh
(1) but, except
for a very limited
study
(2), there exist
no norms
for the ratios of middle-to-upper
limb segments
or for the
ratios
of upper-to-lower
extremity
segments.
We have filled this void and now present
standards
for these
ratios.
They have been calculated
from measurements
of serial radiographs
of normal
children.
TERMS

EVERAL

Brachyme!ia

1982

MATERIALS

AND

METHODS

Radiographs
of the extremities
were obtained
at regular
intervals
from 2 months
to 18 years of age on all children
enrolled
in the Child
Research
Council
Study,
Denver,
Colorado,
between
1935 and 1967.
The children
were
middle
and upper
middle
class, white,
and the
majority

were

of

northern

lengths
lengths

were
measured
(diaphysis
plus

of bone

length

(1): from

measurement

age 0-2

most

distal

proximal
edge

has

to 12 years

axis of the most proximal

From
10 years
through

the most

European

edge
of the

ancestry.

Diaphyseal

bone

from age 2 months

to 12 years,
total bone
epiphysis)
from 10 to 18 years. The technique
been

length

described

was

edge
to the
adolescence,

most
length

of the epiphysis
epiphysis

at the

in detail

measured

parallel

by

Maresh

to the

long

distal
edge
of the diaphysis.
measurements
were
from

at one
opposite

end
end

of the bone
of the

bone,

to the
care

being
taken
to keep the ruler parallel
to the long axis of the bone
(Fig. 1). From
10 through
12 years there are therefore
2 sets of measurements.
No correction
has been
made
for magnification
or
.

1 From
the Department
of Pediatrics,
Wright
State
University,
Dayton,
OH. Received
July 9, 1981; accepted and revision
requested
Oct. 6, 1981; revision
received
Dec. 11, 1981.
This study
was supported
by Grant
HD-AM-l2252,
National
Institutes
of Health
and a Biomedical
support
grant,
Wright
State University
School
of Medicine,
Dayton,
OH.
ht

distortion.

The Child
Research
Council
Study
measurement
data were computerized
this tape, as well as most of the original
to Dr.
Wright

Alex
Roche,
Fels
State
University

to the

authors.

433

Research
School

was terminated
in 1967. All
and stored
on tape. A copy of
radiographs,
are now on loan

Institute,
of Medicine,

Department
and were

of Pediatrics,
made
available

RESULTS
In
a preliminary
study
the
diaphyseal
and total limb
bone
length
ratios were
calculated
separately
for both
sexes
and
for a large
number
of age
groups.
The
results
indicated
the following:
1. There
were
no significant
sex
differences
in the ratios;
2. Middle-to-proximal
length
ratios in upper
and
lower
extremities change
during
the first
two
years
of life
but
remain
almost
constant
thereafter;

3. The

upper-to-lower

extremity

ratios
growth
tremities
upper

decrease
throughout
the
period,
i.e. , the lower
exgrow
faster
than
the
ones;
and
4. After
10 years
of age
there
was
little
difference
in
the
ratios,
whether
computed
from
diaphyseal
or total
bone
lengths.
It was therefore
decided
to combine
the
data
on boys
and girls
and to increase
the number
of groupings
before
2 years
of age while
reducing
the number
of
age groupings
thereafter.
Means
and
standard
deviations
for each
ratio
and
the
respective
percentiles
are presented
in TABLES
I and II. The distribution
of
the
ratios
showed
no significant
deviations
from
normality.
For the radius/humerus,
humerus/femur,
and
radius/tibia
ratios,
the highest
values
occurred
in the youngest
age
group
and
declined
with
age.
The
radius/
humerus
ratio was stable
after
1.0 years
of age,
but
the
humerus/femur
and
radius/tibia
ratios
decreased
throughout the ages
studied.
The tibia/femur
ratio
showed
little
or no change
from
birth
to 15 years
of age.

CLINICAL
AND

Guide
lines
for measuring
(a) and radius
(b).

total

bone

lengths

(see

text)

in humerus

APPLICATION
DISCUSSION

The limb
length
ratios
give
numericab expression
to the terms
rhizomelic
and
mesomelic
dwarfism
and
to the
disproportion
between
the lengths
of
upper
and lower
extremities
(encountered
so often
meningocele

in patients
or spastic

with
diplegia).

myelo-

The
limb
length
ratios
can also
be
included
in construction
of disproportion
profiles.
A comprehensive
profile
would
include:
stature,
length
of limb
bones,
relative
length
of limb
bones
([bone
length
X 100]/stature),
limb
bone
length
ratios,
and length
of
metacarpals

surements
with
the

434

May1982

Volume

143,Numher2

and

phalanges.

and
ratios
appropriate

Robinow

All

are
norms

and

mea-

compared
(1, 3, 4),

Chumlea

TABLE

I:

Diaphyseal

Bone

Length

Ratios
Percentile

Age (years)

No.

Mean

SD

10

50

90

95

Radius

0.2-0.49

134

0.82

0.04

0.77

0.78

0.82

0.87

0.89

Humerus

0.5-0.99

132

0.79

0.03

0.74

0.75

45

0.77

0.03

0.73

0.74

1.5-1.99
2.0-9.99

123
218

0.76
0.75

0.02
0.02

0.72
0.71

0.73
0.72

0.78
0.77
0.76
0.74

0.83
0.81
0.79
0.77

0.85
0.82
0.80
0.78

10.0-15.0

170

0.75

0.02

0.71

0.72

0.75

0.78

0.78

Tibia

0.2-0.49

133

0.81

0.04

0.75

0.77

0.82

0.86

0.87

Femur

0.5-0.99

132

0.81

0.03

0.76

0.77

0.81

0.84

0.85

1.0-1.49
1.5-1.99

45
124

0.81
0.81

0.02
0.02

0.78
0.78

0.78
0.78

0.81
0.81

0.83
0.84

0.83
0.84

Bone

Ratio

1.0-1.49

Humerus
Femur

Radius
Tibia

2.0-9.99

218

0.81

0.02

0.78

0.78

0.81

0.84

0.85

10.0-15.0

170

0.82

0.02

0.78

0.79

0.82

0.85

0.86

0.2-0.49

133

0.83

0.05

0.75

0.76

0.83

0.90

0.92

0.5-0.99
1.0-1.49
1.5-1.99
2.0-9.99
10.0-15.0

132
45
124
218
170

0.79
0.77
0.76
0.71
0.69

0.03
0.02
0.02
0.03
0.02

0.73
0.73
0.73
0.67
0.65

0.74
0.74
0.73
0.68
0.66

0.79
0.77
0.76
0.71
0.69

0.82
0.80
0.79
0.75
0.71

0.83
0.80
0.80
0.75
0.72

0.2-0.49

134

0.84

0.05

0.77

0.78

0.83

0.90

0.94

0.5-0.99
1.0-1.49
1.5-1.99
2.0-9.99
10.0-15.0

132
45
123
218
170

0.77
0.74
0.71
0.65
0.63

0.03
0.02
0.03
0.03
0.02

0.72
0.69
0.67
0.61
0.59

0.73
0.70
0.68
0.62
0.60

0.77
0.74
0.71
0.65
0.62

0.81
0.77
0.75
0.69
0.65

0.82
0.78
0.76
0.70
0.66

converted
into standard
tion
from
mean/standard
and presented
graphically.
An

extensive

scores
(deviadeviation)

study

of

profiles

prove
helpful
in precise
the disproportion
and,
the specific
diagnosis.

epiphyseal
so characteristic

References

are
are

unnecessary
for diagnosis,
but in many
other
dysplasias
a diagnosis
cannot
readily
be made
by inspection
of the
patient
or the radiographs.
In such
cases the norms
presented
here should

II:

Total

Bone

Length

3.

4.

Acknowledgment:

TABLE

of
in

of

various
skeletal
dysplasias
and other
dwarfing
conditions
will be the subject
of a future
report.
At this time profiles
for only one rare skeletal
dysplasia
are
presented
(Fig. 2).
In many
dwarfing
syndromes
the
or diaphyseal
changes
that measurements

description
at times,
aid

We are indebted
to R. W.
McCammon,
M.D., former
Director
of the Child
Research Council Study, for making
the data and
radiographs
available.

5.

6.

1.

2.

Maresh
MM.
Measurements
from
roentgenograms.
In: McCammon
RW, ed. Human
growth
and development.
Springfield,
IL,
Charles
C Thomas,
1970:187-200.
Maresh
MM, Deming
J. The growth
of the
long bones
in 80 infants.
Child Development
1939; 10:91-100.

Cam

SM, Hertzog
KP, Poznanski
AK, Nagy
JM.
Metacarpophabangeal
length
in the
evaluation
of skeletal
malformation.
Radiology 1972; 105:375-381.
Poznanski
AK, Garn SM, Nagy JM, Gall JC.
Metacarpophalangeal
pattern
profiles
in the
evaluation
of skeletal
malformations.
Radiobogy 1972; 104:1-11.
International
nomenclature
of constitutional
diseases of bone. Revision
May 1977. Amer
J Med Genet 1979; 3:21 -26.
Robinow
M, Silverman
FN, Smith
HD.
A
newly
recognized
dwarfing
syndrome.
Amer
J Dis Child 1969; 1 17:645-651.

Childrens
Medical
Center
One Childrens
Plaza
Dayton,
OH 45424

Ratios
Percentile

Bone

Ratio

50

90

95

10.0-15.0

174

0.75

0.02

0.72

0.72

0.74

0.77

0.78

10.0-15.0

174

0.84

0.02

0.80

0.81

0.84

0.87

0.88

10.0-15.0

174

0.67

0.02

0.64

0.65

0.67

0.69

0.70

10.0-15.0

174

0.59

0.02

0.57

0.57

0.60

0.62

0.62

Age

Radius

(years)

No.

Mean

SD

10

Humerus

Tibia
Femur
Humerus
Femur

Radius
Tibia

Bone

Length

Ratios

PEDIATRIC

RADIOLOGY

435

Figure

Bone Length
Height

HRFT

Relative
none Length
HRFT

Limb Bone
Proportions
RI
HFFT

HR

mear

-1
-2
0

-3
-4

-5
-6

1234512345123412345
Disproportion
profile.
The profiles
represent
Robinow
(5). These
patients
have been described
They
demonstrate
that both
patients
have
short
The brachymelia
is predominantly
mesomebic

mesomelic
shortening
profile,
indicates
that
metacarpophalangeab
T = tibia; S.D.

436

May

1982

Volume

than the lower. The lower part of the graph,

the metacarpophabangeal
the patients
have both acromelic
and mesomelic
brachymelia.
Their
patterns
are remarkably
similar.
H
humerus;
R
radius;
F
femur;

standard

143, Number

two brothers
with
Mesomebic
dysplasia,
type
before
(6). The patterns
are remarkably
similar.
stature
and absolute
and relative
brachymelia.
and
the upper
extremities
show
far greater

deviation.

Robinow

and

Chumlea