An X-ray is helpful in the diagnosis of delayed puberty. Findings on an X-ray are specific for bone age. Bone age is used to predict the final adult height of children. There is a strong association between bone age and the puberty onset in boys with developmental disorders. If the difference between measured bone age and chronological age is more than 2 years, it is strongly suggestive of constitutional delay of growth and puberty (CDGP).

• An X-ray is helpful in the diagnosis of delayed puberty. Findings on an X-ray are specific for bone age. Bone age is used to predict the final adult height of children .
• It is one of the first line evaluations in a patient with suspected delayed puberty.

• Studies have shown that there is a strong association between bone age and the puberty onset in boys with developmental disorders.^[2][3]
• Skeletal maturation and hypothalamus–pituitary–gonadal axis maturation rates are useful in diagnosing delayed puberty. Delayed puberty is related to the skeletal maturation delay that can be caused by various chronic diseases,^[4] malnutrition,^[5] hypothyroidism,^[6] constitutional delay of growth,^[7] and growth hormone (GH) deficiency.^[8]
• Bone age is measured by studying X-ray of the left hand and wrist. Greulich and Pyle Atlas may be used to interpret the findings.^[9][10]
• If the difference between measured bone age and chronological age is more than 2 years, it is strongly diagnostic of constitutional delay of growth and puberty (CDGP).
• The metaphysis of the patients with delayed puberty usually takes more time to mature than the normal population. This results in the final adult height slightly more than the final adult height of a normal individual. If the bone age shows the 4 years difference, it may reflect an additional increase of 8 cm in the final adult height of the patient. Final adult height can be calculated through Bayley-Pinneau tables.^[11][12]

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