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2 Babies Hand Imaging andX-ray
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Fig. 2.3 (a, b) Greenstick fracture distal radius left, pr. Ap e lateral comparative
Salter Harris fractures
Normal
Type I Type II Type III Type IV Type V
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In Salter–Harris types I and II, a correct diagnosis can be obtained by using only the AP and
lateral x-ray projections (Fig.2.4).
In high-energy injuries (Salter–Harris types
III and IV) that typically affect the articular prole, CT scan may be required to visualize in
greater detail the comminuted fragments.
CT scans deliver a higher dose of radiation
than standard X-rays, thus this method should be
used according to clinical indication, respecting
the ALARA principles (as low as reasonably
achievable) (Fig.2.5).
For its high resolution, CT scan remains an
essential imaging technique for the settings of
fractures where detection and treatment of subtle
ndings are vital to prevent subsequent complications, also thanks to modern multiplanar
(MPR) and 3D volumetric reconstructions
(Fig.2.6a–c).
Finally, the Salter–Harris type V, which is
hardly visualized on X-ray, is easily diagnosed
with the help of MRI, as the bone injuries show
high signal intensity on T2-weighted images.
Besides, MRI does not deliver ionizing radiations
(Fig.2.7a, b).
Carpal bone injuries are rare in young children,
where the ossication nuclei are still mainly cartilaginous, whereas they are quite common during
adolescence. Carpal lesions are difcult to evaluate
radiologically: both X-ray and CT scan often lead
to misunderstanding, as cartilage is radiolucent.
When clinical assessment remains uncertain,
in persistence of pain and in the absence of evident fracture, a bone bruise must be suspected
and appropriately investigated using MRI.Bone
bruises are not visible on conventional radiographs or CT scan images, whereas they can be
well visualized with MRI on uid-sensitive fatsuppressed sequences.
The bone contusion shows high T2 signal
intensity, a nding that represents marrow
oedema and haemorrhage. The distal radius and
carpal bones are common locations for a bone
contusion in the pediatric wrist (Fig.2.8).
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Fig. 2.4 Salter–Harris type II fracture (II nger right): comparative X-ray, particular AP e LL
Among the carpal lesions, scaphoid fracture is
the most frequent in children. Most pediatric
scaphoid injuries result from falls onto an outstretched pronated hand, but any compressive
force, such as a direct blow that causes a crush
injury, can result in a scaphoid fracture.
Coexisting soft-tissue injuries are often occasional ndings during MR imaging to evaluate
suspected scaphoid fractures.
MR imaging is the best modality for diagnosis
of radiographically occult scaphoid fractures in
children. MR imaging has been shown to have an
extremely high negative predictive value for
scaphoid fracture when performed as early as
2days after injury. Additionally, MR imaging can
Fig. 2.5 Salter–Harris type III fracture (IV nger)
detect signicant soft-tissue injuries, TFCC tear,
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c
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Fig. 2.6 Radial fracture: (a) ray; (b) Ct scan, MPR recontrusction; (c) 3d volumetric recostruction
intercarpal ligament injury and bone contusion
with no distinct fracture (Fig.2.9a–c).
Conventional X-ray has a primary role in
post- traumatic follow-up, to evaluate fragments
misalignments, bone healing and above all bone
remodelling. Bone plasticity and great periosteal vascularization make these processes the
faster, the younger the patient (Figs.2.10, 2.11,
and 2.12).
A careful radiological follow-up can quickly
identify angular deformities of the fracture site,
even before the clinical evidence, thus allowing a
prompt surgical correction and a more favourable
healing. Over a longer time, it is possible to
assess if there are any vascular physeal damages
that hesitated in longitudinal growth arrest,
pseudarthrosis or residual joint stiffness.
Follow-up timing should thus depend on the
type of trauma and, if necessary, it should be
extended until the complete skeletal maturation.
Finally, US is the imaging technique of choice
in pediatric patients: it doesn’t use radiations, it is
repeatable and it provides an excellent investigation of muscle and tendon injuries—which may
be associated with fractures of the hand bones,
especially in the physeal injuries (Fig.2.11).
The high detail of US images—obtained at
high-frequency probes (14–18MHz), currently
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G. A. Rispoli and M. Zompatori
a
b
Fig. 2.7 (a) Frontal comparative X-ray in right wrist
trauma shows normal ndings. (b) Same day MRI:
Coronal uid-sensitive fat-suppressed MR image (STIR)
of the distal forearm and wrist shows marrow oedema
through the distal radius extending into both sides of the
growth plate, a nding that is the imaging hallmark of
unrecognised fracture
Fig. 2.8 Nine-year-old boy with bone scaphoid contusion—MR imaging 10days after trauma in persistent pain
wrist (normal ndings X-ray): (a) MR image cor e sag T1
shows hypointensity in the scaphoid area; (b) Coronal
uid-sensitive fat-suppressed image (STIR) shows hyperintensity in the same scaphoid area, hallmark of marrow
oedema due to bone contusion
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a
b
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c
Fig. 2.9 (a) Suspected scaphoid fracture. (b) MRI-coronal T1 e T2-uid-sensitive fat-suppressed image and fat-
suppressed images show scaphoid fracture with articoular uid effusion. (c) Coesisting TFCC tear
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Fig. 2.10 X-ray scaphoid fracture (11years old)
G. A. Rispoli and M. Zompatori
available—allows an expert operator to obtain
excellent diagnostic results in the morphologic
evaluation of muscle and tendon injuries.
Radiography, CT scan and MRI are static, US
has the advantage of dynamic image acquisitions (through both active and passive mobilization), thus providing more functional
information.
In the very young child, whose tendon structures are so small that they are below the resolution power of the MRI (minimum layer of
3mm), the US is the only exam that can provide useful information. It can show the presence of traumatic injuries of tendons, retinacula,
ligaments, vessels, nerves and soft tissues—
both in acute and old traumas. This applies to
both micro- trauma (lesions of pulleys and tendons of the ngers) and macro-trauma (complex fractures involving large joints, such as the
wrist).
Fig. 2.11 Two months
later—MRI T1-weight
(a) and T2 weight (b):
suspected evolution in
osteonecrosis of the
scaphoid
Fig. 2.12 X-ray scaphoid fracture: (a) 6months later; (b) 30months later
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2.2 Congenital Hand Deformities
andSyndromic
Malformations
withPrevalent Bone
Involvement
Congenital hand malformations comprise a wide
spectrum of congenital anomalies, which occur
between the fourth and the eighth week of pregnancy. They are often associated with a congenital syndrome or they are a part of it.
Once again conventional X-ray is essential for
an initial diagnosis, for its simplicity, low cost,
high tolerability and low dose of radiation
(Fig.2.13).
X-ray investigation is indicated in all congenital malformation, differentiation defects (synostosis, symphalangism, syndactyly, arthrogryposis,
camptodactyly and clinodactily), agenesis, dupli-
a b
cations (polydactyly, triphalangism, and mirror
hand syndrome), hyperplasia and hypoplasia, and
nally in all dysplastic and dystrophic form, both
if isolated or part of a more complex syndrome
(Figs.2.14a, b and 2.15).
The radiological indication includes a single
AP radiograph, but a controlateral limb image
may be useful, and it is thus suggested, to verify
whether the malformation is present on both
sides, and otherwise to compare the alteration to
the normal anatomy (Fig.2.16).
As the current therapeutic approach is aimed
at timely surgical treatment, radiologic investigations are often repeated over time to evaluate the
possible appearance of the ossication nuclei that
are physiologically absent at birth. Thereby serial
X-ray exams show the appearance of supernumerary bones as well as bone agenesis, thus providing to the surgeon critical information to plan
Fig. 2.13 Pacellar fracture proximal phalanx V nger: (a) X-ray; (b) US visualize the fragment of fracture and no
tendon tears
Fig. 2.14 (a) Hypodisplasia and agenesia; (b) duplication phalanx and agenesis
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Fig. 2.15 Mirror hand syndrome and soprannuneraries bone sketch
Fig. 2.16 Bilateral
symmetric syndactyly
bone
G. A. Rispoli and M. Zompatori
ba
Fig. 2.17 (a) Agenesis ngers in 5year old girl; (b) 5years later phalanx ossication nuclei appear
and predene the surgical intervention. Similarly,
in complex syndromes, they are used in postoperative follow-up, to schedule further re-intervention (Fig.2.17a, b).
In planning a therapeutic/surgical approach,
conventional X-ray are supported by other techniques, such as US and MRI.US investigation, in
addition to being cost-effective and well tolerated
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by children, is highly repeatable and provides
dynamic images, which are optimal for the investigation of muscle and tendon alterations associated with hand malformations.
For example, in the pre-operative evaluation,
US is used to assess whether the supernumerary
bones are supported by a muscular-tendon structure or not. Or in the opposite case, to research
muscles before the surgical correction of a major
malformation with partial bone agenesis.
Moreover, US exams provide a dynamic study
of joints, with particular attention to anatomical
alterations of synovial structures and tendons;
this permits to identify the congenital trigger
thumb, with or without the characteristic Notta
nodules (commonly found on the palmar side at
the metacarpophalangeal joint).
MRI, despite showing both bone and muscle
in greater anatomical detail, cannot be indicated
in initial diagnostic preoperative approach
because of the elevated cost and the need of sedation of children. For this reason, MRI is used for
vascular and lymphatic malformations.
2.3 Congenital Vascular
Malformations andVascular
Tumours
Diagnostic approach to vascular anomalies must
provide a distinction between vascular tumours
(haemangioma, haemangiopericytoma) and congenital vascular malformations (CVM).
Appropriate anamnesis and careful clinical
examination are essential in the initial clinical
approach, but, primarily in complex cases and
preoperative evaluations, need to be supported by
diagnostic imaging techniques.
The diagnostic imaging exams aim to identify
and describe anatomical, pathological and haemodynamic characteristics of each lesion, as well
as the secondary effects on surrounding tissues
and the associated systemic manifestations.
The Doppler US is the rst-line and essential
diagnostic technique, which can be followed by
further investigations with CT scan and MRI.
In CVM and vascular tumours, conventional
X-ray has marginal usefulness, whereas it is often
erroneously requested, as the rst-line investigation, for focal pain or swelling. In such cases, the
presence of calcied phleboliths could lead up to
the discovery of unknown CVM. Sometimes
X-ray is indicated in complex CVM, which is
associated with bone-developing anomalies for
excessive or poor blood supply to epiphyseal,
metaphyseal or diaphyseal region (secondary
bone hypertrophy and hypotrophy).
Colour Doppler US is the rst-line investigation for CVM and vascular tumour: it allows to
locate the lesion and dene its haemodynamic
characteristics: low ow in benign lesions, such
as haemangioma; high ow in arteriovenous malformations (AVM); and extremely low ow in
venous malformations (VM) and absence of ow
in lymphatic malformations (lymphangioma—
LM) (Fig.2.18).
Fig. 2.18 US haemangioma hand: (a) B mode show soft echogenic mass; (b) colour Doppler image reveals a highly
vascular mass consistent with capillary hemangioma
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G. A. Rispoli and M. Zompatori
A possible diagnostic limitation of Doppler
US exams may be encountered for lack of patient
collaboration, which can result in different alterations, such as ow abnormalities induced by the
Valsalva manoeuvre consequent to the baby’s
crying; or in movement artefacts. In the event of
bulky or deep-located lesions, the exact denition of the lesion extension can be difcult. In
such cases, the US exam has to be compared to a
second-line investigation, such as MRI.
After the initial US investigation, MRI (with
or without contrast medium) is the imaging technique of choice for all CMV. The great advantages of this method, in addition to the absence of
radiation, are the high spatial resolution, the wide
visual eld (that is far larger than the US one) and
the possibility of displaying simultaneously the
blood ow distribution of the lesion and the surrounding soft and bone tissues.
Unfortunately, the long duration of the exam
and the disturbing noise of the machine may
frighten and irritate the babies, thus requiring the
patient sedation.
The best study for vascular malformations
needs a high-eld MRI machine (at least 1.5
Tesla), so as to obtain the best contrast and spatial
resolution for small lesions. By using different
tissue “weighting” (T1, T2, STIR, generally with
fat-suppression), CVM may be easily characterized in morphological and spatial terms (size,
location and compartmentalization—limited to
subcutaneous tissue or extended to sub-fascial,
muscular or bone structures) (Figs. 2.19, 2.20,
2.21, and 2.22).
Finally, the MR angiography (MRA)—with
contrast medium—allows to differentiate the
CVM according to the type of blood ow (arterial, venous and absence of ow); and the postprocessing reconstruction (MIP and 3D) provides
the surgeon an optimal spatial representation.
In a few selected cases, despite the high dose
of radiation, CT scan is indicated as an alterna-
Fig. 2.19 B mode and colour Doppler US show soft echogenic mass highly vascular in intercarpal space like
haemangioma
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Fig. 2.20 Hand haemangioma MRI: sequence axial T2GE (a), T1 (b) and coronal T2-fat sat (c)
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