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2 Babies Hand Imaging andX-ray
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Fig. 2.21 Post contrast gadolinium T1 sequence coronal and sagittal: rapid omogenous capillar enhancement of the lesion
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ab c
Fig. 2.22 MRI of a venolymphatic malformation. T2 fat sat sequence with MIP reconstruction shows a reticular micronodular pattern with hyperintensity in subcutaneous
tive to MRI for patients who can’t withstand sedation and thus need a faster exam. Furthermore, CT scan is indicated in the follow-up of extremely bulky AVM, which have been previously treated through embolization with spiral or metallic clips—as these materials determine relevant arte­facts in MR images.
Currently, digital angiography is no more indicated as the diagnostic exam for studying the exact architecture and haemodynamics of CVM, the research of arterial afferent pedunculi, nidi and venous efferences—as all these elements are well displayed in MRI.Digital angiography has
fat (a), T1 weight (b), T1 post mdc (c) absence of enhance­ment into the malformation
instead a therapeutic indication for voluminous AVM and other lesions that can be successfully treated through endovascular embolization.
2.4 Tumours, Post-traumatic or Post-surgical Inammatory andInfectious Diseases
Diagnostic imaging of tumours is directly related to the lesion onset location.
Hand neoplastic lesions include: benign bone
tumours (chondroma, aneurismatic bone cyst and
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G. A. Rispoli and M. Zompatori
solitary cyst), malign bone tumours (osteochon­droma, Ewing tumours, etc.) and soft tissue neo­plasm (rhabdomyosarcoma, synovial-sarcoma, etc.).
The diagnostic pathway in bone neoplastic lesions starts with a conventional X-ray exam in standard projections (Fig.2.23a) and needs to be completed by MRI with contrast medium injec­tion (Fig.2.24). This is the diagnostic gold stan­dard, as it allows a simultaneous evaluation of bone and surrounding soft tissues, as long as the exact extension, necessary for the preoperative planning.
The only real MRI limitation is the poor accu­racy in the evaluation of bone erosion and cortex interruption, as they do not change in T1 and T2-weighted sequences. In this case, CT scan provides a greater accuracy, to study the bone structure (Figs. 2.23b and 2.24), identify small early lesions and evaluate the healing process and remodelling after the treatment. For all these advantages, the patients must still be exposed to a signicant dose of radiation.
All benign and malign expansive lesions that originate from soft tissues are well visualized in US investigations: a simple, cost-effective, repeatable exam that, in expert hands, has high sensibility and accuracy.
US exams easily identify the solid or uid nature of a lesion: thus allowing to diagnose benign lesions (lipoma, haemangioma and cyst), that have well-known characteristics, without the need of second-line investigations.
By using high-frequency probes and colour Doppler US in association with B-mode evalua­tion, a rst differentiation between benign and malign lesions can guide the diagnostic pathway (Fig.2.25).
However, when ultrasonography is not suf­cient to provide a diagnostic certainty or the lesion is bulky and thus not entirely visible with a US probe, MRI, with and without contrast medium, is indicated, for an evaluation of local extension and spatial relationship with contigu­ous structures.
ab
Fig. 2.23 Enchondroma V nger: (a) litic expansive lesion without cortical erosion in RX; (b) CT scan—MPR recon- struction—high resolution imaging for the study of bone and cortical structure
2 Babies Hand Imaging andX-ray
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Fig. 2.24 MRI enchondroma V nger—T1 and T2 weight sequence
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Fig. 2.25 US B-mode and colour Doppler in nodular mass III nger: Giant cell tumor of tendon sheath
In soft tissue neoplasms, follow-up MRI has a primary role, as it provides the greatest reliability in recognizing small nodular recurrences against a background of post-therapeutic inammatory tissue (Fig.2.26).
In soft tissue neoplasms, rather than for mor­phological characteristics and spatial location, CT scan is used for disease staging: research of distant metastasis, primarily to the lungs. It is therefore indicated in certain oncologic protocols.
Hand inammatory diseases are frequent in pediatric patients. They can be primary (rheuma-
tologic diseases) or secondary (post-traumatic or post-surgery); these lesions can involve super­cial tissues (inammation and peri-cicatricial abscesses) as well as deep structures, such as joints (synovial membrane, articular capsule, ten­dons, retinacula, etc.).
In all these cases US is once more the rst-line
exam.
In acute primary inammatory disease, with­out involvement of joints and periarticular struc­tures, US high frequency probes allow to visualize joint effusion, synovial hypertrophy and diffusion of the inammatory process to
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G. A. Rispoli and M. Zompatori
Fig. 2.26 MRI—expansive and inltrating mass around I nger (Rabdomiosarcoma): T1 pre (coronal) e post (axial) gadolinium: aggressive tissue with inltration of the bone
contiguous tendon structures (tenosynovitis and peri-tendinitis).
In chronic affections (such as in juvenile rheumatoid arthritis), US evaluates the evolu­tion of erosions, cortex irregularities, synovial hyperplasia, calcications and bone neo-apposi­tion or reabsorption. Furthermore, in these patients, power Doppler (i.e. capable of detect­ing very low ow in hyperaemic areas) can assure a follow-up of the activity of rheumato­logical diseases.
In these patients, there is rarely necessary a second-line investigation, but when there is, MRI is the choice. This expensive and hardly tolerated method is reserved to those joints which are not entirely evaluable by US (coxo-femoral joint, vertebral joints, etc.).
Finally, US is an optimal method for studying the post-traumatic (open wound, compound frac­ture) and post-surgical complications: subcutane­ous panniculus adiposus and its morphologic variations, as well as differentiation between lymphoedema and panniculitis, thanks to colour and power Doppler (panniculitis is highly hyper-
and contiguous muscles with high and inhomogeneous enhancement
aemic); supercial extension and joint diffusion of inammation. This allows a prompt patient orientation to the best therapy, so to assure the success of treatments.
Moreover, US is the exam of choice for the study of post-traumatic or post-surgical abscesses. US identies location, margins, characteristics (uid, with particulate matter; infectious or not­infectious nature according to colour Doppler examination of parietal hyperaemia) and possible presence of gas—that limits US reliability.
When inammatory processes and collections are widely extended, involving surrounding bone structures that are not well evaluated by US method, MRI is indicated. In these cases, T2-weighted sequences with great uid resolu­tion can provide a complete evaluation of loca­tion and extension of the abscess, as well as of the involvement of contiguous bone structures. If bone is affected by the inammatory process, it will show high signal intensity on T2-weighted images, so that a prompt therapeutic intervention may avoid osteomyelitis and other severe consequences.
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the forearm in children. J Bone Joint Surg Br.
1982;64(3):364–7. Greulich WW, Pyle S. Radiographic atlas of skeletal
development of the hand and wrist. 2nd ed. Stanford,
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ing of normal epiphyseal development and common
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agement of scaphoid fractures in skeletally immature
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Waters PM. Normal ranges of scapholunate dis-
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MM. Magnetic resonance imaging after incomplete
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Hand Defects: AnIsolated
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Anomaly Or a Syndromic Disease?
AngeloSelicorni, PaolaCianci, SilviaTajè, andMassimoAgosti
3
Abstract
Patients with hand congenital defects are a very heterogeneous cohort. Like for any other major malformation, one of the goals of the clinical approach is to dene if the anomaly is an isolated problem or if it’s part of a more complex genetic disease. This denition sometimes it’s not so easy, but it’s crucial in order to dene a correct prognosis for the child and a proper genetic counseling for par­ents, for their relatives and, in the future, for the patient itself. Tor achieves the aforemen­tioned result, it’s important to follow a specic methodologic approach that starts from a detailed clinical analysis of the patient and that can properly use the known genetic tests. In this eld in recent years, new very powerful tests have become available (array CGH and NGS) greatly increasing the possibility of a correct framing also in front of very complex children, and so saving time and money.
A. Selicorni (*) · P. Cianci · S. Tajè Pediatric Department, Mariani Foundation Center for Fragile Child, “Sant’Anna” Hospital, ASST Lariana, Como, Italy
M. Agosti Pediatric Department, “F. Del Ponte” Hospital, ASST Settelaghi, University of Insubria, Varese, Italy
Keywords
Major malformations · Hand anomalies ·
Syndromic diseases · Apert syndrome ·
Pfeiffer syndrome · Saethre–Chotzen
syndrome · Crouzon syndrome · Freeman–
Sheldon syndrome · Oro-facio-digital
syndromes · EEC syndrome · Array CGH ·
Next Generation Sequencing (NGS)
3.1 Denitions
Like in other parts of the body, the hands can be an area in which different kind of congenital anomalies can be evident. Generally speaking, we can distinguish these defects into two differ­ent types. We can in fact observe major malfor- mations that are congenital anomalies with relevant medical consequences (e.g., the loss of a thumb, the presence of a supernumerary nger, etc.) and which frequently deserve a surgical approach; or minor anomalies that refes to defects with no or very minimal clinical impact which can have only aesthetic consequences (e.g., a mild skin syndactyly or a clinodactyly of the fth nger) [1]. These defects are due to an intrinsic embryological abnormal process. We know that organogenesis takes place during the rst 10weeks of gestation, so that these anoma­lies develop in the embryo only during that range of time.
© Springer Nature Switzerland AG 2023 G. Pajardi (ed.), Pediatric Hand Surgery, https://doi.org/10.1007/978-3-031-30984-7_3
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Different combination of these possible areas of involvement
Specific genetic defect
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Fig. 3.1 Clinical features of a syndrome
A. Selicorni et al.
-Abnormal growth pattern ( both poor or increased)
-Presence of major malformations ( considering both the classical and the occasional one)
-Abnormal psychomotor development
-Peculiar minor anomalies (especially but not exclusively related to facial gestalt)
Sometimes interpretation of these signals is not so easy. The example can be the evidence of a post-minimum skin appendix on the ulnar side of the hand. This little anomaly has no meaningful medical consequences but it’s a very mild expres­sion of a postaxial polydactyly which is a true major malformation.
Again together with malformations, a hand anomaly could also be the result of deformation. We dene deformation as those congenital defects which are not related to an embryonal abnormal developmental process but that arise after a normal embryogenesis due to a damage to normally developed structures. The classic exam­ple of deformation is the consequences of amni­otic band disruption process in which we can observe lesion at the hands/ngers of various severity, very often asymmetrical in clinical pre­sentation between different ngers and different hands.
Similarly to every kind of congenital defects, also hand anomalies can be isolated or part of a broader disease named syndrome. In 2005, Biesecker discussing this point related to poly­dactyly stated that “… the problem of non syn­dromic polydactyly is formally insoluble…. So we dene “syndrome” a clinical condition in which a child can have various medical/func­tional problems which are due to a single genetic anomaly”. Figure3.1 denes the areas of involve­ment of a syndrome [2]. A classical example is represented by Apert syndrome: a very common pattern of craniofacial anomalies is associated
with an absolutely typical and severe syndactyly pattern of hands and feet, with possible associ­ated anomalies in growth, psychomotor develop­ment; all these features are due to a specic mutation in FGFR2 gene.
3.2 Why aProper Classication ofHand Malformations Is SoImportant?
The relevant question is what are the conse­quences of a correct classication of a hand con­genital defect as isolated or syndromic. Table3.1 analyzes the situation. It’s obvious that in case the child is affected by a genetic syndrome, his prognosis, in the great majority of the situation, is more deeply inuenced by the natural history of the syndrome itself, rather than by the specic functional prognosis of the hand defect. Survival, physical growth, psychomotor and intellectual development can be more or less severely condi­tioned by the natural evolution of the disease. The frequency, needs and type of medical follow­up can be extremely different in the two situa­tions (isolated or syndromic defect) and the hand defect can often represent a minor problem to face in comparison with the others in a syndromic setting. Finally, the recurrence risk of the usually healthy parents and of the child himself as soon as he/she will be an adult will be very different according to the classication of the defect as isolated or syndromic.
3 Hand Defects: AnIsolated Anomaly Or a Syndromic Disease?
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Table 3.1 Consequences of a correct classication of a congenital hand anomalies
Isolated defect Syndromic defect
General health prognosis Survival Normal Potentially
Growth pattern Normal Potentially
Psychomotor and intellectual development Follow-up needs
Functional prognosis of the hand malformation
Recurrence risk for parents
Recurrence risk for the child
a
Related to the natural history of the syndrome
b
Related to the genetic basis of the syndrome
Usually favorable
Normal Potentially
Only related to the hand malformation
Only related to the type of malformation and the possibility of surgical correction Usually low (apart from specic monogenic isolated condition) Usually low (apart from specic monogenic isolated condition)
Potentially critical
abnormal
abnormal
abnormal
Often need for a wider multidisciplinary approach Strongly inuenced also by the general functional prognosis of the syndrome
Potentially increased
Potentially increased
a
a
a
a
b
b
a
3.3 The Clinical-Genetic Diagnostic Process
The classication of a defect as isolated or syn­dromic could not be so easy and quick. Usually hand anomalies are diagnosed at birth, even if sometimes the ultrasound studies during preg­nancy could have generated some doubts. It’s important to state that a complete evaluation of the phenotype is possible only after birth; for this reason, prenatal counseling should always be very cautious because surprises are frequent.
In the neonatal period, we can have different scenarios. In some situations, the clinical data are already clear and absolutely convincing toward a
syndromic condition. This is the case in which the newborn shows multiple congenital defects, clear dysmorphic features, abnormal birth auxo­logical parameters, and/or abnormal neurologic status. In these cases, the question is whether it’s possible to perform a “gestaltic diagnosis” or not. More often the hand anomaly seems at rst glance to be an isolated problem. In this context, it’s important to perform a proper clinical and instrumental evaluation, in order to search for possible associated major malformations, func­tional defects (e.g., audiological or visual de­ciency), and dysmorphic minor anomalies. Family and pregnancy history is essential too in order to better classify the problem. It’s well known the existence of an isolated hand defects which can have a mendelian segregation mostly according to autosomal dominant inheritance (e.g., pre- and postaxial polydactyly, triphalan­geal thumb, and ectrodactyly). In addition, some genetic syndromes (like Pfeiffer syndrome, for example) have a dominant transmission too. It’s always important to consider that in some situa­tions the variability of expression of the disease and the absence of intellectual involvement can have prevented the recognition of the disease in a relative. For all these reasons, a three generations genealogic tree should always be performed and direct parents’ evaluation could be useful, in order to deeply evaluate possible familiar patho­logical traits that can be crucial for the classica­tion of the proband’s defect.
If no associated anomalies are evident, it can be reassuring for the clinicians, but it must be kept in mind that the hypothesis of a syndromic condition needs to be conrmed by the evolution of the child. So a proper pediatric-genetic follow­up is strongly recommended in order to conrm the classication of the hand defect as isolated. Growth and developmental data and somatic and medical evolution are paramount in order to dene the situation [2, 3].
As we have said before, sometimes the diag­nosis could be made quite easily in the neonatal period, if the clinical data are enough expressed and the experience of the clinician related to that condition is high. Table 3.2 summarized some examples of syndromes that can be diagnosed at
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Table 3.2 Possible gestaltic neonatal syndromic diagnosis
Syndrome Hand defect Associated anomalies Genetic defect Apert
syndrome
Cornelia de Lange syndrome
VATER association
Rubinstein– Taybi syndrome Freeman– Sheldon syndrome Holt–Oram syndrome Meckel– Gruber syndrome Fanconi anemia
Complete syndactyly
Limb reduction defects, missing ngers of ulnar side
Radial ray defect Vertebral anomaly imperforate
Large/bid thumbs/hallux
Hand contractures, Whistling face, other joints
Monolateral radial ray defect Postaxial polydactyly
Radial ray deciency
Craniostenosis dysmorphisms, possible growth and developmental anomalies Peculiar dysmorphisms, hirsutism pre- and postnatal growth retardation, psychomotor retardation, intellectual disability
anus, esophageal athresia, trachea esophageal stula, heart anomaly Peculiar dysmorphisms, psychomotor delay, growth retardation
contractures (as in patient with distal arthrogryposis) Heart congenital defects, ECG anomalies Cystic renal disease, occipital encephalocele
Multiple congenital defects, increased risks to develop hematologic and non­hematologic neoplasia, bone marrow insufciency
Autosomal dominant FGFR2 mutation
Mutation in different gene of the cohesion family (NIPBL, SMC1A, SMC3, RAD 21, HDAC8, ANJRD11, BRD4) most genes follow an autosomal dominant inheritance, some others X linked inheritance Unknown
Microdeletion 16p13.3, autosomal dominant CREBP or EP300 gene mutation
Autosomal dominant MYH3 gene mutation
Autosomal dominant TBX3 gene mutation
Four different subtypes involving different genes with autosomal recessive inheritance
Heterogeneous disease with 19 genes involved with autosomal recessive inheritance Karyotype with DEB showing increased chromosome fragility
A. Selicorni et al.
birth in front of a hand anomaly. In these situa­tions, nowadays the clinical hypothesis can fre­quently be conrmed by specic genetic tests. Later the use and the limits of the genetic tests will be discussed more in to details.
3.4 Main Syndromic Conditions Associated withHand Anomalies
The number of syndromes associated with hand anomalies, also limiting the discussion to major hand malformations, is extremely wide, so a detailed discussion is impossible to be performed in a short chapter. So we will briey discuss some malformative/genetic conditions that must be known because of their frequency and clinical relevance.
3.4.1 Amniotic Band Sequence
Amniotic band sequence is a congenital limb dis­order with an extremely variable clinical presen­tation. Its frequency is about 1in 1200 live births. It is characterized by the presence of partial to complete, congenital, brous, circumferential, constriction bands/rings on any part of the body, with a particular predilection for the upper or lower extremities. Phenotypes range between a mild skin indentation to complete amputation of parts of the fetus (e.g. digits, distal limb); fusion of digits mimicking syndactyly can also be evi­dent. Classically, the damage of the extremities is asymmetrical between different digits and differ­ent hands. This feature and constriction rings are the clues of the clinical diagnosis. The commonly accepted view is that amniotic band sequence
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