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D. Pajardi and A. Viano
their child for the parents of a child with congenital pathological hand conditions.
Whether originating from malformation or
traumatic injury, pathological conditions of the
upper limb affect and modify many areas of individual life and requires signicant psychological
effort to accept and adapt.
The relationship between patient and health
specialists grows and is shaped in this difcult
context. Especially when the patient is a child
there is a complex interaction among health
workers, children, and their family system.
1.1 Psychological Aspects
Compared with other congenital problems with
greater resonance and in-depth knowledge, the
congenital hand anomaly is less well known. In
those pathological conditions such as labiopalatoschisis or Down’s syndrome congenital
upper limb anomalies can easily be seen.
Considering that this topic is rarely exposed
by the media and there is a lack of information
and knowledge about it, it could be suspected that
hand pathological conditions have less of a psychological impact than other congenital malformations or traumatic impairments. However,
such a conclusion would underestimate the psychological and social problems raised by a disability involving a part of our body that is
indispensable owing to the functional and relational roles it plays in everyone’s life.
The psychological aspects related to the congenital upper limb or hand anomaly have long
been considered secondary and undervalued
compared with other malformations such as those
affecting the face.
The peculiarity of the hand, however, was
underlined not only by the health specialists
directly involved in this eld, but also by the
importance attributed to the hand by those parents and by those children who face particularly
serious and complex syndromic patterns [1].
Therefore, parents who face the congenital
pathology of their child, may experience more
difculties in receiving information from the
neonatology clinic where the child is born than if
they consult specialized centers.
This difculty, although bypassed by the possibility of checking the internet, highlights the
low mediatic resonance that involves ordinary
people as well as health professionals.
On the other hand, usually because of the
presence of many different problems affecting
the newborn, which can sometimes even affect
body parts that are essential for survival, clinicians have great expectation for a solution to congenital problems.
Health personnel face a problem that requires
a joint and coordinated intervention by various
professionals: surgeons, physiotherapists, and
psychologists.
The parent notes that there are different critical issues that will involve their child. Hypotheses
and expectations are formulated considering the
current problem, the future, and possible solutions at the same time.
It becomes important that parents understand
aspects concerning any functional limitation,
aesthetic dimension, as well as numerous personal and relational factors related to the characteristics and meanings that the hand assumes
within the life of the individual and their family
system.
Several observations proposed by psychologists, surgeons, and physiotherapists working on
this topic highlight the need for a synergistic
approach involving various professionals [2].
Parents will more easily accept and complete
a therapeutic plan if they emotionally process and
accept their child’s hand.
If a parent is not even beginning to emotionally confront his/her child’s hand, the therapeutic
option will always be unacceptable and a source
of frustration, although improving the quality of
life and functionality. The proposal would be
refused because it would be considered inadequate with respect to expectations, especially if
the only acceptable proposal for the parent is an
impossible “restitutio adintegrum.”
Detecting parents’ expectations, particularly
unrealistic and impossible ones, represents a useful tool to identify early on the difculties that
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could alter parents’ ability to guide their child
into the different phases of the therapeutic plan.
This rst approach to parents’ expectations
and desires is very important as clinicians have
the awareness that for young patients it is important to follow a therapeutic plan until the end. If
the parents cannot complete the required steps,
the child loses the possibility of improving his/
her situation. Moreover, starting the therapy
would mean more visits, surgeries, and physiotherapy sessions for the child without improving
his/her functional and physical condition.
Furthermore, patients’ quality of life is equally
important: if an appropriate re-elaboration of the
hand is not achieved and the hand is not emotionally accepted by the owner and their family, it is
likely that it will not be used because it is experienced as a source of psychological problems.
The interventional role of the psychologist
within the team is therefore to support the patient
and their relatives, as early as possible, in a re-elaboration process leading to the acceptance of reelaboration and acceptance of the congenital hand.
In practical terms, it is essential that the psychologist attends the rst visits and then, subsequently, is available to the family throughout the
therapeutic protocol.
1.2 Patients, Hand,
andEmotions
Parents attending the Hand Surgery department
to nd a solution for their child’s hands experience intense emotions of anxiety, depression,
fear, frustration, shame, anger, sadness, and for
some children even total acceptance or a sense of
pride [3].
Even when they are of high intensity, such
emotional manifestations are common reactions
to stressful events, and in most situations, the participants can nd support and reach acceptance
within the proposed therapeutic protocol.
However, if such emotions became stable and
do not spontaneously evolve and resolve, it is
essential to evaluate the duration and, intensity of
these emotions and their impact on quality of life.
In the event of psychological problems that
cannot be solved by counseling, patients should
be switched to a psychotherapeutic approach.
The interview with the psychologist allows the
patient to face emotional aspects, helping the parents to expose and understand his/her doubts and
perplexities. Usually, parents’ uncertainties concern
aspects strictly related to the therapeutic options and
protocol, but usually they are worried also about life
situations involving social skills, general child
development, and educational aspects.
Sometimes parents nd it difcult to tell the
difference between their child with a congenital
hand malformation and somebody who has had
an injury of a traumatic nature.
In the case of a child with a congenital hand
there is no interruption of a psychological and
neuropsychological continnum.
In terms of self-perception, the subject who is
born with a congenital anomaly of the hand is, in
fact, “perfect to himself.”
Even if completely understandable, the fact
that the child is experienced by parents as a
“damaged child”, because it is morphologically
different, requires a prompt response. In fact, this
parents’ perception will inevitably affect the parent/child relationship and it will bias the development of the child’s own self-image. It should not
be forgotten that personal identity arises from the
interaction of the individual with other signicant individuals and with the social systems to
which he/she belongs.
It goes without saying that we can afrm that
the development and evolution of the self-identity is in all respects a development, because it is
a making of meanings that develops during social
interaction. For children, especially younger
ones, parents represent “the other” by antonomasia. It is very important to start the early and
timely processing of acceptance and management of emotions linked to hand malformation: it
is a way of consolidating the construction of self
and social identity and preventing psychological
and psychopathological risks in adolescence [4].
If the parent accepts the hand anomaly of the
child, then the child will be able to accept their
hand, with a positive impact in terms of compli-
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D. Pajardi and A. Viano
ance with the therapeutic plan and in terms of
quality of life.
The birth of a child with a congenital disease
is often a situation for which the parents are not
prepared, especially because it is usually an
unexpected event.
The discovery that their baby has a congenital
hand anomaly obscures a happy moment of parents’ life, whether the parents learn of the child’s
congenital hand anomaly at birth or during prenatal diagnostics.
Most parents discover the congenital hand
condition at childbirth because prenatal screening revealed that the child was healthy, and the
anomaly had not been discovered earlier.
The parents must face a highly stressful situation, which can also be more distressing because
the malformation is unexpected and sometimes
totally ruled out by the prenatal screening.
Prenatal screening is, in fact, commonly considered to be able to rule out any anomaly at all. This
fallacy originates because parents do not consider
that screening results have a statistical value, but
they attribute to them fantastic and unrealistic
powers. Prenatal screening is very important to
allow parents to develop their acceptance of the
malformation and to avoid trauma at the birth of
their child [4].
When parents realize that their child has a
hand anomaly, the request to clinicians is to x
the problem as soon as possible to reach a situation of normality: the parent would like to count
a ve-ngered hand. The intensity of the parents’
emotional reaction to the child’s congenital hand
anomaly is independent of the gravity and vastness of the condition, but it is related to the visibility of the hand by others’ eyes [5].
Parental emotional experiences need to be
accepted in an appropriate professional context
able to recognize the difculty parents are facing
and to support them. In this way, parents’ emotions can become proactive and motivate them to
improve their child’s condition instead of remaining on an emotionally static level.
Initially, the feelings of guilt and the psychological experience of having generated an
“incomplete” child experienced by parents can in
fact in some cases freeze all possible parental
ability to act, making it almost impossible for
them to choose whether or not to follow the proposed plan. On the contrary, some parents are
moved by the urgency to x the problem as soon
as possible without stopping to think about what
they are willing to do. Both reactions highlight
the difculty in accepting the child’s congenital
hand condition and the perception of medicine as
an omnipotent science. This belief, which is
sometimes fed by the media, sustains parents’
often unrealistic expectation of solutions.
When the real potential of surgery is explained,
the parent with unrealistic expectations will inevitably be disappointed. This feeling usually interferes in the surgeon/parent relationship in the
form of mistrust, distrust, or even rejection,
because it disregards what parents expected and
hoped for.
In these situations, even the best possible solution and the most successful intervention will
easily disappoint and there will be less motivation to follow the therapeutic plan, consequently
leading to a higher risk of drop-out.
The relationship between parents and the care
team is a crucial element of medical care and the
psychologist can have a “joint” function.
To fulll this function, in our team the psychologists attend and observe the visit with the
surgeon, perform interviews with parents after
the visits, offer the possibility of the family meeting the psychologists and to be supported through
the entire treatment phase. On the operational
level, the possibility for the different professionals to compare their impressions becomes crucial
to reciprocally activating interventions based on
the patient’s detected needs.
The probability of treatment drop-out is lower
when parents accept the congenital hand condition and when the unrealistic expectations of the
possible solution of the child’s problem are
detected and modied. This approach allows
major compliance with the proposed plan, avoiding that child skipping scheduled surgical interventions or neglecting the physiotherapeutic
protocol, which, for the patient, would mean losing a chance to improve their condition [1, 5].
The therapeutic protocol can have parts that can
be unexpected, both in terms of surgical proposal
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and in terms of activities that the parent did not
expect to continue.
As a matter of fact, some surgical suggestions
are more difcult than others to accept for parents. Indeed, sometimes they fear the proposed
surgery because they perceive the intervention as
possible further damage to their child’s body.
Proposals such as toe transfer and the removal
of nger nubs increase fears and enhance the psychological perception of damage. In the case of
the toe transfer, the parents report the fear that the
foot, from which the toe is removed can be functionally and aesthetically damaged.
In the case of the removal of the nger nubs,
parents may be doubtful about the nubs because
the fact they can count ve ngers can be more
important than functional improvement. In the
case of nger nubs, the segments are not ngers,
neither in anatomical nor in functional terms.
Parents must face a difcult decision-making
process to decide whether to proceed with an
unexpected surgery. In this process, timing is also
fundamental as, from a surgical point of view, it
is essential to intervene when the child is about
1year old to allow the child to develop the functionality of the hand. However, parents perceive
the baby as fragile and delicate, too young and
small to tolerate surgery and anesthesia.
In this view, parents’ request to wait a few
years before performing surgery is completely
understandable. However, the idea that the surgical treatment can be postponed until school age is
still too common and it is also an indications that
is not very respectful of psychological, neuropsychological, functional, and rehabilitative ndings. Actually the hand is important because not
only it is involved at the beginning of child development, it also supports their adequate cognitive
and emotional evolution.
The earlier the surgery is performed, the easier
it will be for the child to accept their post-surgical
hand. Parents must also face the difculty of taking responsibility and deciding for another individual: their child. Parents often report doubts
about how their child will evaluate their decision
about surgery, once grown up. Kim et al. [6]
pointed out that mothers of infants with hand and
foot malformations have a similarly high level of
stress to mothers with infants with other malformations. Stress must be analyzed by clinicians
because it can inuence the decision- making
strategies of parents in adhering to or rejecting a
certain surgical path.
These considerations should have highlighted
the psychological issues involved in the congenital hand condition and in the relationship with the
clinicians and staff, participating in improving
the condition of the child.
To summarize, the decision-making process
regarding the surgery and the subsequent treatment is particularly long and painful: parents face
a problem that they had not ever considered possible and furthermore, for which they must make
a choice on behalf of their child, basing their
decision on unfamiliar and unknown medical
notions.
The contact with the health care setting represents a moment that is particularly full of anxiety:
the parents bring their own expectations, and they
must face them to the limits of medical/surgical
knowledge. On the one hand, the possibility of
facing a diagnosis and the consequent proposal of
a therapeutic plan uplift and reassure the parent.
On the other hand, however, comparing their
unrealistic expectations with the available possibilities is a difcult and emotional moment for
parents who have to face a truth for which they
are not ready and that is difcult to accept.
Parents may be so involved in their feelings and
expectations. Therefore, it is essential that the
surgeon communicates using comprehensible
language, avoiding at best the use of technical
terms, to prevent increasing anxiety levels in the
parents and overcoming their distress [7].
The gap between the professional assessment
of the surgeon and the evaluation of the parents is
sometimes intense and relevant. The surgeon values functionality the most, whereas the parents
also value the aesthetic dimension, which also
has high expectations invested in it. It is important that the surgeon is aware of the link between
functional and aesthetic elements: a hand with
unnatural movements, although morphologically
normal, catches the eyes more than a hand that
can be moved naturally, even if morphologically
different from what is expected.
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Hoping for success in giving their child a
“ve-ngered hand”, the parents keep repeating
the same question and asking for the same explanations, requesting unrealistic solutions: it is not
due to a cognitive problem but to the emotional
difculty in complying on a psychological level.
Understanding means that they must leave
behind their illusions and hopes of giving their
child a “normal” hand. Parents’ pain can be so
intense that they try to propose unlikely solutions
that do not have any scientic basis such as using
stem cells or replacing their child’s hand with
their own. In the latter case it can be classied as
“acting out” from a psychological point of view.
This attention to aesthetic aspects and the
desire to remove the psychological distress
caused by the hand of their child lead some parents to request the use of aesthetic prostheses,
even for very small children. The request for the
use of these safeguards must be carefully assessed
and evaluated in relation to the specic case to
avoid the prosthesis becoming a hiding place for
the malformation and a way of not accepting the
condition [8].
From a psychological point of view, the
request for prosthetics should come directly from
the person concerned. In order to allow the development of the sensitivity and functionality of the
limb, the guidelines suggest not introducing aesthetic prostheses before adolescence. This would
allow complete and optimal development of the
limb. However, when talking of a request for
early prosthesis, we refer to those that are asked
for in children who are only a few months old: in
these cases, the request expresses a parents’ need.
The specialist can accept the prosthesis
request when there is no risk of mystication of
the parent’s difculties in accepting the child’s
congenital hand anomaly and the related difculty in accepting the child entirely with his
hand.
The prosthesis, in fact, does not replace a hand
and does not eliminate the malformation, but it
simply hides it. Furthermore, from a pragmatic
point of view, the child grows quickly, and the
prostheses must be replaced every 6 months
which is unnecessary and harmful, as well as
very onerous. The strong emotional involvement
in every proposed treatment, especially surgery,
aimed at improving a child’s situation represent
crucial moments for the parents.
For some parents, the possibility of identifying the optimal solution is closely related to the
possibility of starting to accept the child and the
malformation. It is not strange that each parent
seeks a solution that can help to cope with the
experiences raised by the hand anomaly of their
child, depending on the emotional experiences
and the extent of their acceptance of the
situation.
The phase following surgery represents for
some parents facing a situation that has been
immediately experienced to be better than the
starting one, whereas for others it is the clash
with the limits of surgery and, therefore, the end
of their unrealistic and miraculous expectations.
After the surgery, the hand needs a new process
of acceptance and re-elaboration of the situation
of the child, which is sometimes as tiring and as
intense at the emotional level as the time of the
birth of the child.
Despite the difculties during the decisionmaking process that lead to the decision to perform the surgery, it should be underlined that
during follow-up parents conrm that they are
satised with the results obtained, both from an
aesthetical and from a functional point of view
[9, 10]. Furthermore, it is easier to deal with surgery, even if experienced as aggressive and
potentially damaging, rather than facing the
impossibility of intervening in any way.
Therefore, it is not correct to talk about a single
event of re-elaboration and acceptance of the
congenital hand anomaly, but it would be more
appropriate to consider re-elaboration and acceptance as a process involving different moments of
a family system’s life related to the different steps
of the clinical pathway.
1.3 Psychologist’s Intervention:
Timing Mode
The interview with the psychologist offers a
space where the parent can reprocess the problem, gives the opportunity to express doubts and
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perplexities about the therapeutic pathway, supports parents in decision-making, highlighting
realistic or even unrealistic expectations, and
facilitates communication between the care team
and the family. Sometimes in rare and specic
situations the psychologist can veto, even if temporarily, the possibility of performing surgery.
It is important that the family that welcomes
the newborn receives the psychological support
as close as possible to the moment when the malformation is discovered.
The promptness of the psychological assistance has the aim of receiving the family’s emotional experiences triggering the resources to
support or activate the re-elaboration of the
child’s situation that are present within the family
system. Franzblau etal. [11] underlined the risk
that children live with stress that is unrecognized
by parents and caregivers. Parents play a strategical role in promoting coping resources, selfesteem, social and emotional support: for this
reason, it is very important that clinicians inform
parents about potential stressors and help them to
screen for signs of unmanaged emotional stress
(e.g., anxiety, anger).
The presence of the psychologist during the
rst medical examination is useful to support the
family because it allows us to observe relational
aspects that are discussed and expanded in the
interview following the meeting with the surgeon. It is advisable that this rst medical examination takes place as soon as possible; it can even
occur before the child’s birth when a prenatal
diagnosis is made.
In the presence of prenatal diagnosis, the parents can start the emotional process of accepting
the child’s condition before birth. On the contrary, parents who discover their child’s problem
at birth experience it as a particularly traumatic
event especially because they have been reassured by prenatal screening. As mentioned above,
prenatal screening is too often interpreted as
absolute certainty regarding the health and integrity of the unborn child, instead of being considered a statistical probability, which it is.
From the viewpoint of offering support to the
family system, it should not be surprising that the
rst medical examination is planned a long time
before the surgical procedure: it is in fact crucial
to allow the parents to have time and space to discuss the above-mentioned aspects. One of the
advantages is the possibility of meeting the surgeon on many different occasions and at different
stages of the re-elaboration process, which leads
to the parents accepting the situation of the child.
Sometimes the parent repeats the same question
several times, not because they do not cognitively
understand what has been explained to them, but
because they must reprocess the difference
between hopes and expectations and what can
really be done by the surgeon.
The importance of parents’ and children’s
emotional reactions requires all the clinicians
involved to pay attention to the whole family,
and, therefore, that the whole team are able to
understand and give meaning to behaviors and
attitudes of the family that are often incomprehensible to the health personnel: the role of the
psychologist is also to help the whole team in this
task by consulting together.
The presence of a psychologist as a stable gure in a surgical team is not yet common practice.
The possibility of the patient being admitted for
psychological consultation on the surgeon’s indication as a common practice and as part of the
standard protocol is essential; in fact, through
this the family can be helped to accept the specialist and the team without feeling its emotions
as pathological reactions.
Furthermore, the psychological consultation
can help to better manage their child’s condition,
so that parents feel relieved and can shift their
attention toward a process of elaboration and
acceptance of the psychological support of the
whole family system, thus considering not only
the parents and the child but also any siblings.
The latter are in fact involved in their sibling’s
problem as part of the family and it is important
to understand how parents report to them about
the condition because it is a meter indicating how
parents are emotionally processing it. It is also
important to notice if a sibling’s role is correctly
balanced or if they are excluded or hyperresponsible in their relative’s condition.
The whole family is included in the therapeutic pathway starting from the psychological inter-
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D. Pajardi and A. Viano
view following the rst medical examination
with the surgeon and all the following access to
medical care before and after surgery, and at
follow-ups.
As expected, even the young patient must be
involved, and it can be done in many different
ways according to their age, because, based on it,
the relevant main topics will be different. During
the rst years of the child’s life, they do not compare themselves with the social environment nor
are they aware of or emotionally challenged by
their condition. Consequently, the interview will
focus on parents’ needs while taking care not to
exclude the child from communication, to avoid
feelings of exclusion and anxiety. In fact, even if
very young, the baby pick up on the fact that
much attention and focus are concentrated on
excluding inadequate modality of processing
experiences associated with their hand, and it can
damage the relationship with the care team.
If at rst all the members of the family are
involved with respect to their cognitive and emotional resources, the child will have more opportunities to have an individual space to expose
their own feelings and doubts in the future. In
fact, at around 4/5 years of age the child is more
competent and involved in the discussion both
during the surgical visits and during the interviews. It is therefore essential that surgeon and
clinicians explain their points using clear and
concise language. They should also encourage
parents to offer clarications and information to
their child in order to lead and reassure them during the steps of the therapeutic plan. As patients
are followed up until complete physical development, the opportunity for individual interviews
may also be evaluated. Some thematic nuclei are
more typical of the rst years, whereas others
appear later, among them, it is important to
underline the critical topic of the comparison
with others and with the child’s social
environment.
Initially, parents report experiencing glances
as intrusive, disturbing, and indelicate, capable of
arousing feelings of shame and intense discomfort; they are afraid that the child might experience the same emotions. These fears become
more intense and reappear at specic moments of
the life cycle, and particularly when the child
needs to be included in new social contexts such
as school [3, 12].
The child perceives that they is different from
others at about 2 years of age and sometimes
people start asking them about it. Therefore, the
child will start asking questions about what happened and the reasons for this difference.
During the interview between the psychologist and parents it is important to discuss this
topic, in order to help parents to accept the child’s
questions and supporting him during the inclusion in new contexts, for example, by talking and
explaining to teachers and educationalists.
It is also important to remember that even the
surgery and its results need to be discussed, as
after any surgery there is a change that requires
parents and child to adapt to the new reality.
Furthermore, after surgery it is always necessary
to undergo physiotherapy treatment that is usually highly intense and challenging, even on the
psychological side. Unlike the surgeon, who
manages the surgical gesture inside the operating
room, the physiotherapist involves the parents in
a program that proceeds slowly and requires the
direct involvement of the parent. The parent will
be required to touch and manipulate the child’s
“hand” and therefore, to become aware of the
results achieved, but also to confront the limits.
The attention of the psychologist must therefore always be directed to the whole family system and its subsystems: the individual, the
couple, interpersonal, and the sibling systems.
Considering the complexity of the congenital
hand condition, it is essentially a multidisciplinary approach that carefully and respectfully
deals with the needs of the child and those of the
family. This requires many professionals to integrate in order to provide a complete and adequate
response to the child’s problem and able to promote the harmonious development of the child
and not only of their malformed hand.
Working in a multidisciplinary team, in a context in which the surgical gesture and the subsequent rehabilitation steps remain undoubtedly
central, is fundamental when dealing with a traumatic event that has such a strong impact on daily
living [2, 13].
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Babies Hand Imaging andX-ray
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GaetanaA.Rispoli andMaurizioZompatori
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Abstract
Pediatric diagnostic imaging for hand pathology uses all the basic radiology exams such as
X-ray, CT scan, MRI, ultrasound and colour
Doppler US.The choice of the best diagnostic
imaging technique depends on the specic
disease and on the patient’s collaboration.
Conventional X-ray is still today an invaluable diagnostic approach, notably for trauma
and malformations. Radiography has many
advantages in pediatric examinations: most
importantly it does not need sedation and
exposes the child to a very low radiation dose.
On the other hand, when required by the
clinical assessment, the choice of a secondline investigation must be taken, considering
the obstacle of a not-collaborating patient, in a
long and static MRI examination, as well as
the risk of a high dose radiation exposure, in
CT-scan exams.
Ultrasound provides an excellent diagnostic potential in tendon, muscle and soft tissue
injuries and diseases. Furthermore, US does
not use radiations, and it is highly repeatable
and undemanding. Therefore, when performed
G. A. Rispoli (*) · M. Zompatori
Department of Radiology, San Giuseppe
MultiMedica Hospital, IRCCS University of Milan,
Milan, Italy
e-mail: gaetanaanna.rispoli@multimedica.it;
maurizio.zompatori@unibo.it
by experienced radiologists, US can provide
complete clinical information.
Diagnostic imaging has a primary role in
patient treatment and preoperative planning,
and it can lead to signicant changes in patient
therapeutic pathways.
Keywords
Pediatric hand pathology · Diagnostic
imaging approach · X-ray · Computed
tomography · Ultrasound · Magnetic
resonance
2.1 Traumatic Injuries
Hand traumatic injuries are extremely common
in children. The growth and development of the
skeletal system inuence both the radiological
aspect of a fracture and its remodelling characteristics during the healing process.
A child bone lesion may appear typical and
thus easily detectable, yet it is often insidious;
therefore, a correct interpretation of radiological
imaging requires a thorough knowledge of the
evolutionary anatomy of the skeleton.
Conventional radiography comprises two
standard projections: antero-posterior (AP) and
latero-lateral (LL), taken to investigate the ngers and the wrist; or AP and oblique, to investigate the hand. Additional oblique projections,
such as the scaphoid projection, can complete the
© Springer Nature Switzerland AG 2023
G. Pajardi (ed.), Pediatric Hand Surgery, https://doi.org/10.1007/978-3-031-30984-7_2
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G. A. Rispoli and M. Zompatori
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Fig. 2.1 Standard projections (a) AP e obl of the hand; (b) lateral projection for the ngers; (c) scaphoid projection
exam if indicated by the radiology specialist
(Fig.2.1).
In case of uncertain radiologic interpretation,
notably in the physeal region traumas, a comparative radiograph of the contralateral limb may
help resolve any doubts.
Pediatric diaphyseal nger fractures have
aspects similar to the adult ones (simple or compound, displaced or undisplaced, transverse,
oblique, spiral, etc.) (Fig. 2.2), but there is a
peculiar diaphyseal injury, typical of the pediatric
age: the Greenstick fracture (Fig. 2.3). In the
upper limb, it usually concerns the forearm
(radius and ulna): it is a transverse fracture of the
cortex and the spongy bone, without disruption
of the cortex and the periosteum on the opposite
side, that appears simply bent.
Physeal fractures are very common in children, as the cartilage of the growth plate is fragile
and porous, thus vulnerable in most traumas.
Physeal injuries are classied into ve catego-
Fig. 2.2 Diaphyseal nger fractures (III metacarpal)
ries according to the Salter–Harris classication.
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