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 Pediatric Hand Therapy
Edited by
JOSHUA M. ABZUG, MD
Associate Professor
Departments of Orthopedics and Pediatrics
University of Maryland School of Medicine
Director
University of Maryland Brachial Plexus Practice
Director of Pediatric Orthopedics
University of Maryland Medical Center
Deputy Surgeon-in-Chief
University of Maryland Children's Hospital
Baltimore, MD, United States

SCOTT H. KOZIN, MD
Clinical Professor
Orthopaedic Surgery
Lewis Katz School of Medicine at Temple University
Philadelphia, PA, United States
Clinical Professor
Orthopaedic Surgery
Sidney Kimmel Medical College at Thomas Jefferson University
Philadelphia, PA, United States
Chief of Staff
Shriners Hospital for Children
Philadelphia, PA, United States

REBECCA NEIDUSKI, PHD, OTR/L, CHT

Dean of the School of Health Sciences
School of Health Sciences
Elon University
North Carolina
United States

]
Pediatric Hand Therapy ISBN: 978-0-323-53091-0
Copyright Ó 2020 Elsevier Inc. All rights reserved.

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This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).

Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be
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contained in the material herein.

Publisher: Cathleen Sether

Acquisition Editor: Kayla Wolfe
Editorial Project Manager: Sandra Harron
Production Project Manager: Sreejith Viswanathan
Cover Designer: Alan Studholme
List of Contributors
Joshua M. Abzug, MD
Associate Professor
Departments of Orthopedics and Pediatrics
University of Maryland School of Medicine
Director
University of Maryland Brachial Plexus Practice
Director of Pediatric Orthopedics
University of Maryland Medical Center
Deputy Surgeon-in-Chief
University of Maryland Children's Hospital
Baltimore, MD, United States
Allison Allgier, OTD, OTR/L
Cincinnati Children’s Hospital
Cincinnati, OH, United States
Clinical Program Manager
Occupational and Physical Therapy
Cincinnati Children’s
Cincinnati, OH, United States
Sarah Ashworth, OTR/L, BS
Occupational Therapist
Rehabilitation Services
Shriners Hospital for Children
Philadelphia, PA, United States
Jamie Berggren, OTR/L, BS
Division of Pediatric Rehabilitation Medicine
Occupational Therapist
Children’s Hospital Los Angeles
Los Angeles, CA, United States
Matthew B. Burn, MD
Hand Fellow
Hand & Upper Limb Fellowship
Stanford University
Redwood City, CA, United States
Alexandria L. Case, BSE
Research Coordinator
Department of Orthopedics
University of Maryland School of Medicine
Baltimore, MD, United States
Department of Orthopaedics
University of Maryland
Baltimore, MD, United States
Jennifer M. Chan, OTR/L, CHT
Hand Therapist
Rehabilitation Therapy
Lucile Packard Chidren’s Hospital
Palo Alto, CA, United States
Roger Cornwall, MD
Cincinnati Children’s Hospital
Cincinnati, OH, United States
Professor
Orthopaedic Surgery and Developmental Biology
Cincinnati Children’s Hospital
Cincinnati, OH, United States
Jenny M. Dorich, MBA, OTR/L, CHT
Occupational Therapist III
Adjunct Faculty
Cincinnati Children’s Hospital Medical Center
Univeristy of Cincinnati College of Health Sciences
Cincinnati, OH, United States
Reeti R. Douglas, OTD, OTR/L
Texas Scottish Rite Hospital for Children
Dallas, TX, United States
Kelly Anne Ferry, MOTR/L
Rick Gardner FRCS (Trauma & Orthopaedics)
CURE Ethiopia Children’s Hospital
Addis Ababa, Ethiopia
v
vi LIST OF CONTRIBUTORS

Theodore J. Ganley, MD Christine A. Ho, MD

Director of Sports Medicine at the Children’s Hospital Staff Orthopaedist
of Philadelphia Dept of Orthopaedics
Professor of Orthopaedic Surgery at the University of Texas Scottish Rite Hospital for Children
Pennsylvania Dallas, TX, United States
Associate Professor of Orthopaedic Surgery Division Director
Director of Sports Medicine Department of Pediatric Orthopaedics
Division of Orthopaedic Surgery Children’s Health Dallas
Children’s Hospital of Philadelphia Dallas, TX, United States
Philadelphia, PA, United States
Associate Professor
Department of Orthopaedics
Richard Gardner, FRCS
University of Texas Southwestern Medical School
CURE Ethiopia Children’s Hospital
Dallas, TX, United States
Addis Ababa, Ethiopia
Danielle A. Hogarth, BS
Ritu Goel, MS, OTR/L
Department of Orthopaedics
Occupational Therapist
University of Maryland
Department of Orthopaedics
Baltimore, MD, United States
University of Maryland School of Medicine
Baltimore, MD, United States Research Coordinator
Orthopaedics
Donald Goldsmith, MD University of Maryland School of Medicine
Professor Batlimore, MD, United States
Pediatrics
Drexel University College of Medicine Deborah Humpl, OTR/L
Philadelphia, PA, United States Children’s Hospital of Philadelphia
Department of Occupational Therapy
Director
Philadelphia, PA, United States
Section of Rheumatology
St Christopher’s Hospital for Children Clinical Specialist Outpatient Occupational Therapy
Philadelphia, PA, United States Occupational Therapy Department
Children’s Hospital of Philadelphia
Namrata Grampurohit, PhD, OTR/L Philadelphia, PA, United States
Assistant Professor
Department of Occupational Therapy Gina Kim, MA, OTR/L
Jefferson College of Rehabilitation Sciences Division of Pediatric Rehabilitation Medicine
Thomas Jefferson University Occupational Therapist
Philadelphia, PA, United States Children’s Hospital Los Angeles
Los Angeles, CA, United States
Elliot Greenberg, PT, DPT, PhD
Board Certified Specialist in Orthopaedic Physical Scott H. Kozin, MD
Therapy Clinical Professor
Sports Medicine & Performance Center Orthopaedic Surgery
The Children’s Hospital of Philadelphia Care Network, Lewis Katz School of Medicine at Temple University
Pediatric & Adolescent Specialty Care Philadelphia, PA, United States
Bucks County Clinical Professor
Clinical Specialist / Research Scientist Orthopaedic Surgery
Sports Medicine Physical Therapy Sidney Kimmel Medical College at Thomas Jefferson
Philadelphia, PA, United States University
Philadelphia, PA, United States
Chief of Staff
Shriners Hospital for Children
Philadelphia, PA, United States

Ryan Krochak, MD
Orthopaedic Sports Medicine Fellow at the University
of Pennsylvania
Orthopedic Surgeon
Orthopedic Sports Medicine
Orlin & Cohen Orthopedics/Northwell Health
Long Island, NY, United States
Amy L. Ladd, MD
Elsbach-Richards Professor of Surgery
Orthopaedic Surgery
Stanford University School of Medicine
Stanford, CA, United States
Amy Lake, OTR, CHT
Occupational Therapy
Texas Scottish Rite Hospital for Children
Dallas, TX, United States
Carolyn M. Levis, MD, MSc, FRCSC
Division of Plastic Surgery
McMaster University
St. Joseph’s Healthcare Hamilton
Hamilton, ON, Canada
Kevin J. Little, MD
Director
Pediatric Hand and Upper Extremity Center
Fellowship Director
Mary S. Stern Hand Surgery Fellowship
Associate Professor of Orthopaedic Surgery
Cincinnati Children’s Hospital Medical Center
University of Cincinnati School of Medicine
Cincinnati, OH, United States
Director, Hand and Upper Extremity Surgery
Division of Pediatric Orthopaedics
Cincinnati Children’s Hospital Medical Center
Cincinnati, OH, United States
Erin Meisel, MD
Assistant Professor of Orthopaedic Surgery
Children’s Hospital Los Angeles
University of Southern California
Los Angeles, CA, United States
Michelle Hsia, MS, OTR/L
Outpatient Supervisor
Occupational Therapy
The Children’s Hospital of Philadelphia
Philadelphia, PA, United States
LIST OF CONTRIBUTORS vii
M.J. Mulcahey, PhD, OTR/L, FASIA
Professor of Occupational Therapy
Director, Center for Outcomes and Measurement
Jefferson College of Rehabilitation Sciences
Thomas Jefferson University
Philadelphia, PA, United States
Rebecca Neiduski, PhD, OTR/L, CHT
Dean of the School of Health Sciences
Professor of Health Sciences
School of Health Sciences
Elon University
Elon, NC, United States
Scott Oishi, MD
Director of Hand Service
Orthopaedics
Texas Scottish Rite Hospital for Children
Dallas, TX, United States
Heta Parikh, OTR/L, MPH
Occupational Therapist
Department of Orthopedics
University of Maryland School of Medicine
Baltimore, MD, United States
Meagan Pehnke, MS, OTR/L, CHT, CLT
Senior Occupational Therapist
Occupational Therapy
The Children’s Hospital of Philadelphia
Philadelphia, PA, United States
Nicholas Pulos, MD
Texas Scottish Rite Hospital for Children
Pediatric Upper Extremity Fellow
Dallas, TX, United States
Lydia D. Rawlins, MEd, OTR/L
Children’s Hospital of Philadelphia
Department of Occupational Therapy
Philadelphia, PA, United States
Roberta Ciocco, MS, OT
Senior Occupational Therapist
Out patient Occupational Therapy
Children’s Hospital of Philadelphia
Philadelphia, PA, United States
viii LIST OF CONTRIBUTORS

Daniel W. Safford, PT, DPT Kathleen Tate, MS, OTR/L

Board Certified Orthopaedic Specialist Children’s Hospital of Philadelphia
Certified Strength & Conditioning Specialist Department of Occupational Therapy
Penn Therapy and Fitness at Arcadia University Philadelphia, PA, United States
Good Shepherd Penn Partners
Research Physical Therapist Daniel Waltho, MD
Physical Therapy Department Resident
Arcadia University Plastic Surgery
Glenside, PA, United States McMaster University
Hamilton, ON, Canada
Sandra Schmieg, MS, OTR/L, CHT
Senior Occupational Therapist Heather Weesner, OT
Occupational Therapy Occupational Therapist
The Children’s Hospital of Philadelphia University of Maryland Rehabilitation
Philadelphia, PA, United States and Orthopedic Institute
Baltimore, MD, United States
Apurva S. Shah, MD, MBA
Assistant Professor of Orthopaedic Surgery Aviva Wolff, EdD, OT, CHT
Division of Orthopaedic Surgery Clinician Investigator
The Children’s Hospital of Philadelphia Rehabilitation
Department of Orthopaedic Surgery, Perelman School Hospital for Special Surgery
of Medicine at the University of Pennsylvania New York, NY, United States
Philadelphia, PA, United States
Cheryl Zalieckas, OTR/L, MBA
Francisco Soldado, MD, PhD Department of Orthopaedics
Pediatric Hand University of Maryland
Nerve and Microsurgery Institute Baltimore, MD, United States
Barcelona, Spain
Dan A. Zlotolow, MD
Milan Stevanovic, MD Hand and Upper Extremity Surgeon
Physician Shriners Hospitals for Children Philadelphia and
Professor of Orthopaedic Surgery Greenville
Department of Orthopaedic Surgery The Hospital for Special Surgery
Division of Orthopedic Surgery The Philadelphia Hand to Shoulder Center
Keck School of Medicine of USC Professor of Orthopaedics
Los Angeles, CA, United States The Sidney Kimmel Medical College of Thomas
Jefferson University
Tami Konieczny, MS, OTR/L Philadelphia, PA, United States
Supervisor Occupational Therapy Attending Physician
Occupational Therapy Shriners Hospital for Children
Children’s Hospital of Philadelphia Philadelphia, PA, United States
Philadelphia, PA, United States
AcknowledgmentsdPediatric Hand
Therapy
This book is dedicated to all healthcare providers who
care for the child’s upper limb. Specifically, the goal of
this book was to provide a resource for the occupa-
tional therapist who cares for children’s upper limbs.
Several of the conditions and injuries are somewhat
rare to see for most providers and therefore, we have
tried to make a quick, easy to read resource for these
providers and people interested in caring for the child’s
upper extremity. The work performed to bring this
book to completion would not have been possible
without the collaboration and efforts of all of the au-
thors of the various chapters as well as my coeditors. I
must also thank my parents for their continued support
and encouragement. Most importantly, I want to thank
my wife, Laura, and our three boys, Noah, Benjamin,
and Zachary, for always loving and supporting me.
Although I know the time necessary to do projects like
this takes away some of our time together, you always
continue to support me, understand the work that I am
doing, and most importantly love meeeand for that I
thank you.
Joshua M. Abzug, MD
Hand surgery and hand therapy are synergistic. The
results of hand surgery require preoperative and post-
operative communication between the surgeon and the
therapist. Our therapists provide invaluable preopera-
tive input into the families and their children regarding
expected outcomes, cooperation, and compliance. Our
therapist provides critical postoperative care. This care
requires communication as the therapist must under-
stand the procedure performed and the status of any
repaired structures, such as a nerve or tendon. A stout
repair can be managed with early mobilization. In
contrast, a weaker repair must be treated with gentle
mobilization. At Shriners Hospitals for Children-
Philadelphia, hand surgeon and hand therapist work
in tandem. We work as a team to provide state-of-the
-art surgery and optimum therapy to maximize our
children’s outcome. Complex procedures mandate a
skilled and talented therapist. We require our families
to travel back to Philadelphia to begin their rehabili-
tation process. This prerequisite avoids miscommuni-
cation and initiates the rehabilitation process with a
therapy team accustomed to the surgical procedure.
Our therapists are familiar with the potential trials and
tribulations in the early therapy period. Addressing
these problems can avoid a suboptimal outcome,
which is disappointing to the family, therapist, and
surgeon. Over the last 25 years at Shriners Hospitals for
Children, I have had the privilege to work with many
gifted therapists. They have enhanced our patient’s
outcomes and made me a better surgeon. I want to
thank each and every one of them for all their knowl-
edge, for all their expertise, and for all their service to
the children at Shriners Hospitals for Children.
Scott H. Kozin, MD
The key to achieving excellent outcomes in upper
extremity rehabilitation is relationships. The relation-
ship between hand surgeon and hand therapist creates
the foundation on which communication, shared
values, trust, and collaboration are built. The relation-
ship between therapists in the subspecialty of pediatric
hand provides a network of colleagues and problem
solvers who share resources and opportunities. The
relationships among healthcare providers, children,
caregivers, and families enable our youngest clients to
embrace possibility and participation through surgery,
therapy, and adaptation. This text was built on
invaluable relationships between therapist and sur-
geons, and we hope it adds an impactful resource to
your pediatric hand therapy practice.
Rebecca Neiduski, PhD, OTR/L, CHT
ix
Preface
Caring for the child’s upper extremity is challenging
due to the rarity of various injuries and/or conditions
as well as the child’s inability to cooperate and un-
derstand instructions. Despite these obstacles, occu-
pational therapy is a critical component of caring for
the child’s upper limb. Whether the therapist is helping
a child with a congenital limb difference learn how to
perform activities of daily living or rehabilitating a
child following a traumatic injury, the occupational
therapist is maximizing the function of the child.
Despite this critical role, few resources exist to aid the
occupational therapist in caring for the child’s upper
limb. The purpose of this book is to provide a
comprehensive, easy to read and use reference for the
healthcare provider who is caring for pediatric and
adolescent upper extremities. The book details the
formation and functional development of the child’s
upper limb. Subsequently, the necessary details and
key points of the examination are discussed along with
details of various outcome measures. In addition,
splinting and taping techniques as well as prosthetic
use are emphasized. The remainder of the book is
organized into various sections to permit the reader
easy access to specific diagnoses. Although the book
provides a concise, yet thorough discussion regarding
these topics, we envision that the treater will keep the
book at “arm’s length” as a resource for caring for
children with an upper extremity condition. Many of
the chapters provide protocols to use during rehabili-
tation as well as specific splints that are necessary to
improve function or during the postoperative course.
The goal of this book is to provide the reader with the
knowledge to perform a thorough examination,
establish an accurate diagnosis, refer for timely treat-
ment, and perform specific rehabilitation including
therapy and splinting to maximize the child’s outcome.
xi

CHAPTER 1
Embryology and Intrauterine Diagnosis
FRANCISCO SOLDADO, MD PHD • SCOTT H. KOZIN, MD
INTRODUCTION
Someone’s first-ever sip of coffee is often an unpleasant
experience that renders them pondering how they could
ever learn to like such a foul-flavored drink. Similarly,
many health professionals’ first exposure to embry-
ology, and the basic science that is so integral to it, is
often a bitter experience. However, over time, dedicated
professionals learn how interesting the field is and how
essential the knowledge gleamed is pertinent to patient
care. This fundamental principle is particularly true for
those who choose to enter a field that evaluates and
treats newborns with congenital defects.
Congenital anomalies affect somewhere between
1% and 3% of newborns. Among these infants, roughly
1 in 10 has one or more abnormalities that affect their
upper extremities.1,2 In prevalence, upper-extremity
anomalies rank second only to congenital heart defects
among malformations present at birth.3 Most limb
anomalies manifest spontaneously or are inherited,
with congenital anomalies secondary to teratogens
decidedly rare.4,5
For those clinicians that evaluate newborns with
hand anomalies as patients, or counsel parents who
have already born such a child, a basic understanding
of embryogenesis, limb formation, and genetics is ut-
terly essential. Also crucial is understanding how these
anomalies may relate to more systemic conditions, as
these healthcare providers often are required to
counsel parents about the potential effect on future
pregnancies and what intervention can and should
be done. Understanding genetic criteria and their asso-
ciated anomalies affords such healthcare providers the
capacity to make appropriate recommendations to
families and/or referral to clinical geneticist and/or ge-
netic counseling.
Pediatric Hand Therapy. https://doi.org/10.1016/B978-0-323-53091-0.00001-4
Copyright © 2020 Elsevier Inc. All rights reserved.
SECTION I BACKGROUND
The requirements are not the same with all upper-
limb congenital anomalies. For example, transverse de-
ficiencies are usually sporadic and carry no appreciable
hereditary risk. As such, subsequent pregnancies require
no more monitoring than standard care,1 and there is
no need to refer this family to a clinical geneticist. How-
ever, concerns about the risks of teratogen exposure
elevate when multiple limbs are affected and deficient.
This clinical finding suggests some widespread insult
to all the developing limb buds and potential teratogen
or bleeding abnormality.
Conversely, many other upper-limb anomalies
(e.g., radial deficiency) are associated with concomi-
tant, systemic defects (Fig. 1.1).6 At the same time dur-
ing embryogenesis when upper-limb anomalies are in
their formative stage, other organ systems are devel-
oping at the same time. These organ systems can be
affected and require evaluation. It is essential that the
clinician recognizes those anomalies that typically
occur in isolation versus those anomalies that are asso-
ciated with concomitant anomalies; many of these
anomalies may initially be unapparent with dire con-
sequences. This principle is especially crucial when
the concomitant anomalies of other organ systems
are of greater clinical importance than the limb anom-
alies. Hand surgeons assessing such patients must
focus on the infant’s general health before addressing
hand malformations.
Some congenital hand anomalies are linked to other
musculoskeletal problems, such as ulnar deficiency.7
Some anomalies can even be associated with more
than one musculoskeletal disorder. For example, central
deficiency may be linked to the triad of ectrodactyly
ectodermal dysplasia and facial clefts (the so-called
EEC syndrome) or lower-limb hemimelia (in which
1
2 SECTION I Background
FIG. 1.1 Nine-month-old boy with an inherited radial
deficiency associated with HolteOram syndrome. Mother
and child’s heart anomalies were surgically treated.
either the tibia or fibula is absent or inadequately
formed) (Fig. 1.2).
HOW LIMBS DEVELOP IN UTERO
Embryogenesis
After an egg is fertilized, the first stage of growth is
called embryogenesis. During this period of time, a
sequence of events occurs that will determine the
number of limbs, their location, and their orienta-
tion.8 In addition, during this time, between the
fourth and eighth week of gestation, most upper-
FIG. 1.2 Ulnar longitudinal deficiency associating a proximal femoral focal deficiency.
extremity congenital anomalies occur. The sequence
of events that determines upper-limb development is
as follows:
• Day 26 after fertilization: The limb buds initially
become visible. The embryo is only about the size of
a single grain of rice, roughly 4 mm in length.9,10
• Days 27e47: Over the next 3 weeks, limb buds
develop rapidly, but the fingers and toes are not yet
identifiable. Even at the end of this period of time,
the entire embryo is still only about the size of a lima
bean, roughly 20 mm in length.
• Days 48e53: Over the next five or so days, the fin-
gers and toes separate, so that hands and feet
become clearly recognizable.
• Day 56: By the end of the eighth week after fertil-
ization, all the essential limb structures are present.
Embryogenesis is complete and the next stage of
development, the fetal period, has begun.
Fetal Period
Upon the completion of embryogenesis, the fetal period
begins. During this stage of development existing structures
differentiate, mature, and grow.3e13 In the limbs, part of
the differentiation and maturation process involves the
creation of articulations. Joints form as chondrogen con-
denses into dense plates between limb structures that
will ossify to become bones.14 Joint cavitation develops
the articulation further, though each joint’s development
ultimately requires fetal movement to ensure the joint sur-
face is modeled into its final prenatal form.
 CHAPTER 1 Embryology and Intrauterine Diagnosis
At a cellular level, limb buds are an outgrowth of
mesoderm into overlying ectoderm. Cells from two
mesodermal sourcesdlateral plate mesoderm and so-
matic mesoderm. These cell lines migrate from their or-
igins into the limb bud.3,14 The lateral plate cells
eventually become bone, cartilage, and tendon. The so-
matic cells form muscles, nerves, and vascular elements.
Blastemas are clusters of cells that all are destined to
differentiate into the same type of tissue. In the fetus’s
developing limbs, muscular and chondrogenic blas-
tema, derived from lateral plate mesoderm differentiate
into muscles and bones, respectively.15 The level of ox-
ygen tension appears to play a part in this differentia-
tion process. Chondrogenic blastema is located more
centrally within the limb bud where oxygen tension is
relatively low. Muscular blastema is more peripheral
in location where oxygen tension is greater. Both mus-
cles and the cartilaginous structures that ultimately
will ossify to become bones develop sequentially, start-
ing proximal and progressing in a distal direction.
Joints form between the ends of adjacent blastemas,
a joint capsule surrounding the interzone and the inter-
vening blastemas cavitating within the interzone’s cen-
ter to create the articular space. Joint fluid is produced
within this space, while cartilage caps the two ends of
FIG. 1.3 Ulnohumeral fusion or synostosis associated with
ulnar longitudinal deficiency.
3
each bone. Joints ossify and fuse, resulting in synosto-
sis, when the process mentioned earlier fails. Two joints
commonly effected by are the proximal radioulnar and
ulnohumeral joints (Fig. 1.3). Another component of
fetal development that is required for the formation
of a functional mobile joint is movement. When fetuses
fail to move adequately, as in arthrogryposis, joint
spaces become infiltrated by fibrous tissue resulting in
contracted and immobile joints (Fig. 1.4).
Signaling Centers
Three growth signaling centersdthe apical ectodermal
ridge (AER), the zone of polarizing activity (ZPA) and
the Wnt (Wingless type)dcentral to limb patterning
align the three spatial axes of limb development. The
axes are labeled proximodistal, anteroposterior, and
dorsoventral, respectively (Table 1.1).14e17 As demon-
strated later, our understanding of embryogenesis has
been advanced by ingenious experiments performed
by embryologists. In these experiments, animal
models with limb patterning have been manipulated
to permit the dissection and alteration of crucial
signaling centers that effect limb development and
orientation.12,13,18
FIG. 1.4 Eleven-month-old girl with arthrogryposis
involving predominantly the shoulder girdles. Absence of
elbow creases revealing intrauterine poor motion.
4 SECTION I Background

TABLE 1.1
Spatial Axes of Limb Development, their Signaling Centers and Malformation Associated.
Signaling Center Signaling molecule Limb Axis Malformation
Apical ectodermal ridge Fibroblast growth factors Proximal to distal Transverse deficiency
Zone of polarizing activity Sonic hedgehog protein Radioulnar Mirror hand
Wnt pathway Transcription factor, Lmx-1 Ventral and dorsal Abnormal nail and pulp arrangement
Nail-patella syndrome

Proximodistal limb development

Limbs develop in a proximal to distal direction, from
shoulder / arm / forearm / hand. The proximodis-
tal signaling center, called the apical ectodermal ridge
(AER), is a thickened layer of ectoderm that condenses
over each limb bud14 and secretes proteins that create
this effect.19,20 Experimental models have been devel-
oped to mimic proximodistal limb development. They
include removing the AER, which results in limb trunca-
tion. Conversely, ectopic implantation of the AER in-
duces the formation of additional limbs.10,12,14
Interestingly, however, removing the AER can be over-
ridden by administering certain fibroblast growth fac-
tors that are released by the AER. Moreover, mice
deficient in these fibroblast growth factors exhibit com-
plete transverse limb defects.21,22
Given these results, transverse deficiencies are now
attributed to deficits in the AER or certain signaling mol-
ecules, such as fibroblast growth factors, that it produces
(Fig. 1.5).

Anteroposterior limb development

In animal models, both transplantation of the anteropos-
terior (i.e., radioulnar or preaxialepostaxial) signaling
center, called the zone of polarizing activity (ZPA), and
transplanting the sonic hedgehog protein that the ZPA se-
cretes have been demonstrated to cause mirror duplica-
tion of the ulnar aspect of the limb.23 Mutant mice with
sonic hedgehog protein in their anterior limb bud
develop polydactyly.24 Also in models, triphalangeal
thumbs (thumbs with three phalanges, instead of the
usual two) have been found to arise secondary to point
mutations that generate ectopic sonic hedgehog com-
pound at the anterior margin of the limb bud.25 In
humans, therefore, both mirror hand and certain forms
of polydactyly are now attributed to deficits in the ZPA
or sonic hedgehog protein (Fig. 1.6).3,18
Dorsoventral limb development
The mechanism behind the development of the dorsum
of the finger with its fingernail and the volar surface
FIG. 1.5 Adactylous form of symbrachydactyly a
manifestation of transverse deficiencies. “Nubbins” are the
vestiges of digits and are the hallmark of symbrachydactyly.
The nubbins are comprised of the remaining ectodermal
structures of the distal finger (the pulp, nail fold, and nail).
with its abundant pulp tissue are differentiated and
developed is not well understood.11 The pathway
responsible for this differentiation produces one tran-
scription factor, Lmx-1, that induces the mesoderm to
adopt dorsal characteristics.26 In the ventral ectoderm,
the Wnt pathway is blocked by a product of a gene
called engrailed-1 (En-1). Mice lacking the anteroposte-
rior Wnt signaling pathway, which resides in dorsal
ectoderm and secretes Lmx-1, exhibit ventralization of
the dorsal surface of their limbs, such that they manifest
palmar pads on both sides of their hand: front and
back.27 Conversely, mice lacking the engrailed-1 protein
exhibit dorsalization of their limbs’ volar surfaces
 CHAPTER 1 Embryology and Intrauterine Diagnosis 5

FIG. 1.6 Mirror hand attributed to abnormal anteroposterior limb patterning. The result is duplication of the
ulnar field but absence of the radial field.

(so-called bidorsal limbs).28 Alterations in this latter

pathway are relatively rare. Loss of Lmx-1 is associated
with a condition called nail-patella syndrome, in which
affected individuals have small, poorly developed nails
and kneecaps. Affected individuals also have musculo-
skeletal defects in other areas of the body including
their elbows, hips, and chest.29 Other children may pre-
sent with anomalies that include extraneous nail or
abnormal pulp development, both linked to an altered
Wnt signaling pathway.30 In humans, dorsal dimelia
with the nails may present on the palmar surface of fin-
gers, is explained by alterations in the Wnt signaling
pathway or Lmx-1 (Fig. 1.7).23

Programmed Cell Death

Programmed cell death (PCD) is another essential
component of proper limb development. PCD is an active
process that is genetically controlled. PCD eliminates un-
wanted cells during embryogenesis.23 Apoptotic cells un-
dergo a degenerative process, associated with DNA
fragmentation, and eventually are engulfed by phago-
cytes. A clear example of this is the separation of fingers
and toes during days 48e53 of gestation. Before day 48,
all human digits are webbed. Over the next 5-day period
of gestation, interdigital necrosis occurs with extraneous,
web-like tissue between fingers and toes undergoing
PCD. Failure of interdigital PCD results in syndactyly.31
FIG. 1.7 Dorsal dimelia with abnormal dorsoventral limb
patterning can cause duplication of the dorsal field resulting
in the presence of a nail both in the dorsal and volar sides of
the finger.
Widely recognized for their role in chondrogenesis
and osteogenesis, bone morphogenetic proteins
(BMPs) also trigger apoptotic pathways in interdigital
mesenchyme to separate the fingers.23 Antagonists to
6 SECTION I Background
BMP are capable of blocking BMP signaling and pre-
venting this process of apoptosis and interdigital necro-
sis. An obvious animal example of this are bats,
mammals whose limbs are webbed, and whose BMP
has been shown to be blocked during limb embryogen-
esis.32 Similarly, altered signaling of fibroblast growth
factors can negate BMP-mediated apoptosis and result
in syndactyly, which occurs in individuals with Apert
syndrome (Fig. 1.8).
Genes and Molecular Abnormalities and
www.omim.org
Research on gene misexpression and altered anatomical
and functional development has enhanced general
FIG. 1.8 Syndactyly in Apert syndrome is related to altered signaling of fibroblast growth factors resulting in
abnormal BMP-mediated apoptosis.
understanding about how limbs develop in utero.3,18
This research has included intense work focusing on
genotypeephenotype correlations that may have sub-
stantial clinical implications.
Online Mendelian Inheritance in Man (OMIM, www.
omim.org) is a reliable and comprehensive, online
compendium of human genes and genetic phenotypes
that is updated daily and freely available to help clini-
cians, investigators, and other interested parties under-
stand the vast evolving field of genetics and countless
number of different phenotypes.
Numerous congenital deformities have a known ge-
netic link. However, most possess variable inheritance
patterns and breadths of expression. Healthcare
 CHAPTER 1 Embryology and Intrauterine Diagnosis
providers who evaluate patients with hand deformities
must have basic knowledge about congenital differences
that are familial and potentially inherited versus those
differences that are not inheritable. This understanding
will justifiably recommend to families whether or not
they should undergo evaluation by a clinical geneticist.
Parents also require appropriate counseling pertaining
to the spectrum of phenotypic expressions that can occur
with a particular mutation. One misconception that
frequently affects parents with a mild phenotype of a
congenital disorder is that the extent and severity of their
own disorder is a “worst-case scenario” for their child.
This misperception can lead such parents to purse with
pregnancy and birth, naïve to the possibility that their
offspring may have a phenotypically much worse form
of their difference. Their severely affected offspring ren-
ders those parents devastated, ill prepared, and engulfed
with feelings of guilt. Appropriate genetic counseling
referral can mitigate the misconception of variable
phenotype with similar genotype.
Mutations that encode signaling proteins, receptor
molecules, and transcription factors can alter normal
limb arrangement, resulting in anomalies that range
from almost imperceptible to complete limb absence.
The number of molecularly identifiable congenital
anomalies that practicing hand surgeons are seeing is
steadily increasing. Other anomalies, though less well
defined at a molecular level, have been mapped to spe-
cific chromosomal segments.3 Table 1.2 lists examples
of genes that encode transcription factors and exert
some crucial level of control over upper-limb formation
(Figs. 1.9 and 1.10).33e36
TABLE 1.2
Consequence of Mutation of Some Genes Encoding Transcription Factors Crucial for Limb Formation.
Gen Syndrome
Hox Synpolydactyly
Hand-foot-genital syndrome
Leri-Weill dyschondrosteosis
T-Box Holt-Oram Sd (Tbx-5)
Ulnar-mamary Sd (Tbx-3)
Cartilage-derived Grebe chondrodysplasia
morphogenetic protein
Hunter-Thompson chondrodysplasia
7
Intrauterine Diagnostics and Treating Upper-
Limb Anomalies
Diagnosing congenital anomalies in utero can lead to
parental counseling by a geneticist and/or by a surgeon
who specializes in the anomaly identified and its treat-
ment. In utero diagnosis may guide parental decisions
on difficult personal and ethical questions, such as
should gestation be terminated? In addition, in-utero
procedures reevolving and may be considered based
upon the certainty of diagnosis.37 In addition, in utero
diagnosis permits investigations to screen for associated
anomalies, via further imaging studies or other proced-
ures such as amniocentesis and chorionic villus sam-
pling for fetal karyotyping and genetic analysis.38
To date, ultrasound remains the primary modality
for fetal evaluations and/or monitor fetal development.
Ultrasound also guides prenatal care and identifies fetal
abnormalities (Fig. 1.11A).39,40 Ultrasound-based pre-
natal diagnosis has improved substantially over the
last several decades because of technological advances,
improved image resolution, increased standardization
of prenatal ultrasound protocols, and enhanced
training of diagnosticians.37 Prenatal ultrasound has
the potential to identify isolated musculoskeletal ab-
normalities, including a broad range of hand and
upper-limb condition including transverse and longitu-
dinal deficiencies, syndactyly, polydactyly, clinodactyly,
and clasped thumbs (Fig. 1.12).40
Both the American College of Radiology and
American Institute of Ultrasound in Medicine recom-
mend routine second-trimester screening with trans-
abdominal ultrasound, between 18 and 22 weeks of
Limb anomaly Inheritance
Synpolydactyly (Fig. 1.9) A.D.
Short great toes and
hipoplastic thumbs
Madelung’s deformity
Radial deficiency A.D.
Ulnar digits hipoplasia
Brachidactily A.R.
Brachidactily (Fig. 1.10)
8 SECTION I Background
FIG. 1.9 Mutation in Hox genes can result in this autosomal dominant familial synpolydactyly.
FIG. 1.10 This familial brachydactyly may be explained by an underlying mutation in cartilage-derived
morphogenetic protein gen.
gestation, to confirm the fetuses gestational age, eval-
uate their intrauterine development, and screen for
congenital anomalies. Current recommendations
only require that the ultrasonographer document
that all four extremities are present, although
enhanced ultrasound imaging will likely change this
basic recommendation. Currently, even with level-2
(‘‘targeted’’) ultrasound studies, further detailed
assessment of the extremities is ‘‘encouraged,’’ but
formalized standards are nonexistent.41 In fact, despite
improvements in ultrasound technology and tech-
niques, its sensitivity detecting upper-limb anomalies
remains low.42
At one tertiary level hospital, the postnatally
confirmed sensitivity of prenatal ultrasound detecting
upper-extremity anomalies was approximately 40%.42
This sensitivity was lower when the anomalies were
limited to the upper extremities (25% vs. 55%). Sensi-
tivity for upper-limb anomalies was highest for condi-
tions affecting the entire upper extremity (85%) and
lowest for those affecting the digits alone (10%). Fe-
tuses with limb-reduction defects, radial longitudinal
deficiency, phocomelia, arthrogryposis, abnormal
hand positioning, and cleft hand were more likely to
be accurately diagnosed, because they were more likely
to have an associated anomaly.
Several strategies can be utilized to enhance the
sensitivity and accuracy of ultrasound imaging. One
such technique is transvaginal ultrasound, which allows
better visualization of the fetus and limbs.40 In some
high-risk groups, early risk assessment with ultrasound
is performed between 11 and 14 weeks of gestation.
 CHAPTER 1 Embryology and Intrauterine Diagnosis 9

(A) (B)

(C)

FIG. 1.11 Ultrasound showing severe leg constriction with markedly distal edema and risk of intrauterine
amputation (A) Prenatal MRI confirming the ultrasound findings (B) Fetoscopic image of the leg constriction
and longitudinal release with a Yag-Laser fiber (C).

Within this time period and by employing transvaginal
techniques, initial limb development can be assessed.
Three-dimensional (3-D) ultrasound also improves
the modality’s diagnostic potential, allowing for the
identification and characterization of more-complex
anatomical structures. Authorities have advocated
adopting 3D ultrasound as the imaging modality of
choice for analyzing fetal limbs, particularly their hands
(Fig. 1.13).43
The hand is best visualized by ultrasound during the
late part of the first and early part of the second
trimester. At this time, the fingers are large enough to
be visualized and characteristically extended and
abducted, facilitating the examiner’s ability to discern
anatomical alterations. Later in gestation, the hands
often position in a clasped fist-like appearance
obscuring hand anomalies. Additionally, the relative
decrease in intrauterine space and amniotic fluid in later
gestation limits fetal motion and the likelihood that the
fetus will move into a position more suitable for
detailed ultrasound assessment.
Magnetic resonance imaging (MRI) has particular
advantages for evaluating neural axis, thoracic, and
head or neck abnormalities, relative to the conventional
ultrasound, because imaging the fetus with MRI is less
dependent upon the presence of normal amniotic fluid
volume, fetal position, and maternal body habitus.44
However, due to artifacts caused by moving extremities,
the accuracy of MRI in evaluating the hand and remain-
ing upper limb remains to be determined (Fig. 1.11B).
10 SECTION I Background

(A) (B)

(C) (D)

FIG. 1.12 A variety of congenital differences diagnosed by ultrasound at 21 weeks of gestational age: (A)
complex syndactyly, (B) postaxial polydactyly, (C) ulnar deficiency with oligosyndactyly, and (D) radial
clubhand with absent radius.

PRENATAL TREATMENT
Fetal surgery is an emerging and established procedure.
Intrauterine surgery was initially restricted to the treat-
ment of life-threatening anomalies, given risks to both
the mother and fetus (e.g., diaphragmatic hernia, twine
twin transfusion syndrome, giant teratomas, etc.).45 As
the prerequisite of anesthesia (maternal and fetal) and
technology (fetal endoscopy) have improved, the risks
have been reduced and the indications for intrauterine
surgery have been extended to include nonlethal ortho-
pedic conditions, including myelomeningocele and
amniotic band syndrome.46
Currently, the only upper-limb indication for feto-
scopic examination and treatment is the risk of limb
amputation by an extremity amniotic band
(Fig. 1.11C). The progressive strangulation of a limb
by an intrauterine amniotic band leads to gradual wors-
FIG. 1.13 27 weeks 3D ultrasound showing an Apert’s ening of the deformity and ultimate amputation. Prena-
hand. tal band release arrests the progression of strangulation
 CHAPTER 1 Embryology and Intrauterine Diagnosis
and allows the fetal tissue’s natural healing capacity to
potentially restore the affected limb’s normal
morphology and function (Fig. 1.11C).36 Fetal wound
repair also occurs without scar formation, which yields
the potential application to treating other congenital
upper limb deformities (e.g., syndactyly). As future ad-
vances in technology and anesthesia decrease
maternalefetal risks further, the indications for prenatal
interventions to correct congenital anomalies will likely
expand.
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2. Parker SE, Mai CT, Canfield MA, et al. Updated National
Birth Prevalence estimates for selected birth defects in
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Mol Teratol. 2010;88:1008.
3. Bamshad M, Watkins WS, Dixon ME, et al. Reconstructing
the history of human limb development: lessons from
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4. Taussig HB. A study of the German outbreak of phocome-
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5. Temtamy SA, McKusick VA. The genetics of hand
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7. Schmidt CC, Neufeld SK. Ulnar ray deficiency. Hand Clin.
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8. O’Rahilly R, Gardner E. The timing and sequence of events
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9. Uthoff HK. The Embryology of the Human Locomotor System.
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10. Zaleske DJ. Development of the upper limb. Hand Clin.
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11. Moore KL. The Developing Human: Clinically Oriented
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13. Shubin N, Tabin C, Carroll S. Fossils, genes and the evolu-
tion of animal limbs. Nature. 1997;388:639.
14. Daluiski A, Yi SE, Lyons KM. The molecular control of up-
per extremity development: implications for congenital
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15. Al-Qattan MM, Yang Y, Kozin SH. Embryology of the up-
per limb. J Hand Surg Am. 2009;34:1340.
16. Laufer F, Nelson CE, Johnson RL, et al. Sonic hedgehog
and Fgf-4 act through a signaling cascade and feedback
loop to integrate growth and patterning of the developing
limb bud. Cell. 1994;79:993.
11
17. Niswander L, Jeffrey S, Martin GR, et al. A positive feed-
back loop coordinates growth and patterning in the verte-
brate limb. Nature. 1994;371:609.
18. Riddle RD, Johnson RL, Laufer E, et al. Sonic hedgehog
mediates the polarizing activity of the ZPA. Cell. 1993;
75:1401.
19. Mariani FV, Ahn CP, Martin GR. Genetic evidence that
FGFs have an instructive role in limb proximal-distal
patterning. Nature. 2008;453:401.
20. Niswander L, Martin GR. FGF-4 expression during gastru-
lation, myogenesis, limb and tooth development in the
mouse. Development. 1992;114:755.
21. Fallon JF, Lopez A, Ros MA, et al. FGF-2: apical ectodermal
ridge growth signal for chick limb development. Science.
1994;264:104.
22. Niswander L, Tickle C, Vogel A, et al. FGF-4 replaces the
apical ectodermal ridge and directs outgrowth and
patterning of the limb. Cell. 1993;75:579.
23. Chen Y, Zhao X. Shaping limbs by apoptosis. J Exp Zool.
1998;282:691.
24. Masayu H, Sagai T, Wakana S, et al. A duplicated zone of
polarizing activity in polydactylous mouse mutants. Genes
Dev. 1995;9:1645.
25. Lettice LA, Hill AE, Devenney PS, et al. Point mutations in
a distant sonic hedgehog cis-regulator generate a variable
regulatory output responsible for preaxial polydactyly.
Hum Mol Genet. 2008;17:978.
26. Riddle RD, Ensini M, Nelson C, et al. Induction of the LIM
homeobox gene Lmx1 by WNT7a establishes dorsoventral
pattern in the vertebrate limb. Cell. 1995;83:631.
27. Parr BA, McMahon AP. Dorsalizing signal Wnt-7a required
for normal polarity of D-V and A-P axes of mouse limb.
Nature. 1995;374:350.
28. Loomis CA, Harris E, Michaud J, et al. The mouse
Engrailed-1 gene and ventral limb patterning. Nature.
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29. Dreyer SD, Zhou G, Baldini A, et al. Mutations in LMX1B
cause abnormal skeletal patterning and renal dysplasia in
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33. Basson CT, Bachinsky DR, Lin RC, et al. Mutations in hu-
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35. Polinkovsky A, Robin NH, Thomas JT, et al. Mutations in
CDMP1 cause autosomal dominant brachydactyly type C.
Nat Genet. 1997;17:18.
12 SECTION I Background
36. Ross JL, Scott Jr C, Marttila P, et al. Phenotypes associated
with SHOX deficiency. J Clin Endocrinol Metab. 2001;86:
5674.
37. American College of Obstetricans and Gynecologists.
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pregnancy. Obstet GyneCol. 2009;113(2 Pt 1):451e461.
38. Drummond CL, Gomes DM, Senat MV, Audibert F,
Dorion A, Ville Y. Fetal karyotyping after 28 weeks of gesta-
tion for late ultrasound findings in a low risk population.
Prenat Diagn. 2003;23:1068e1072.
39. Chitty LS, Hunt GH, Moore J, Lobb MO. Effectiveness of
routine ultrasonography in detecting fetal structural ab-
normalities in a low risk 40 population. BMJ. 1991;303:
1165e1169.
40. Bronshtein M, Keret D, Deutsch M, Liberson A, Bar
Chava I. Transvaginal sonographic detection of skeletal
anomalies in the first and early second trimesters. Prenat
Diagn. 1993;13:597e601.
41. Wientroub S, Keret D, Bronshtein M. Prenatal sonographic
diagnosis of musculoskeletal disorders. J Pediatr Orthop.
1999;19:1e4.
42. Piper SL, Dicke JM, Wall LB, Shen TS, Goldfarb CA. Prena-
tal detection of upper limb differences with obstetric
ultrasound. J Hand Surg Am. 2015;40(7):1310e1317.
43. Kos M, Hafner T, Funduk-Kurjak B, Bozek T, Kuriak A.
Limb deformities and three-dimensional ultrasound.
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44. Breysem L, Bosmans H, Dymarkowski S, et al. The value of
fast MR imaging as an adjunct to ultrasound in prenatal
diagnosis. Eur Radiol. 2003;13:1538e1548.
45. Cortes RA, Farmer DL. Recent advances in fetal surgery.
Semin Perinatol. 2004;28(3):199Y211.
46. Soldado F, Aguirre M, Peiró JL, et al. Fetoscopic release of
extremity amniotic bands with risk of amputation. J Pediatr
Orthop. 2009;29(3):290e293. https://doi.org/10.1097/
BPO.0b013e31819c405f.
CHAPTER 2
Hand Function: Typical Development
AVIVA WOLFF, EDD, OT, CHT
INTRODUCTION
Hand motor skill development begins early in utero
with spontaneous movements and is fully completed
during adolescence with the mastery of fine motor skills
and coordination. During the first few years of a child’s
life, the hand motor skills undergo rapid and remark-
able developmental change to allow for exploration
and use of objects.1e3 Early spontaneous movements
give way to nonspecific, generalized movements. The
infant uses the generalized movements to explore the
surrounding area and gather information from the envi-
ronment. These critical sensory experiences are funda-
mental to the development of voluntary controlled
hand movements.1,4,5 Nonspecific movements further
evolve into exploratory movements that begin with
rudimentary grasp patterns and develop into precise
movements that allow for dexterous manipulation of
objects. The skills required for functional hand use
encompass multiple discreet sequential components:
recognition of an object, accurate reach for the object,
proper hand orientation, proper calibration of aperture
(hand opening) as it approaches the object, proper cali-
bration of forces to grasp the object, and finally, grasp
and manipulation of the object with one or both hands
for the intended use.6 Timing and coordination for each
of these subskills develop throughout early childhood,
as the reach-to-grasp movements develop from an
immature feedback mechanism to a mature feedfor-
ward, anticipatory approach.6e8 In late childhood and
early adolescence, these skills continue to develop for
maximum control of speed, accuracy, and coordina-
tion.6,7 Fig. 2.1 represents a timeline of key components
of hand motor skill development from the prenatal
period through adolescence.
The development of hand skills integral for hand use
and function emerges from a complex interaction of
multiple systems and maturation of the central nervous
system that is further influenced by many contributing
factors such as postural control, cognitive and percep-
tual abilities, vision, sensory experiences, and
Pediatric Hand Therapy. https://doi.org/10.1016/B978-0-323-53091-0.00002-6
© 2020 Published by Elsevier Inc.
interaction with the environment.9,10 The develop-
mental process parallels the typical sequential progres-
sion of neuromotor maturation yet varies in timing of
onset among children. Typical patterns of hand skill
development emerge at specific stages and age ranges
with a wide variation in individual development that
corresponds to maturation of the central nervous sys-
tem.6,9 Influences of the environment and sensory expe-
rience on development of hand skills are believed to be
largely responsible for this variation.9e12 Visual, tactile,
and proprioceptive sensory experiences play an impor-
tant role in the development of hand function. Sensory
and visual stimulation provide essential feedback for
ongoing development of skills and can be manipulated
by caregivers and clinicians to enrich the environment
and promote and encourage development in typically
and atypically developing children.
The purpose of this chapter is to provide clinicians
with an understanding of how hand skills develop
from basic crude movements to precise patterns that
enable skilled manipulation of objects for functional
use. This chapter will review the motor development
of the range of skills necessary for functional use of
the hand for each of these skills: the reach-to-grasp
movement, object release, object manipulation, and
bimanual coordination. The first section describes the
characteristics of spontaneous movements, the second
section covers the development of unimanual skills
and function, and the third section describes the devel-
opment of bimanual hand skills and function. Each sec-
tion explicates the specific characteristics and skills that
emerge and mature throughout the developmental con-
tinuum and the important factors that influence and
shape development. The components and characteris-
tics of key hand motor skills with the corresponding
developmental age ranges are listed in Table 2.1.
SPONTANEOUS MOVEMENTS
The earliest movements exhibited by infants are nonspe-
cific, nonpurposeful, and seemingly random. These
13
14 SECTION I Background
FIG. 2.1 Timeline of key components of hand motor skill development.
movements, called as generalized movements, are not iso-
lated to the upper extremity and occur in all four limbs.
They are described as spontaneous movements because
they are not elicited by any cause.13 In the upper limb,
general movements have been identified as early as
8 weeks of gestation and continue through early infancy
until purposeful and directed reach emerges by approxi-
mately 16 weeks.4,14 Early fetal preterm general move-
ments show large variability until 36e38 weeks of
gestation. These movements are replaced by writhing
movements that are observed between 36 weeks of gesta-
tion to 2 months postterm. Writhing movements are
proximal, and characterized by a slow-to-moderate speed
and small-to-moderate amplitude.15 Fidgety movements
appear next between 2 and 5 months old, and are more
distal, have smaller amplitude, lower speed, and varied
acceleration.15 General movements of the arms are
thought to be precursors to reaching and grasping move-
ment and are described in the literature as prereaching
behavior16 because they allow infants to explore their
own bodies and surrounding surfaces to gather informa-
tion critical for future development of reach and
grasp.1,17 Absent, abnormal, and erratic spontaneous
movements (especially fidgety movements between 2
and 5 months) are highly predictive of risk for later
neurologic dysfunction and conversely, normal move-
ments are predictive of normal development.14,18,19
When impairment is suspected, the environment can be
manipulated by caregivers and clinicians to provide op-
portunities for enriched sensory experiences to allow for
early intervention and further stimulate development.
The general movement assessment is the most
commonly used early screening tool to assess abnormal
motor activity and identify infants at risk for develop-
mental disorders.14,15,18e20 It is the most reliable clinical
assessment currently available and considered highly
predictive for cerebral palsy.21 Motion capture tech-
niques also provide the opportunity to detect, assess,
and track hand and arm movements in infants over the
course of development. These techniques are not as
well developed but are becoming more available and
feasible for use. An extensive review of the advantages
and disadvantages of various movement recognition
technology (video cameras, 3D motion capture, and
direct sensing) in assessing spontaneous general move-
ments was recently published by Marcroft et al.22 Regard-
less of the method used, early detection of infants at risk
allows for early intervention with a focus on encouraging
and facilitating motor control of the hand and arm by
providing opportunities that encourage increased use.
UNIMANUAL FUNCTION
Unimanual Reaching
Voluntary, goal-directed, functional movements begin
to emerge by 3 months old and replace spontaneous
movements. These changes are associated with changes
in neuromotor developmental processes and a shift
from subcortical to cortical processing.23,24
The reach movement observed in early infancy
broadly encompasses two types of reach: reaching to-
ward an object, a precursor for a reach-to-grasp move-
ment, and reaching toward the self that is described as
bringing the hand to the face (usually mouth and
eye). Both movements have a directed arm movement
in common. The movements differ in the sensory

TABLE 2.1
Components of Upper Limb Movements
Category Movement
Spontaneous Generalized movements
movements
Writhing movements
Fidgety movements
Reach Spontaneous reach
Voluntary unilateral reach
Voluntary bilateral reach
Mature reach
Grasp Reflexive
Instinctive/Squeeze
Ulnar palmar grasp
Radial palmar grasp
(superior palmar grasp)
Scissors grasp
Inferior pincer
Superior pincer
Deft and precise grasp
Dexterity and manipulation
Release Reflexive
Accidental release
Forced withdrawal
Release to table or surface
Intentional dropping
Precision release
Controlled release
Manipulation Premanipulation
Transfer objects
Finger differentiation
In-hand manipulation
CHAPTER 2 Hand Function: Typical Development 15
Developmental Age
Range Characteristics/Examples
8e36 weeks prenatal Spontaneous, large variability, reach to
mouth
36 weeks prenatal Proximal, slow-to-moderate speed,
e8 weeks postnatal small-to-moderate amplitude
2e4 months postnatal Distal, smaller amplitude, low speed,
varied acceleration
Birth to 2 months Gross, symmetrical, swipe for objects,
predominantly bilateral
4e5 months Irregular trajectory, variable movement
patterns
4 months Attempted bilateral movements
1e2 years Straighter, smoother movement path,
consistent trajectory
1e4 months Grasp objects placed in hand,
nonpurposeful
5 months Touching, feeling, raking, beginning
anticipatory grasp
6 months Four finger grasp, no thumb
7 months Radial fingers and thumb press object
into palm
9 months Small objects picked up with thumb and
lateral border of finger
10 months Objects held between pads of thumb
and fingertip
12 months Objects held between tips of thumb and
fingertip
15 months Adjustments for weight and size, varies
grip
18 months Increased control for speed and
precision, manipulates utensils
1e4 months Response to tactile stimulation of
extensors
5 months Object falls out of hand
6 months Pulling
7 months Variable, and clumsy
10e11 months Throwing/dropping food
12 months Graded release, stacking blocks
18 monthse2 years Accurate, precise release, puzzle
pieces
1e4 months Object exploration, fingering, raking,
shaking objects
4e6 months Transfer from hand to hand, banging,
wave and rotate objects
9e10 months Able to isolate finger movements,
pointing
1e2 years Move items from palm to fingers
16 SECTION I Background
determination of the target. The reach-to-self target is
determined by proprioceptive input, whereas the
reach-to-object target is determined by visual input.5,25
The earliest observation of reaching to a target has been
documented prenatally at 22 weeks of gestation in the
context of reaching toward the mouth.5
Reach to grasp
Reach
The phases of a mature reach-to-grasp movement
include reach, grasp, transport, and object release. The
reach component refers to the movement of the arm to-
ward a target and occurs in parallel with the hand open-
ing and shaping in preparation to grasp the object.
Although these movements occur simultaneously in
mature reaching, each component develops sequen-
tially during infancy with voluntary goal-directed reach-
ing preceding grasp formation.26 Successful reaching
toward a target requires integration of visual and propri-
oceptive information. A mature reach is characterized
by a smooth trajectory with a consistently continuous
straight path to the target, although the speed and tra-
jectory of reach vary depending on the size and location
of the target and the intended action. The velocity of a
mature reach has a defined acceleration and decelera-
tion phase as the arm approaches the target and con-
cludes with a grasp phase as the hand prepares to
grasp the object. These distinct phases are indicative of
motor planning and reflect the ability for anticipatory
control27 (Fig. 2.2).
In infants, goal-directed reaching that is character-
ized as anticipatory and visually guided emerges by
the age of 4 months.4 Before this, infants may attempt
to occasionally swipe at objects within their visual field
with occasional success. Over time with repeated expo-
sure and experience, hand and arm movements become
more purposeful and directed toward a target. However,
this early reach is characterized by an irregular trajectory
that lacks smoothness and consistency and is highly
FIG. 2.2 Wrist velocity curve of mature reach-to-grasp movement over the course of time.
variable. During early reaching, infants must learn to
coordinate the movements of the shoulder, arm, and
hand. They begin by using the shoulder and torso to
move the hand to the target, while keeping the elbow
stiff in an attempt to control the degrees of freedom.28
Movement trajectories of reach begin to stabilize at
the age of 1 year with straighter movement paths, and
stereotypical patterns by the age of 2e3 years.29,30
Grasp
Successful manipulation of objects is achieved through
a combination of several discreet components of hand
motor skills: controlled grasp and release, the ability
to transfer an object from one hand to another, and
individuation of the fingers. Mature grasp is character-
ized by an anticipatory mechanism that evolves during
the reach movement with the hand simultaneously
opening and shaping to match the approximate size
and shape of the object. The timing of hand opening
and closing is critical for smooth and coordinated grasp.
Closing the hand too early or too late results in unsuc-
cessful or awkward grasp. During mature grasp, the
hand opening (aperture) reaches the maximum open-
ing at about 75% of the reach movement and begins
to close as it nears the object.27,31
In infants, purposeful grasp is preceded by sponta-
neous opening and closing of the fingers. These nonpur-
poseful “pregrasp” hand movements have been called as
“vacuous hand babbling.”32 Reflexive grasp exists in in-
fancy from birth to 4 months and is observed as infants
curl their fingers around an object in response to stimu-
lation of the palm. Purposeful grasp control develops be-
tween 4 and 6 months through exposure to tactile and
verbal stimulation.33 During this time, infants begin to
integrate visual information to prepare the hand in antic-
ipation of grasping an object. The combination of tactile
and visual stimulation is critical for the development of
the ability to grasp, orient, and adjust the hand to objects
for purposeful grasp.9 Grasp patterns emerge over time
 CHAPTER 2
from experience and interaction with a variety of object
shapes and sizes. At 5 months, a child will touch and
feel an object. Voluntary grasp develops through these
experiences and is at first accidental. Subsequently, a
range of grasp patterns develop through stimulation
and exposure to various objects and toys. The character-
istics and development of the repertoire of grasp patterns
is discussed and detailed later. The earliest anticipatory
grasp ability is seen in 5e6 month olds as they open
the hand in preparation for grasp and start to close the
hand before making contact with the object.
Preshaping the hand to match the object size begins
to develop by 8 months old and continues over the next
year.26 Young children, up to age 6, overshoot when
reaching for objects and open their hands wider than
necessary (Fig. 2.3). Older children demonstrate accu-
rate grip formation to the size and shape of the object
with normalization of hand shaping occurring by age
6e8.34,35 The ability to adjust and orient the grip orien-
tation to the object begins to develop at 6 months and
continues to become more accurate up to the age of
15 months.16,26 Calibration of force control is another
critical component of precision grasp that allows for ob-
jects to be held without being dropped or crushed. The
amount of force generated during grasp is dependent on
the size, friction, weight, and texture of the
object.8,36e38 The ability to anticipate force control de-
velops gradually beginning in the second year. Before
that, infants control force development via a feedback
mechanism. Fingertip force control continues to
develop throughout early childhood and reaches adult
levels by age 6e9.39
Grasp patterns
Mature grasp encompasses a larger repertoire of patterns
utilized for the performance of an infinite number of
everyday tasks. The specific grasp pattern employed for
FIG. 2.3 Anticipatory opening of the hand in preparation for
grasp. Note: the hand is opening wider than necessary to
grasp the cube. (Photo credit: Naomi Polatsek)
Hand Function: Typical Development 17
a given task is determined by the size and shape of the
object, location, and intended use.9 Grasp patterns
have been classified historically into either power or pre-
cision grips.39 In a power grip, the finger and thumb are
directed to the palm and the force is directed at the ob-
ject. Types of power grip include cylindrical grasp (hold-
ing a cup or glass), spherical grasp (holding a round
object), and a hook grasp (carrying a bag with handles).
In precision grasp, the object is held between the thumb
and fingers to allow for manipulation of the object rela-
tive to the hand and the force is transmitted between the
thumb and fingers. Types of precision grasp include tip-
to-tip pinch (picking up a marble), pad-to-pad pinch
(squeezing a clothespin), three-point pinch or three-
jaw chuck (picking up a cube), and lateral pinch (pulling
a zipper).39
In infants, early spontaneous grasp movement is
governed by reflexes from birth to 4 months. The devel-
opment of purposeful grasp follows a consistent trajec-
tory that begins with a raking and scratching movement
of the fingers in 4e5 month olds.9,40 This is important
for tactile stimulation. At first, the fingers flex and
extend simultaneously and by 5e6 months most in-
fants exhibit individual finger differentiation and iso-
lated finger movements, most notably the ability to
extend the index finger for pointing.41 These behaviors
are largely automatic with the occasional “accidental”
grasp. Early grasp at this age (5 months) is instinctive
and resembles a squeezing motion. Voluntary grasp be-
gins at age 6 months and has been studied for the last
century. Although the development of grasp patterns
has traditionally been described in a sequential manner,
there is recent evidence to suggest that the emergence of
grasp patterns may be more dependent on the object
and the requirements of the task.42,43 The common
grasp pattern development described historically is
detailed later, and begins with the emergence of a
palmar grasp of the four fingers without the thumb
that is often more ulnar-based (Fig. 2.4).9,39,40
Palmar grasp is succeeded by a radial grasp (also
known as a superior palmar grasp) at 7 months. The in-
fant uses the radial fingers and thumb to press the object
into the palm when using this pattern (Fig. 2.5A). This
allows for easy access to the mouth when the forearm
is supinated (Fig. 2.5B). Infants frequently mouth objects
during this phase as a method of exploring and learning
object properties. In this position objects can also be
easily transferred from one hand to the other.
At 8e9 months, precision grasp begins to emerge,
and most infants can grasp an object with the distal as-
pects of the fingers without use of the palm. For small ob-
jects, a scissors grasp is used between the thumb and
18 SECTION I Background
FIG. 2.4 Palmar graspdobject is grasped with four fingers
against the palm without the thumb. (Photo credit: Naomi
Polatsek)
lateral border of the index with the hand stabilized on a
surface (Fig. 2.6). This is an important developmental
step toward being able to manipulate and use objects.
At 10 months, small objects can be held with the
distal fingertip pads. This grip allows for greater control
for release and is called as inferior pincer grasp or fore-
finger grasp (Fig. 2.7A). The superior pincer grasp, tip-
to-tip pinch, emerges at 12 months and allows for
greater accuracy and stabilization (Fig. 2.7B).
At this stage, the child is also able to begin adjusting
for size and weight of the object. By 15 months, the in-
fant becomes more adept at using a variety of grasps
FIG. 2.5 (A) Radial graspdobject is grasped by radial fingers and thumb and pressed into palm, (B) Forearm
is supinated to allow easy access to the mouth. (Photo credit: Naomi Polatsek)
with increased precision. The ability to manipulate ob-
jects with increased dexterity continues over the next
few months and by 18 months, there is an increase in
dexterity and manipulation of tools and utensils such
as using a spoon for self-feeding.9,39,40
Object release
Object release emerges following the development of
early grasp patterns. Similar to grasp, object release is first
observed in infants as reflexive behavior in response to
stimulation of primitive reflexes. Brushing the back of
the hand elicits a spontaneous extension of the fingers.44
Purposeful release is seen at 5e6 months, at first incon-
sistently and accidentally. By 6 months, release of objects
is consistent and purposeful and mostly observed when
bringing an object to the mouth. Initially, there is a
forced withdrawal as the child uses one hand to pull
the object out of the other hand. By 7 months, the child
is able to release objects on to a surface (table), and ob-
ject release occurs consistently during bilateral transfer of
objects. Sophisticated release in the context of play is
seen by 10e11 months.9 This is the time that children
revel in this newfound ability and create a game out of
dropping items and food from their high chair.9 Graded
hand opening for precision release such as stacking
blocks is achieved by 12 months. At first, the child will
press hard while releasing, and lack the ability to pre-
cisely and gently release the object. Controlled release
continues to develop between ages 1 and 2 for more
complex tasks that require precise release of small objects
with greater accuracy (placing puzzle pieces, small items
in jar). Timing and controlling release continues to be
 CHAPTER 2
FIG. 2.6 Scissors graspdobject is grasped between thumb
and lateral border of the index with the hand stabilized on a
surface. (Photo credit: Naomi Polatsek)
difficult for 2e3 year olds, who often exhibit difficulty
with delicate tasks.45 This skill continues to develop by
age 5e6 for improved accuracy, speed, and dexterity.9
Manipulation
Efficient manipulation of objects requires a combina-
tion of skills and the ability to differentiate movement
between the fingers, calibrate grip force, regulate precise
release, and control timing and speed. Dexterous
manipulation of objects is a skill that develops from in-
fancy through adolescence.
Premanipulation behavior is observed in early in-
fancy, even before voluntary grasp and reach is devel-
oped. In early infancy (1e4) months, arm movements
are used for object exploration. When an object is
placed in the hand of a 1e2-month-old child, the child
will twist the wrist to move the object when it is within
the visual field (rotation).46,47 A child will also use
movements of the arm to deliberately change the loca-
tion of the object (translation), or to shake the object
(vibration). An increase in fingering and raking
behavior is observed at age 4 months.48 Object explora-
tion continues to develop at 5e6 months with the abil-
ity to transfer objects. By 6 months, infants are able to
rotate, wave, and bang objects as well as transfer from
one hand to the other. With the ability to differentiate
finger movements and control release at age 9e
10 months, manipulation skills further develop allow-
ing for poking, prodding, and picking up small objects.
In-hand manipulation skills begin to develop at the
age of 1 year. The term was first described by Exner
Hand Function: Typical Development 19
FIG. 2.7 (A) Inferior pincer graspdobject is grasped
between pads of thumb and index finger. (B) Superior
pincer graspdobject is grasped between tips of thumb and
finger. (Photo credit: Naomi Polatsek)
(1992) who described in hand manipulation as the
adjustment of objects by movements of the fingers so
that the objects are placed in a more appropriate posi-
tion to accomplish the task.49 Exner defines several sub-
components of this skill:
1. The ability to move an object from the palm to the
fingers (translation) as in moving a coin to the fin-
gers from a fistful of change.
2. The ability to rotate an object in the pads of the
finger as in loosening a screw.
3. Using the thumb to move an object in a linear di-
rection on the finger (shift) as in rolling a pencil.
Finger to palm translation and simple rotation occur
by 2 years old, and complex rotation movements such
as manipulating a pencil for writing use continues to
develop until age 7.49 Between ages 3 and 7 years old,
children master more complex manipulation skills
such as fastening buttons and manipulating writing
and eating utensils. The ability to perform these skills
with precision is directly related to the concurrently
20 SECTION I Background

developing ability to properly calibrate grip forces.8 Bimanual Grasp

Finger movements continue to become more accurate
in older children (ages 6e12) with demonstrated im-
provements in reaction times and speed.34,50 By age
12, fine motor coordination and accuracy approximate
adult behavior.34
BIMANUAL FUNCTION
Bimanual Reach to Grasp
Most daily tasks require some level of bimanual func-
tion where demands are required of both hands. This
adds a level of complexity on both a functional and
neural control level for regulation of timing and coordi-
nation between the two hands. Depending on the task
requirements, bimanual movements can be symmetri-
cal as in throwing, lifting, pushing, and pulling, or
asymmetrical movements where either one hand acts
to stabilize and the other manipulates, or both hands
function independently in a differentiated role as in
typing on a keyboard or playing a musical instrument.51
Bimanual function is controlled by interactions of
many neural structures, and the development of
bimanual coordination is related to the maturation
and myelination of the corpus callosum that connects
the two hemispheres.52 In early infancy, these connec-
tions are incomplete and continue to develop over
several years. As the nervous system develops, the inter-
manual control improves with the ability to regulate the
timing and spatial coordination of both hands for com-
plex tasks.52 Additionally, bimanual tasks require
mature postural and trunk control to allow for both
hands to function independently.
Bilateral fingering precedes bilateral grasp and is evident
in 4e5 month olds. Between the ages of 6e8 months,
objects are approached most frequently with both hands.
During this stage, both simultaneous and sequential
bilateral reach-to-grasp patterns emerge9,53 (Fig. 2.8).
At 7 months, infants appear to use both a unilateral
and bilateral approach depending on the size and posi-
tion of the object, and the amount of external support
provided. They tend to use a bilateral approach to grasp
large objects and a unilateral approach for small ob-
jects. In an unsupported environment, they may utilize
a unilateral strategy while using the other arm for stabi-
lization. By 8e11 months, improved motor and
postural control allows for increased discriminatory
ability of unimanual and bimanual strategies as they
are now unconstrained by factors that predispose a spe-
cific strategy.12,54 However, a return to a predominant
bilateral reach-to-grasp strategy emerges when postural
stability is challenged as seen with early walking.55
Bimanual Manipulation
Transfer from hand to hand is evident as early as 4e
6 months and becomes more consistent and fluid by 7e
8 months once the infant masters radial grasp.56 This is
the age when infants will begin to play with two objects
simultaneously by banging them together, waving them
in the air, or banging on a surface57 (Fig. 2.9).

Bimanual Reaching
Bilateral asymmetric and symmetric arm movements
are present from early infancy, first as spontaneous gen-
eral movements. Although most spontaneous arm
movements appear to be simultaneous and symmetri-
cal, alternating arm movements are also typically pre-
sent from birth to 2 months when elicited by reflexes
and tactile input. Voluntary bimanual reach first
emerges at 2 months as gross symmetrical movements
of both hands reaching for objects, although swiping
movements tend to be predominantly unilateral.9 Sym-
metrical bilateral reaching continues to evolve and pre-
dominate by 4 months as trunk stability increases.
There is also an increased drive toward symmetrical
movements to midline. By 5 months, the bilateral
approach for reach to grasp becomes more consistent
as both hands move toward the object simultaneously.
At this age, in spite of the bilateral reach, the grasp re- FIG. 2.8 Symmetrical bilateral grasp of single object. (Photo
mains unilateral.1,6,9 credit: Naomi Polatsek)
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The Project Gutenberg eBook of Palaavien
parissa
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Title: Palaavien parissa

Author: Marja Salmela

Release date: December 8, 2023 [eBook #72358]

Language: Finnish

Original publication: Porvoo: WSOY, 1915

Credits: Juhani Kärkkäinen and Tapio Riikonen

*** START OF THE PROJECT GUTENBERG EBOOK PALAAVIEN

PARISSA ***
PALAAVIEN PARISSA

Kirj.

Marja Salmela

Porvoossa, Werner Söderström Osakeyhtiö, 1917.

SISÄLLYS:

"Kunnes kuolema meidät eroittaa"

Ilja Riffkin
Paul Pavlovitsin kasvot
Vierustoverit
Suuri todistajain joukko
(S.H.)

He palasivat. Sodan kelmeät, ruhjotut ja vankeutensa näännyttämät

uhrit palasivat kotiin.

Pohjolan kuulakan kirkas ilma ympäröi heitä. Riisuutumiseensa

alistunut luonto heille hymyili. Liput liehuivat, torvet raikuivat heidän
kunniakseen. Ystävälliset kädet ojentautuivat heitä palvelemaan.
Mutta heidän katseensa puhui kärsimyksistä, jotka olivat siirtäneet
heidät etäälle kaikesta mikä heitä ympäröi.

Paljon kokeneina, paljon kadottaneina, sodan kauhut syvälle

syöpyneinä sieluun he kaikki palasivat. Mutta kullakin heistä oli oma
tarinansa, niin raskas ja kipeä, ettei sitä jaksanut yksin kantaa, ei
toiselle uskoa. Lyhyt pieni sana, viittaus vain, — alla piili järkyttävä
todellisuus.

Tällaisina he palasivat elämään, joka ei koskaan enään voinut

asettua entiselleen.
"KUNNES KUOLEMA MEIDÄT
EROITTAA"

I.

Istuimme yöjunassa vastakkain. Matkustajia oli ihmeen vuoksi siksi

vähän, että hyvin olisimme voineet paneutua pitkäksemme, mutta
maattuamme jonkun aikaa silmää ummistamatta, olimme kumpikin
asettuneet istumaan.

Jo maatessani olin tuon tuostakin salaa koettanut tarkastaa

toveriani. Hän oli ollut vaunussa minun noustessani siihen ja
huomioni oli kohta kiintynyt häneen sekä hänen ystävällisen
käytöksensä, että hänessä silmäänpistävän väsymyksen johdosta.

Toverini oli erittäin miellyttävä, oikeinpa kaunis nainen. Hänen

piirteensä olivat hienot ja tumma, hiukan aaltoileva tukka oli upean
runsasta. Erityisesti kiintyi kuitenkin huomioni hänen hienoon,
läpikuultavan valkoiseen ihoonsa, joka antoi koko hänen
ulkomuodolleen erehdyttävän germaanilaisen leiman.

Monista, tuohon hienoon hipiään uurtautuneista rypyistä päätin,

että toverini, joko oli kärsinyt paljon, tai oli vanhempi kuin miksi häntä
aluksi luulin. Muutama hänen tummasta tukastaan esiin pilkistävä,
hopeankarvainen hiussuortuva todisti myöskin samaa.

Asetellessani tavaroitani junaverkkoon, olimme vaihtaneet

muutamia sanoja. Myöhemmin sattui eräs ruusuistani putoamaan
lattialle, (Eräs ystäväni oli osaaottavassa rakkaudessaan tuonut
minulle kolme tummanpunaista ruusua, joiden merkityksen kohta
ymmärsin.) Kumarruimme yhtaikaa nostamaan ruusuani ja
jouduimme siten katsomaan toisiamme aivan silmästä silmään.
Silloin näin, että hän oli itkenyt, ja että katse oli kärsimyksestä
väsynyt.

Ajattelin rakkaita, reippaita poikiani, ja päätin mielessäni että

toverini oli yksi niistä lukemattomista, joiden sisin viime-aikaisten
tapahtumien kautta oli verille raastettu.

Olisin mielelläni sanonut jotain, mutta lämmin osanotto, joka avaa

monen suun, sulkee sen usein minulta. Niin nytkin.

Olimme istuneet kotvan aikaa kumpikin ajatuksiimme painuneena,

kun toverini yhtäkkiä, junan seisoessa jollain asemalla, katkaisi
äänettömyyden.

— Mikä kauhea yö! Kuuletteko tuulen vaikerrusta?

Olin sitä jo kauvan tarkannut. Olin kysynyt itseltäni oliko se vain

kuvittelua, heijastus omista tunteistani, vai säestikö luonto todella
ihmissydänten tuskaa. Taivaskin tuntui minusta kätkeytyneen niin
etäälle, että sen ainoa ilmaus olemassa olostaan oli virtanaan valuva
sade. — Taivaskin itki maan lasten kanssa.

Toverini tarttui kohta ja tulisesti sanoihini.

 — Mutta maa ei itke, se riehuu. Kuuletteko? Ettekö jo iltapäivällä
huomanneet miten armottomasti myrsky ahdisti nuorta nousemassa
olevaa metsää. Se pani vanhat, jäykkäniskaiset puutkin taipumaan.
Ja siellä, missä ei metsä ollut suojaamassa, pieksi se maata kuin
raipaniskut alastonta selkää. — Kuulkaa! Ilma on täynnä
temmellystä.

En kohta vastannut. En ollut selvillä siitä, mistä jatkaa. Sitä paitse

tahdoin jättää johdon toverini käsiin, nähdäkseni, mihin suuntaan
hänen ajatuksensa kääntyisivät.

— Onko teillä ketään rintamassa, kysäisi hän äkkiä.

— Kolme kukoistavaa poikaa. Minä olen leski.

Matkatoverini kasvojenilme muuttui äkkiä. Sisar ei olisi voinut

osoittaa sydämmellisempää osanottoa kuin hänen katseensa.

— Kolme, — kolme! — Hän huojuttelihe edes takaisin.

— Kolme, vahvistin katsoen ruusuihin. Hän ymmärsi heti ja se

vaikutti odottamattoman voimakkaasti häneen. Hän painoi nenäliinan
silmilleen ja istui pitkän aikaa siten, luullakseni taistellen itkua
vastaan, — Tummanpunaisilla ruusuilla on erityinen merkityksensä
miehelleni ja minulle, sanoi hän selittävästi ottaessaan nenäliinan
silmiltään, — Siinäkin kukkaisvihossa, jonka hääpäivänämme sain,
oli valkoisten ruusujen joukoissa vihon toisella kulmalla kimppu
hehkuvan punaisia.

— Miehenne on rintamassa, arvelin varmana siitä, että selitykseni

hänen mielenliikutukseensa oli yhtä oikea kuin luonnollinen. Mutta
minä erehdyin.
 — Ei,— ei vielä ainakaan — — Ja sittekin — — Minä olen jo
maistamassa sitä tuskaa, — (hän katsoi minuun kuin vaa'alla
punnitakseen tyyneyttäni) johon te jo ehkä olette tottuneet, lisäsi hän
hieman epäröiden.

Tottunut? Saattoiko, senlaiseen tottua. Siihen alistuttiin: tyynesti,

kapinoiden tai murtuen. Senlaiseen ei kukaan tottunut, ei äiti
ainakaan. Sanoin sen suoraan.

Mainitessani äitiyttä ja äidin tunteita, näin hänen katseessaan

terävän, miltei loukkautuneen välähdyksen, mutta muuten näkyivät
sanani herättäneen vastakaikua hänessä. Hän tarttui kaksin käsin
minun käteeni ja puhkesi puhumaan kai enemmän oman mielensä
kevennykseksi kuin uskoutuakseen minulle.

— Miten hyvää tekeekään kuulla tuollaista! Löytyy oikeastaan niin

vähän ihmisiä, jotka osaavat rakastaa, todella rakastaa. Mutta se,
joka sitä osaa, hän on samalla avannut sydämensä elämän
suurimmalle ilolle ja sen suurimmalle tuskalle. Ne käyvät usein
käsityksin. Olen kokenut sitä ennen ja nyt taaskin, — Katsokaa, —
hän alensi äänensä kuiskaukseksi, — mieheni on paraikaa
Pietarissa, Hän on siinä asemassa, että oikeastaan voisimme olla
aivan rauhalliset, mutta tämä kauhea sota on kuin myrsky, joka ei
säästä suojatuintakaan lahden poukamaa. — Me saimme viime
viikolla huolestuttavia uutisia. Boris matkusti silloin heti Pietariin. Hän
lupasi minun tähteni koettaa kaiken voitavansa. Ja minä tiedän että
hän koettaa. Vaan en sittekään saanut rauhaa kotona.

Lausuin arveluni, että asiain näin ollen oli ymmärtämätöntä surra

ennen aikojaan. Olihan monta mahdollisuutta.
 Hän käsitti minua väärin. Näin sen hänen katseensa tulisesta
leimauksesta ja tavasta, jolla hän kohotti päätänsä.

— Boris ei koskaan, ei koskaan alennu ostamaan itselleen

etuuksia! Tietäisitte minkälainen hän on. Oikeus merkitsee hänelle
enemmän kuin mikään muu maailmassa. Oikeus merkitsee
enemmän kuin elämä ja onni!

Hänen äänensä värähti ylpeätä, ihanoivaa rakkautta.

— Oh, jatkoi hän, ja sanat tulivat kuin ryöppynä, — kukaan ei

oikeastaan tunne häntä. Hän näyttää usein ympäristölleen karun
pinnan. Monet arvelevat, ettei hänessä ole mitään, ei kerrassaan
mitään erikoista. Mutta minä tunnen ja tiedän. — Olisinko minä
muuten valinnut juuri hänet niiden monien joukosta, —

Lause katkesi kesken. Tuntui siltä kuin hän olisi hämmästynyt

omaa avomielisyyttään. Mutta vaikka sanat olivatkin aivan kuin
vahingossa luiskahtaneet hänen huuliltaan, en voinut olla tarttumatta
niihin. Olin alunpitäen arvellut, että toverini oli voimakas,
eheäpiirteinen persoonallisuus. Ja koko hänen esiintymisensä oli
vahvistanut käsitystäni. Sentähden minä hyvilläni kaikesta mikä
houkutteli häntä puhumaan, tartuin äsken katkenneen puheen
päähän. Sanoin hieman hymyillen hyvinkin uskovani, että hänellä
tyttönä oli ollut paljon pyytäjiä. Olihan hän kaunis vieläkin.

Kohteliaisuuteni näkyi ilahduttavan häntä, vaikka hän puolittain

torjui sen. — Mitä vielä, minähän jo olen vanha. — Mutta hän
naurahti samassa, ja minusta tuntui siltä kuin hän tietämättään olisi
nauttinut siitä, että ajatukset hetkeksi suuntautuivat pois hänen
sisintään raatelevasta surusta. Ehkäpä hän juuri siitä syystä puoleksi
naurahtaen jatkoi: Eihän sitä oikeastaan tällaisesta jutella, mutta
moni kohta on yksinomaan koomillisena jäänyt mieleeni. Olin
ainoastaan viidentoistavuotias tyttöletukka kun leikki alkoi. Herra oli
muuten puolihassu. Hän tuli kasvatti-isäni kotiin ja aikoi aivan
väkipakolla sekä suudella että kihlautua. Me juoksimme ruokasalin
pöydän ympärillä, minä pakoon, hän perässä. Mutta luuletteko että
minä siihen aikaan ymmärsin pitää sitä minään, en pahana enkä
hyvänä. Olipahan vain kuin hippasilla juoksua.

Hän nauroi hetken itse makeasti. Mutta sitte hänen kasvojensa

ilme äkkiä muuttui. — Vaan siihenpä lapsuuden huolettomat päivät
loppuivatkin, — tai oikeammin kohta sen jälkeen, — Hän huokasi
raskaasti ja hänen valkealle otsalleen muodostui kaksi syvää
laskosta. Ne syntyivät syvinä ja terävinä ja ilmestyivät niin
kotiutuneesti hänen otsalleen, etten voinut olla kiinnittämättä
huomiota niihin. Toverini oli nainen, joka oli kärsinyt paljon. Siitä olin
vakuutettu.

Osanottoni esti minua hetkeksi jatkamasta puhelua. Mutta haluni

lähemmin tutustua matkatoveriini oli siksi suuri, etten voinut jättää
keskustelua siihen. Olin sitä paitsi vakuutettu siitä, että hän
ennenkaikkea kaipasi henkilöä, jolle hän saattoi avautua. Ja vento
vieras oli tällä kertaa ehkä sopivampikin kuin joku läheinen, etenkin
vieras, jonka omat kokemukset tavallaan tekivät hänet läheistä
läheisemmäksi. Jatkoksi toverini viime sanoihin lausuin siksi sen
arvelun, että vasta suuri ja todellinen rakkaus oli kypsyttänyt hänet
naiseksi. Lapsuusaika ja lapsenmieli jäivät häneltä hänen
tutustuessaan tulevaan mieheensä.

Odotin että huomautukseni johdosta toverini kasvot äkkiä

kirkastuisivat ja hän innostuisi kertomaan tutustumisestaan
mieheensä. Mutta taaskin erehdyin. Poimuihin painunut otsa pysyi
yhä laskoksissaan, ja suun ympärillä väreili haikea piirre.

— Ei, sanoi hän hitaasti ajatuksiinsa painuen, — pikemmin voin

sanoa että se ilta, joka teki lapsesta naisen, samalla kypsytti minut
rakkaudelleni. — Nähkääs, sille, joka ei kasva vanhempiensa
kodissa, ei ole oikeata huoletonta lapsuutta, — tai jos onkin,
tapahtuu kypsyminen äkkiä ja usein katkeralla tavalla. Näin kävi
minun. Olin aivan pieni isäni kuollessa. Äitini, joka oli vanhaa,
arvossapidettyä sukua, heikko terveydeltään, sekä aikansa lapsena
sidottu toimimaan yksinomaan kodin piirissä, lupautui hoitamaan
erään leskeksijääneen serkun taloutta, Hänen asemansa muodostui
siksi, miksi naisten yleensä tällaisissa tapauksissa. Hän oli
armoleivän syöjä, jonka asema oli tavallistakin vaikeampi siksi, että
hänellä päälle päätteeksi oli lapsi. Itse en pitkään aikaan ymmärtänyt
asemaani, äitini asemaa vielä vähemmän. Mutta sitte tuli
herääminen. Ja niin katkera kuin se olikin, saan ehkä kiittää
kypsymistäni kärsimyksen ymmärtämiseen siitä, että katseeni
monien joukossa kiintyi juuri Borikseen.

Hän kavahti äkkiä pystyyn ja tarttui molempiin käsiini. Minä tunsin

otteesta miten hän vapisi, — Te ette voi aavistaa mitä hän on
minulle, kuiskasi hän ääni liikutuksesta värähdellen. — Nyt tunnen
selvemmin kuin koskaan, miten kaikki minussa, koko elämäni on
tarkoittanut ja yhä tarkoittaa häntä, yksin häntä. Hänelle olen elänyt
ja elän — kaikesta huolimatta — ilolla. Ilman häntä? — Ei, ei! —
Minä en voi sitä ajatellakaan. Se on mahdottomuus. Minä en voi, —
en tahdo.

— Sadat, tuhannet ja miljoonat ovat ehkä ajatelleet samoin, ja

sittekin — — Te tiedätte itse — — Sanoin sen niin pehmeän
säälivästi kuin mahdollista, vaikka äidinsydämeni värisi tuskasta.

Hänen katseensa painui. — Olen sanonut sitä itselleni. Olen

kysynyt miksi juuri me säästyisimme. — Ja sittekin. Ehkä
ymmärtäisitte minua, jos tietäisitte minkälaista elämämme on ollut.
Hän oli hyvin sairas kun menimme naimisiin. Meillä ei ollut varoja, ei
omaisia. Me omistimme vain toisemme. Hän makasi vuoteessa.
Minä tein työtä yöt päivät ja siinä ohessa hoidin häntä. —
Vuosikausia olen kamppaillut saadakseni pitää hänet. Ja nyt, kun
hän on terve ja kukoistava, kun olen saavuttanut voiton elämäni
suuressa taistelussa, nytkö minun olisi luovuttava hänestä? —
Luovuttava? Niin, miksei, jos hänen onnensa olisi kysymyksessä.
Silloin minä jaksaisin. Mutta luovuttaa hänet, sodan kauhuihin — —

Hän painui hervottomasti takaisin paikalleen ja rajut nyyhkytykset

vapisuttivat koko hänen ruumistaan.

Minä nousin, tartuin hänen päähänsä ja painoin sen rintaani

vastaan. Sykkihän siinä äidin sydän. Ja olinhan itse antanut
rakkaimpani juuri sodan kauhuihin.

Luulen, että hän käteni kosketuksessa tunsi mielialani, sillä hän

tarttui toiseen käsistäni ja painoi sen kiihkeästi huulilleen. Puhua hän
ei voinut.

En tiedä, miten kauan olimme siinä, hän itkien kokon

lyyhistyneenä paikallaan, minä vieressä seisomassa, painaen hänen
päätään rintaani vasten ja silloin tällöin hyväilevästi puristaen häntä
lähemmäksi itseäni. Ajan kulku tuntuu tuollaisina hetkinä
pysähtyneen. Sisäinen näkemyksemme on niin teroittunut, sisäinen
korvamme niin herkkä, että kaikki ulkonainen on kuin lakannut
olemasta.
 Sinä hetkenä jaksoin melkein tuntea kiitollisuutta siitä, että omasta
kohdastani olin tullut pakoitetuksi uhraamaan niin paljon. Tunsin
mikä luja ja läheinen yhdysside se oli minun ja kärsivien
lähimmäisteni välillä. Tunsin, etten ollut vain äiti, jolta kaikki mikä on
hänelle kalleinta oli viety, olin osa kärsivässä kokonaisuudessa. Ja
tuska, jota tunsin ei ollut vain minun, se oli kaikkien. Mutta ymmärsin
samalla, että se taudin kipeänä ilmaisuna nostattaisi meidät
taisteluun itse tautia ja sen alkujuurta vastaan.

— Lapsi, sanoin niin hiljaa ja hyväilevästi kuin taisin, ja ääneni

värähti, sillä sitä nimitystä en ollut käyttänyt sen jälkeen kuin
nuorimpani läksi rintamaan. — Lapsi, teidän täytyy panna levolle.

Tunsin kuinka hän vapisi rintaani vasten. Ajattelin taaskin sitä, että
hän oli vain yksi lukemattomien joukosta. Mutta se, että näin hänet
osana kärsivää kokonaisuutta, ei suinkaan siirtänyt häntä
etäämmälle minusta. Päinvastoin. Suuri suru opettaa meitä suuresti
rakastamaan ei ainoastaan muutamia, vaan kaikkia. Sinä on sen
siunaus.

— Teidän täytyy välttämättä panna maata, sanoin nyt miltei

käskevästi.
— Te tarvitsette voimia hänen tähtensä.

Enempää ei tarvittu. Hän nousi kuin kuuliainen lapsi ja rupesi

purkamaan tavaroitaan. Kun suojahuivit ja päänalunen olivat
paikoillaan, asettui hän pitkäkseen ja minä peitin hänet. Sitte
paneuduin itsekin maata.

Makasimme taas vastatusten kuten pari tuntia aikaisemmin, mutta

miten paljon olikaan mahtunut noihin tunteihin! Ne olivat tehneet
meidät, ventovieraat läheisiksi toisillemme ja ne olivat kai ainakin
jonkun verran syventäneet ymmärtämystämme muitakin kärsiviä
kohtaan.

Katsoin matkatoveriini ja näin, että hän valvoi. Käännyin selin

häneen toivossa että hänen ehkä siten olisi helpompi nukkua. Itse en
voinut unta ajatellakaan. Nyt, kun en enää toisen tähden eläytynyt
hänen kokemuksiinsa, olin kokonaan poikieni luona. Makuupaikkani
pehmeys pakoitti minua ajattelemaan heidän kylmää vuodettaan
juoksuhaudoissa. Lämpö junavaunussa muistutti minulle, että
kamala surmantuli ehkä oli heille ainoa valon ja lämmön liesi.

Ymmärrän hyvin äitiä, jonka selkään ilmestyi jälkiä

raipparangaistuksesta silloin, kun hänen poikaansa tuhansien
peninkulmien päässä piestiin. Lapsi pysyy aina — olipa hän
ulkonaisesti kuinka etäällä tahansa — osana äidistään, vieläpä
osana, joka äidinsydämelle välittää kaikkein syvimmät ja herkimmät
tuntemukset.

Heräsin omista ajatuksistani kuullessani vierustoverini liikahtavan.

Käännyin häneen päin ja näin hänen makaavan silmät selkosen
selällään,
katse lasittuneena, keskitettyä tuskaa ilmaisevana tähdättynä
kattoon.
Hän ei nähtävästi ollut nukkunut sen enempää kuin minäkään.

Koetin löytää sopivaa puheen alkua, mieluimmiten sellaista, joka

veisi hänen ajatuksensa pois häntä kalvavasta huolesta, ja joka
kuitenkin olisi siksi lähellä sitä, että se pystyisi kiinnittämään hänen
mieltään. Pääsinkin ilokseni käsiksi aikaisemmin katkenneeseen
puheenpäähän.
 — Koska emme kuitenkaan nuku, voimme yhtä hyvin keskustella
kuin maata vaiti, huomautin alotteeksi.

Matkakumppalini vavahti kuin odottamatonta kosketusta

säikähtävä. Hänen ajatuksensa olivat nähtävästi olleet etäällä.

— Niin puhella, toisti hän hitaasti, tietämättä itsekään mitä sanoi.

Mutta minä en hellittänyt. — Te pidätte minua kenties

tunkeilevana, mutta minusta me surun sitein olemme tulleet niin
lähelle toisiamme että meillä jo on jonkinlaisia oikeuksia. Sentähden
pyytäisin teiltä jatkoa erääseen kohtaan, josta itse aikaisemmin
aloitte puhua.

Hän katsoi kysyvästi minuun. Näin että hänen ajatuksensa

ainoastaan vähitellen ja vaivalla kääntyivät pois tavallisesta
uomastaan.

— Niin, jatkoin itsepintaisen päättävästi. — Te mainitsitte

aikaisemmin pikku tapahtumasta, joka lapsesta äkkiä teki kypsyneen
aika-ihmisen, Mutta tapahtuma jäi teiltä kertomatta sen kautta että
ajatuksenne silloin luiskahtivat toiseen uomaan.

— Niin todellakin! — Hän näytti havahtuvan. — Joku teidän

kysymyksistänne kai herätti eloon tuon muiston. Se koski itsessään
hyvin mitätöntä tapahtumaa. — — Hän näytti epäröivän, — Mutta se
jätti pysyväisen jäljen elämääni, lisäsi hän ja huokasi.

Huomautin, etten suinkaan tahtonut kuulla mitään, jos puhuminen

rasitti häntä tai jos se muuten herätti surullisia muistoja. Mutta silloin
hän vilkastui. Hän tahtoi mielellään kertoa. Se päinvastoin oli
helpoitukseksi.
 Hän palasi kertomukseen ensimäisestä kosijastaan. — Tiedättekö,
niin hullulta kuin se kuluukin, oli kasvatti-isäni hyvillään
tapahtumasta. Häntä tyydytti nähdä minussa haluttua tavaraa. Mutta
samalla hän oli hyvillään siitä, etten ollut valmis kiittämään ja
myöntymään ensi tarjoukseen. Puhuessaan asiasta hän viskasi
silmilleni sanan, jonka vaikutusta hän ei itse edeltäkäsin arvannut.
Hän mainitsi jotain siitä, että haluttu tavara helposti löytää ottajansa
eikä jää toisten elätettäväksi.

— Ne sanat herättivät minut. En tahtonut syödä armoleipää.

Tahdoin itse ansaita. — Näen itseni vieläkin, kuudentoista maissa
olevana tyttösenä, paksu palmikko niskassa seisomassa kasvatti-
isäni huoneessa.

— Setä, sanomalehdissä olleen ilmoituksen perustuksella olen

aikonut hakea erästä ääneenlukijan paikkaa. Minä tahdon ansaita.

Vanhus nahkaisessa nojatuolissaan rähähti nauruun, kumartui

hieman eteenpäin ja katsoi yli kakkulainsa minuun. Katse pisti kuin
naskali. Terävä, aatelinen kotkannenä näytti entistäänkin
terävämmältä, — Sinä unohdat mitä alkujuurta sinä olet. Meidän
sukumme jäsenet eivät ansaitse leipänsä, ei ainakaan sillä tavalla.

— Silloin haen toista työtä. — Siinä oli kova kovaa vastaan,

— Ja otat, jos minä siihen suostun. — Katse käski minut ulos, ja

minä menin, — menin äidin huoneeseen ja itkin siellä sekä
tappiotani, asemani riippuvaisuutta että ennen kaikkea pimeältä
näyttävää tulevaisuuttani. Olin hillittömässä surussani itsekäs ja
ajattelematon kuin nuori ainakin. En tullut ajatelleeksikaan, että
sanani yhtenään sattuivat kuin piiskan sivallus äitiin, ja että hillitön
suruni hänelle oli veitsen terän upottamista yhä syvemmälle kipeään
haavaan, — — Kun mielenkuohuni oli vähän asettunut, tunsin äidin
pehmeän, pienen käden päälaellani. Se käsi oli pehmeätä silkkiäkin
pehmoisempi, ja sen hyväilyt sekä lohduttivat että hallitsivat minua,
— nyt kuten usein ennenkin. — Hänen siinä minua hyväillessään,
tulin kohottaneeksi katseeni häneen, ja silloin — näin mitä en
koskaan ennen ollut nähnyt: näin miten syvästi hän itse kärsi.

Toverini kertomus katkesi siihen. Hän painui muistoihinsa enkä

tahtonut häiritä häntä. Mutta hetken kuluttua hän itsestään jatkoi:

— Missä määrin äitini varhaisemmat kokemukset olivat syynä

siihen surumielisyyteen, jonka huomasin pysyväisesti asustavan
hänen olemuksensa pohjalla, siitä en koskaan päässyt kokonaan
perille. Mutta sen ymmärsin, että hän oli kokenut paljon raskasta.
Hänen ainoa poikansa, minua viisitoista vuotta vanhempi veljeni, oli
osaksi hurjan elämänsä, osaksi kasvatti-isäni ankaruuden johdosta
nuorena lähtenyt Amerikkaan ja sille tielle hävinnyt. Veliraukallani oli
kai peruja isäni suvusta, jonka miehiset jäsenet olivat tunnetut sekä
pelikiihkostaan että suurellisesta yli-varojensa-elämisestä. Monet
kodin naisjäsenistä olivat sekä tavalla että toisella saaneet kuitata
heidän laskujaan.

Toverini huokasi syvään, mutta jatkoi taas.

— Kun, äiti sinä iltana katsoi minuun, kysyi hänen katseensa:

Vieläkö sinäkin? Eikö maljani jo ole täysi. — — Ymmärrätte että sinä
iltana kypsyin täysi-ikäiseksi. En ollut lapsi enään. Olin nainen. Ja
riippuvassa asemassa olevan naisen tavoin keinottelin siitä alkaen,
päästäkseni pyyteitteni perille. Opin iloitsemaan siitä, että olin kaunis
ja että nuorekkaalla naiskauneudella oli vaikutuksensa vanhaan
ukonrähjäänkin. Opin käyttämään näpperyyttä, sanansutkauksia ja
leikinlaskua aseinani. Sanalla sanoen: lapsellinen välittömyys vaihtui
valtioviisaan naisen harkittuun menettelyyn. Mutta enemmän kuin
mitään muuta opin sittekin suhteessani äitiin. Siitä illasta asti oli hän
elämäni keskipiste. Hänelle, hänen hyväkseen elin. Ja siitä
maaperästä nousi myöskin vastaisuudessa rakkauteni Borikseen.

Muistot olivat kokonaan temmanneet toverini muassaan. Luulen

ettei hän ollut tietoinen milloin hän puhui, milloin hän painui
ajatuksiinsa. Kaikkein vähimmin hän muisti sitä, että hänellä oli
kuulija.

— En tiedä, jatkoi hän kuin itsekseen, olisinko minä toisissa

oloissa kasvaneena kiintynyt Borikseen. Joskus ajattelen, että me
joka tapauksessa olisimme löytäneet toinen toisemme. Mehän
olemme luodut toisiamme varten. Toiste taas tuntuu siltä, kuin juuri
ahtaat olot ja rakkauteni äitiin olisivat kehittäneet minussa sitä, mikä
kohta ensi näkemältä kiinnitti minut Borikseen.

— Te ette koskaan ole rakastaneet toista miestä?

— En koskaan. — Lämmin ilon kajastus kirkasti hänen väsyneet

kasvonsa, ja hän kohoutui äkkiä istumaan.

— Se oli oikeastaan omituinen pieni asianhaara, joka tutustutti

meidät toisiimme. Eräs lapsuusaikani leikkitovereista oli oltuaan
useampia vuosia ulkomailla kasvatettavana palannut kotiin. Hänen
veljensä kuului ihailijoitteni joukkoon, ja kun pidettiin kutsut
täysikasvuisena kotiinsaapuneen kunniaksi, kutsuttiin minutkin sinne.
Boris oli myöskin kutsuttujen joukossa, ja me kiinnyimme kohta,
joskin hyvin eri tavalla toisiimme.

— Te olette ehkä miehenne ainoa rakkaus, kuten hän teidän,

rohkenin tiedustella.