The serious full-length forearm injury - a case report and literature review.

BACKGROUND: Among upper limb injuries, carpal bone fractures and dislocation, Essex-Lopresti injury, and the terrible triad injury of the elbow are serious and relatively rare injuries. These injuries require surgical intervention. The surgical method is difficult, and the treatment effect is poor. These injuries have not been described in the same limb in the literature. CASE PRESENTATION: A 21-year-old male patient fell from a height in our institution and sustained multiple injuries, including carpal bone fracture-dislocation, Essex-Lopresti injury, and the terrible triad injury of the elbow of his right upper limb. After 2 surgeries and rehabilitation, he returned to work. We reviewed available reviews and related literature on serious upper-limb damage. CONCLUSIONS: Full-length forearm injury is very rarely encountered, and the management of such fractures is difficult. Radial head replacement with a metal prosthesis, reconstructed the IOM with Tightrope, and fixed the DRUJ with a K-wire pin is appropriate treatment.

Quality of life for up to 18 months after low-energy hip, vertebral, and distal forearm fractures-results from the ICUROS.

This study used data from the International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) to estimate the quality of life (QoL) impact of fracture. Hip, vertebral, and distal forearm fractures incur substantial QoL losses. Hip and vertebral fracture results in markedly impaired QoL for at least 18 months. INTRODUCTION: The International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) is a multinational observational study that aims to describe costs and quality of life (QoL) consequences of osteoporotic fractures. To date, 11 countries have participated in the study: Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, the UK, and the USA. The objective of this paper is to describe the QoL impact of hip, vertebral, and distal forearm fracture. METHODS: Data were collected at four time-points for five QoL point estimates: within 2 weeks after fracture (including pre-fracture recall) and at 4, 12, and 18 months after fracture. Quality of life was measured as health state utility values (HSUVs) derived from the EQ-5D-3L. Complete case analysis was conducted as the base case with available case and multiple imputation performed as sensitivity analyses. Multivariate analysis was performed to explore predictors of QoL impact of fracture. RESULTS: Among 5456 patients enrolled using convenience sampling, 3021 patients were eligible for the base case analysis (1415 hip, 1047 distal forearm, and 559 vertebral fractures). The mean (SD) difference between HSUV before and after fracture for hip, vertebral, and distal forearm fracture was estimated at 0.89 (0.40), 0.67 (0.45), and 0.48 (0.34), respectively (p < 0.001 for all fracture types). Eighteen months after fracture, mean HSUVs were lower than before the fracture in patients with hip fracture (0.66 vs. 0.77 p < 0.001) and vertebral fracture (0.70 vs. 0.83 p < 0.001). Hospitalization and higher recalled pre-fracture QoL were associated with increased QoL impact for all fracture types. CONCLUSIONS: Hip, vertebral, and distal forearm fractures incur substantial loss in QoL and for patients with hip or vertebral fracture, QoL is markedly impaired for at least 18 months.

The effectiveness of exercise for the management of musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.

OBJECTIVE: The purpose of this systematic review was to evaluate the effectiveness of exercise compared to other interventions, placebo/sham intervention, or no intervention in improving self-rated recovery, functional recovery, clinical, and/or administrative outcomes in individuals with musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand. METHODS: We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers independently screened studies for relevance and assessed the risk of bias using the Scottish Intercollegiate Guidelines Network criteria. We synthesized the evidence using the best evidence synthesis methodology. RESULTS: We identified 5 studies with a low risk of bias. Our review suggests that, for patients with persistent lateral epicondylitis, (1) adding concentric or eccentric strengthening exercises to home stretching exercises provides no additional benefits; (2) a home program of either eccentric or concentric strengthening exercises leads to similar outcomes; (3) home wrist extensor strengthening exercises lead to greater short-term improvements in pain reduction compared to "wait and see"; and (4) clinic-based, supervised exercise may be more beneficial than home exercises with minimal improvements in pain and function. For hand pain of variable duration, supervised progressive strength training added to advice to continue normal physical activity provides no additional benefits. CONCLUSION: The relative effectiveness of stretching vs strengthening for the wrist extensors remains unknown for the management of persistent lateral epicondylitis. The current evidence shows that the addition of supervised progressive strength training does not provide further benefits over advice to continue normal physical activity for hand pain of variable duration.

Rehabilitation of a patient following hand replantation after near-complete distal forearm amputation.

STUDY DESIGN: Case report. INTRODUCTION: Reports of comprehensive rehabilitation following hand replantation are limited. PURPOSE OF THE STUDY: To describe hand therapy of a patient following hand replantation. METHODS: Right hand dominant 55 year-old male assessed 9 days following left hand replantation to treat distal forearm amputation. Patient presented with dorsal blocking orthotic. Initial status: AROM digits and thumb 0-20° extension, 0-40° flexion; absent light touch sensation; 0-1/5 hand strength. Patient underwent 70 hand therapy sessions over 13 months focusing on A/PROM, therapeutic exercise, neuromuscular re-education, and modalities to address functional limitations. RESULTS: Hand therapy discharge status: AROM digits and thumb form composite fist, thumb opposition to digit 3, light touch sensation (monofilament) 4.03 (digits 2, 4) and 4.17 (digits 1, 3, 5); 3- to 4-/5 hand strength. DISCUSSION: Hand therapy allowed for near complete functional return of the hand following replantation. CONCLUSION: Comprehensive Hand therapy aided restoration of adequate sensation and strength for functional use of the replanted hand. LEVEL OF EVIDENCE: 4.

Repair of complete nerve lacerations at the forearm: an outcome study using Rosén-Lundborg protocol.

A comparison of outcomes based on a scoring system for assessments, described by Rosén and Lundborg, after sharp complete laceration of median and/or ulnar nerves at various levels in the forearm was carried out. There were 66 males (90.4%) and 7 females (9.6%), with a mean age of 31 years (range: 14-62 years). The patients were categorized into three groups according to the type of nerve injury. The median nerve was injured in 25 cases (group M, 34.3%), the ulnar in 27 (group U, 36.9%), and both the nerves in 21 (group MU, 28.8%). The demographic data of the patients and the mechanism of injury were recorded. We also examined the employment status at the time of the injury and we estimated the percentage of patients who returned to their work after trauma. In all cases, a primary epineural repair was performed. Concomitant injuries were repaired in the same setting. The mean period of time between injury and surgery was 5.3 hours (range: 2-120 hours). A rehabilitation protocol and a reeducation program were followed in all cases. The mean follow-up was 3 years (range: 2-6 years), with more distal injuries having a shorter follow-up period. The total score was 2.71 in group M (range: 0.79-2.99) and 2.63 in group U (range: 0.63-3), with no significant differences observed. There was a significant difference between these two groups and group MU (total score 2.03, range: 0.49-2.76, P = 0.02). Up to the last follow-up, 61 patients (83.5%) had returned to their previous work. The Rosén-Lundborg model can be a useful and simple tool for the evaluation of the functional outcome after nerve injury and repair temporally reflecting the processes of regeneration and reinnervation.

[Diametaphyseal forearm fracture in childhood. Pitfalls and recommendations for treatment]. / Die diametaphysäre Unterarmfraktur im Kindesalter. Pitfalls und Empfehlungen in der Behandlung.

The optimal treatment for fractures in the diametaphyseal transition zone of the forearm is still a matter of debate. Stable fractures should be immobilized or treated by closed reduction when non-tolerably displaced. Unstable and displaced fractures can be treated by various operative techniques, which are all characterized by technical impracticability or disadvantages for the patient. In younger patients transepiphyseal intramedullary K-wire fixation represents a minimally invasive, quick and technically easy treatment option but requires additional immobilisation. In adolescent patients volar locking plate osteosynthesis constitutes an immobilisation-free treatment option, but is combined with high invasiveness. Percutaneous K-wire fixation and elastic stable intramedullary nailing may lead to poor results in the diametaphyseal region due to technical or biomechanical problems associated with the implant. The external fixator is indicated in some multifragmentary fractures. The choice of treatment option often results from an individual decision based on the patient's age, complexity and stability of the fracture and interest of the patient. The priority objective of all treatment modalities is a fully functional upper extremity, i.e. full range of motion.

Occupational therapy interventions for work-related injuries and conditions of the forearm, wrist, and hand: a systematic review.

A systematic review of the literature related to effective occupational therapy interventions in rehabilitation of individuals with work-related forearm, wrist, and hand injuries and illnesses was conducted as part of the Evidence-Based Literature Review Project of the American Occupational Therapy Association. This review provides a comprehensive overview and analysis of 36 studies that addressed many of the interventions commonly used in hand rehabilitation. Findings reveal that the use of occupation-based activities has reasonable yet limited evidence to support its effectiveness. This review supports the premise that many client factors can be positively affected through the use of several commonly used occupational therapy-related modalities and methods. The implications for occupational therapy practice, research, and education and limitations of reviewed studies are also discussed.

Recovery of strength after reduced pediatric fractures of the forearm, wrist or hand; A prospective study.

INTRODUCTION: The way strength recovers after reduction of pediatric fractures of the upper extremity has not previously been the specific scope of research. This is remarkable, since strength measurements are often used as an outcome measure in studies on trauma of the upper extremity. The aim of this study was to evaluate how strength recovers after sustainment of fractures of the forearm, wrist or hand treated by closed or open reduction in children and adolescents in the first 6 months after trauma. How much strength is lost at 6 weeks, 3 months and 6 months after trauma, and is this loss significant? Are there differences in the pattern of recovery between children who underwent a different treatment? And finally, which of the following factors are associated with an increase in the ratio between affected grip strength and expected strength: type of fracture, cast immobilization, occurrence of complications, and degree of pain? DESIGN: Prospective observational study. PARTICIPANTS: Children and adolescents aged 4-18 years with a reduced fracture of the forearm, wrist or hand. METHODS: Grip strength, key grip and three-jaw chuck grip were measured twice in each hand 6 weeks, 3 months and 6 months after trauma. Details on fracture type and location, treatment received, cast immobilization and complications were obtained. Hand-dominance and pain were verbally confirmed. RESULTS: Loss of strength was more prominent and prolonged the more invasive the treatment, hence most extensive in the group receiving open reduction with internal fixation (ORIF), intermediate in the group receiving closed reduction with percutaneous pinning (CRIF), and least extensive in the group undergoing closed reduction without internal fixation (CR). Besides time passed, gender and age were of significant influence on strength, although there was no difference in pattern of recovery over time between children who received a different treatment. In the period of 6 weeks to 3 months after trauma, female gender, type of fracture sustained and occurrence of an unwanted event were associated with an increased ratio between affected and expected grip strength. For the later phase of recovery, between 3 and 6 months, this was only true for the occurrence of an unwanted event.

The impact of incident fractures on health-related quality of life: 5 years of data from the Canadian Multicentre Osteoporosis Study.

UNLABELLED: Using prospective data from the Canadian Multicentre Osteoporosis Study (CaMos), we compared health utilities index (HUI) scores after 5 years of follow-up among participants (50 years and older) with and without incident clinical fractures. Incident fractures had a negative impact on HUI scores over time. INTRODUCTION: This study examined change in health-related quality of life (HRQL) in those with and without incident clinical fractures as measured by the HUI. METHODS: The study cohort was 4,820 women and 1,783 men (50 years and older) from the CaMos. The HUI was administered at baseline and year 5. Participants were sub-divided into incident fracture groups (hip, rib, spine, forearm, pelvis, other) and were compared with those without these fractures. The effects of both time and fracture type on HUI scores were examined in multivariable regression analyses. RESULTS: Men and women with hip fractures, compared to those without, had lower HUI measures that ranged from -0.05 to -0.25. Both women and men with spine fractures had significant deficits on the pain attributes (-0.07 to -0.12). In women, self-care (-0.06), mobility and ambulation (-0.05) were also negatively impacted. Women with rib fractures had deficits similar to women with spine fractures, and these effects persisted over time. In men, rib fractures did not significantly affect HUI scores. Pelvic and forearm fractures did not substantially influence HUI scores. CONCLUSION: The HUI was a sensitive measure of HRQL change over time. These results will inform economic analyses evaluating osteoporosis therapies.

Long-term results of elastic-stable intramedullary nailing (ESIN) of diaphyseal forearm fractures in children.

Since its introduction by Metaizeau and Prevot, elastic-stable intramedullary nailing (ESIN) has been used for almost all diaphyseal fractures in children. Here, we present a retrospective study analyzing the long-term results of ESIN of forearm fractures in children.A total of 122 patients with diaphyseal forearm fractures and single subtypes in childhood were treated from 2000 to 2007 at our University Hospital by ESIN. At follow-up, the current conditions of the patients were evaluated using the Disabilities of Arm, Shoulder, and Hand (DASH) Score, and the Mayo Wrist score. Moreover, an individual questionnaire with 16 items was used to collect further information about the patient's condition and limitations as adults.The evaluation was performed at 12.4 years (average) after surgery. In our study population (n = 90), the average DASH scores for sports, performing arts, and work were 0.4 (standard deviation: 1.45), 0.9 (standard deviation: 5.68), and 0.3 (standard deviation: 7.39), respectively. Furthermore, 77% of our patients achieved a DASH Score of 0 (optimum outcome). The average Mayo Wrist Score was 97.64 (standard deviation: 7.39), and 82% of the study population achieved a score of 100 (optimum outcome). A correlation between the DASH and Mayo Wrist Scores was found in few patients. Overall, the DASH Score, Mayo Wrist Score, and results of our individual questionnaire demonstrated convincing point values.This study demonstrated favorable long-term results achieved by ESIN of forearm fractures in children. It seems that good outcomes, reported by various studies with short- to mid-term follow-up beforehand, do not deteriorate over time.Level of Evidence: Level III; retrospective study; therapeutic study.

Differing trends in fall-related fracture and non-fracture injuries in older people with and without dementia.

OBJECTIVES: To explore the impact of dementia on the trends in fall-related fracture and non-fracture injuries for older people. METHODS: Individuals aged ≥65years who were admitted to a NSW hospital for at least an over-night stay for a fall-related injury from 2003 to 2012 were identified. Age-standardised hospitalisation rates, length of stay, access to in-hospital rehabilitation, 30-day and 1-year mortality were examined. Annual percentage change (PAC) over time was calculated using negative binomial regression. RESULTS: Of the 228,628 fall-related injury hospitalisations, 20.6% were for people with dementia. People with dementia were more likely to be admitted with a hip fracture, and less likely to be admitted with a fracture of the forearm/wrist, and received less in-hospital rehabilitation than people without dementia. Fall-related hip-fracture rates for people with dementia decreased by 4.2% (95%CI -5.6 to -2.7, p<0.001) per annum; there was no change over time for people without dementia (PAC-0.2%; 95%CI -0.8 to 0.5, p=0.643). Rates for other fractures decreased by 1.2% (95%CI -1.9 to -0.5, p<0.001) per annum in people with dementia, while rates increased by 2.2% (95%CI 1.9-2.5, p<0.001) for people without dementia. By contrast, non-fracture injuries including traumatic brain injury increased significantly for both people with and without dementia. CONCLUSION: Rates of fall-related fracture and non-fracture hospitalisations for people with dementia remain higher than for those without dementia. However, fall-related fracture hospitalisation rates have decreased for people with dementia, while there has not been a corresponding decrease in people without dementia.

Impairment and employment issues after nerve repair in the hand and forearm.

PURPOSE: To evaluate retrospectively subjective impairments, experienced disabilities, job and leisure restrictions and job changes in patients at least 2 years after repair of a peripheral nerve injury in the forearm, wrist or hand. METHODS: Between January 1,997 and January 2,000, 125 patients were treated surgically for a peripheral nerve injury in the hand and forearm at the Department of Plastic Surgery of a University Hospital. Sixty-one patients met the inclusion criteria. Using a questionnaire the ability to return to work (RTW), the possible consequences on Activities of Daily Life (ADL) and Instrumental Activities of Daily Life (IADL), job, hobby and housekeeping related disabilities and subjective pain were assessed. RESULTS: Forty of the 61 included patients returned the questionnaire. As a result of the injury, seven patients (19%) were not able to return to their own job and eight patients (20%) needed to quit or change their hobbies. Mean Time Off Work (TOW) was significantly longer (p=0.024) in non-digital nerve lesions (21.4 weeks) as compared to digital nerve lesions (9.5 weeks). CONCLUSIONS: From this study it was concluded that digital nerve lesions have little consequence on the ability to return to work and the time off work. However, the patients' hobbies are significantly affected. At least 2 years after the injury, the effects on ADL and IADL are minor.

[The effect of injury level, associated injuries, the type of nerve repair, and age on the prognosis of patients with median and ulnar nerve injuries]. / Onkol median ve ulnar sinir yaralanmalarinda yaralanma seviyesi, ek patolojiler, sinir onarimi türü ve yasin prognoza etkileri.

OBJECTIVES: In this study, we aimed to evaluate the functional results of nerve repair (median and/or ulnar) in patients with forearm clean-cut injuries and investigated the effect of injury level, associated injuries, the type of repair (primary or secondary), and age on the prognosis. METHODS: The study included 42 patients (34 males, 8 females; mean age 31 years; range 9 to 62 years) who were treated for forearm clean-cut injuries. Involvement was in the proximal forearm in four, mid-forearm in 11, and distal forearm in 27 cases. There were 51 nerve injuries affecting the median nerve (n=30) and the ulnar nerve (n=21). Nerve injuries were isolated in 12 patients, associated with tendon injuries in nine patients, and with tendon and artery injuries in 21 patients. The patients were evaluated in four age groups including 0-15, 16-30, 31-45 years, and 46 years or above. Functional evaluations were made using the Seddon classification. The effect of injury level, associated injuries, the type of repair, and age on the prognosis was assessed. The mean follow-up was 39 months (range 11 to 57 months). RESULTS: Although the clinical and functional results of primary and late-primary repairs were less favorable than those of secondary repairs, the difference did not reach a significant level (p>0.05). The injury level, associated injuries, and age did not influence the Seddon scores significantly (p>0.05). In the age group of 0-15 years, the results were very good in all the patients (100%), but good and very good results accounted for only 20% in the age group of 46 years or above. CONCLUSION: In appropriate cases with clean-cut nerve injuries, primary repair must be the first choice. Taking the low regeneration capacity into consideration, priority should be given to reconstructive procedures in patients at older ages.

Radio-ulnar dissociation. A review of twenty cases.

The results of treatment were reviewed for twenty patients who had sustained concomitant injuries of the lateral compartment of the radiohumeral joint and the ipsilateral distal radio-ulnar joint. The ages of the patients ranged from eight to seventy-four years (average, thirty-five years) and the duration of follow-up ranged from four months to twenty-seven years (average, 113 months). In fifteen patients, the injury of the wrist was diagnosed after a mean delay of seven years and eleven months (range, one month to twenty-six years). In all fifteen, the radial head injury was treated by excision, either initially or after some delay. After excision of the radial head, all fifteen patients complained of severe pain at the distal radio-ulnar joint. The results, on the basis of elbow and wrist scores of fair or better without complications, were satisfactory in only three patients. In the remaining five patients, in whom the injuries of both the elbow and the wrist had been identified at the initial evaluation, the radial head was either preserved or replaced. The results, on the basis of elbow and wrist scores of fair or better, were graded as satisfactory in four of these patients. Our data show that any injury to the lateral side of the elbow should prompt a careful evaluation of the ipsilateral distal radio-ulnar joint for associated instability.

Treatment of unstable fractures of the forearm in children. Is plating of a single bone adequate?

Unstable fractures of the forearm in children present problems in management and in the indications for operative treatment. In children, unlike adults, the fractures nearly always unite, and up to 10 degrees of angulation is usually considered to be acceptable. If surgical intervention is required the usual practice in the UK is to plate both bones as in an adult. We studied, retrospectively, 32 unstable fractures of the forearm in children treated by compression plating. Group A (20 children) had conventional plating of both forearm bones and group B (12 children) had plating of the ulna only. The mean age was 11 years in both groups and 23 (71%) of the fractures were in the midshaft. In group B an acceptable position of the radius was regarded as less than 10 degrees of angulation in both anteroposterior (AP) and lateral planes, and with the bone ends hitched. This was achieved by closed means in all except two cases, which were therefore included in group A. Union was achieved in all patients, the mean time being 9.8 weeks in group A and 11.5 weeks in B. After a mean interval of at least 12 months, 14 children in group A and nine in group B had their fixation devices removed. We analysed the results after the initial operation in all 32 children. The 23 who had the plate removed were assessed at final review. The results were graded on the ability to undertake physical activities and an objective assessment of loss of rotation of the forearm. In group A, complications were noted in eight patients (40%) after fixation and in six (42%) in relation to removal of the radial plate. No complications occurred in group B. The final range of movement and radiological appearance were compared in the two groups. There was a greater loss of pronation than supination in both. There was, however, no limitation of function in any patient and no difference in the degree of rotational loss between the two groups. The mean radiological angulation in both was less than 10 degrees in both AP and lateral views, which was consistent with satisfactory function. The final outcome for 23 patients was excellent or good in 12 of 14 (90%) in group A, despite the complications, and in eight of nine in group B (90%). If reduction and fixation of the fracture of the ulna alone restores acceptable alignment of the radius in unstable fractures of the forearm, operation on the radius can be avoided.

The care of burned upper extremities.

Two sets of factors will ultimately influence the outcome of the burned upper extremity. The first set of factors is the depth and severity of the burn. The second set is the group of complications of the burn injury attributable to edema, inflammation, immobility, and malposition. An awareness of the potential pitfalls that follow burn injury has resulted in improved primary care and a lessening of deformity. Progressive acute care with topical chemotherapy, early motion, thoughtful splinting, and timely burn wound closure are essential to reduce the need for secondary operations. Reconstructive efforts should be tailored to the individual needs of the patient. These procedures should be carefully planned with a view toward balancing aesthetic and functional considerations and minimizing the time required for rehabilitation.

Immediate forearm reconstruction with a functional latissimus dorsi island pedicle myocutaneous flap.

Immediate forearm reconstruction with a functional latissimus dorsi island pedicle myocutaneous flap was performed following a shotgun injury to the left forearm. The procedure provided excellent coverage of the defect and eliminated the need for multiple procedures and the immobilization required for groin or abdominal pedicle flaps. In addition, the latissimus muscle provided active flexion of the wrist and limited finger flexion.

Reliability of 2 functional goniometric methods for measuring forearm pronation and supination active range of motion.

STUDY DESIGN: Test-retest reliability study. OBJECTIVES: To determine intra- and intertester reliability of the hand-held pencil (HHP) and the plumbline goniometer (PLG) methods for measuring active forearm pronation and supination motions in individuals with and without injuries. BACKGROUND: The distal forearm method has been considered the gold standard for measuring forearm pronation and supination motion. The HHP and PLG, however, are 2 more functional methods for measuring forearm motions, though limited information on the psychometric properties of these tests is currently available. METHODS AND MEASURES: Intra- and intertester reliability of the HHP and PLG methods were determined in 40 subjects of convenience (20 injured and 20 noninjured). Two testers performed 3 repeated measurements for each motion and method on all subjects. Intraclass correlation coefficients (ICC3,1 for intratester reliability, ICC2,3 for intertester reliability) and standard error of measurements (SEMs) were determined. RESULTS: The ICCs for the measurements of pronation and supination using the HHP and PLG methods were high (range, 0.86-0.98) for individuals with and without injuries, with the reliability for the PLG method being equal or slightly greater than the HHP method for the majority of pronation and supination measurements. Intratester ICCs were higher (SEMs were conversely lower) than intertester ICCs for nearly all measurements. The ICC values were generally the same or higher for individuals with injuries compared to individuals without injuries. CONCLUSIONS: The HHP and PLG are highly reliable methods for measuring functional forearm pronation and supination. Because plumbline goniometers are not commercially available and the instrumentation for the HHP method is readily accessible, clinicians should consider the latter as their method of choice for measuring functional forearm pronation and supination.

Local bone mineral response to brief exercise that stresses the skeleton.

OBJECTIVE: To compare grip strength and bone mineral content in the forearm in women and to test the effects on bone mineral content of short periods of exercise that stresses the skeleton. DESIGN: Assessment of both wrists in 69 volunteers and of the non-fractured wrist in 30 patients followed by an exercise regimen entailing squeezing a tennis ball as hard as possible for 30 seconds each day for six weeks. SETTING: Old people's homes and outpatient departments of Hammersmith and Northampton general hospitals. PATIENTS: 99 Women, of whom 69 were volunteers and 30 had a fractured forearm. MAIN OUTCOME MEASURE: Grip strength and bone mineral content after six weeks and at six months after the exercises had stopped. RESULTS: The bone mineral content of the women's forearms was measured with a densitometer and the grip strength with a semi-inflated bag connected to an anaeroid barometer. Measurements before exercise showed that the two variables correlated closely, irrespective of age, and that there were significant differences in both between the dominant and non-dominant arms of the volunteers. After six weeks of exercise there was a mean increase in grip strength of 14.5% (95% confidence interval 9.9 to 19.2%) and in bone mineral content of 3.4% (1.4 to 5.3%) in the stressed forearms of the 77 women who attended for examination. After six months without exercise the improvements in the 33 women who attended for follow up had reversed. Women who had had a fractured forearm (n = 13), however, had continued to gain grip strength and bone mineral content in the arm that had not been injured. CONCLUSIONS: Grip strength in the forearm is a good indicator of bone mineral content. Both variables may be increased by brief periods of stressful exercise. If this principle can be applied to the whole skeleton it may provide a means of reversing osteoporosis.

Successful voluntary grasp and release using the cookie crusher myoelectric hand in 2-year-olds.

We examined the ability of two 2-year-old children with limb deficiency to demonstrate grasp and release while using the cable-operated voluntary opening hook-hand and the externally powered single-site myoelectric Cookie Crusher system. The Cookie Crusher circuit is an electronic package that causes the prosthetic hand to open in response to muscle contraction and closes (as if crushing a cookie) when the muscle is relaxed. Both children were consistently good prosthetic wearers, beginning with their initial passive devices and progressing through their cable-operated hooks and hands. However, before they began to use the Cookie Crusher (Subject 1 at 25 months, Subject 2 at 30 months), neither had developed voluntary grasp or release in spite of 3 to 12 months' use of cable-operated voluntary opening prehensors. Both children developed a voluntary grasp and release for the first time within minutes of starting to use the Cookie Crusher. The more adept of the two children, a girl with a traumatic above-elbow amputation, showed prehensile function with the Cookie Crusher during play. The spontaneous use of the Cookie Crusher may be related to the predominance of associated reactions in young children. As children play bimanually, associated movements of the nondominant extremity often occur and, in the case of children with limb deficiencies fitted with Cookie Crusher prehensors, these associated reactions result in successful grasp and release. We will continue to follow the choice of effective control schemes in these children as they mature.