Ultrasound assessment of the posterolateral elbow ulnohumeral gap in normal subjects with and without posterolateral drawer testing.

Background: Posterolateral rotator instability (PLRI) is the most common pattern of recurrent elbow instability, and current imaging to aid PLRI diagnosis is limited. Thus, we sought to define use of ultrasound (US) to determine normal lateral ulnohumeral joint measurements, with and without posterolateral drawer testing to provide an insight into how US may aid diagnosis. Methods: Sixty elbows were evaluated in thirty healthy volunteers. The lateral ulnohumeral gap (LUHG) was measured with US in the resting position while the posterolateral drawer stress test maneuver was applied. Joint laxity was calculated as the difference between maximum stress and average rest measurements. Two independent readers assessed each elbow with comparison performed between stress and rest positions. Results: Differences in the LUHG were evident between stress and rest conditions (reader 1: P < .0001 and reader 2: P = .0002). At rest, median LUHG values were 2.31 mm and 2.05 mm for readers 1 and 2 respectively, while at stress 2.88 mm and 2.9 mm for readers 1 and 2. Median joint laxity was 0.8 mm for reader 1 and 1.1 mm for reader 2. Pearson correlation was r = 0.457 (absolute intraclass correlation coefficient [ICC] = 0.608) while under stress and r = 0.308 (absolute intraclass correlation coefficient [ICC] = 0.417) at rest. Median joint laxity demonstrated a Pearson correlation of r = 0.161 and absolute intraclass correlation coefficient [ICC] = 0.252. Conclusions: This study demonstrates a dynamic US assessment for PLRI, which aimed to assess the usefulness and feasibility of a laxity measurement after the application of a posterolateral drawer stress maneuver in a healthy population. Although establishing concordance between readers in measuring an LUHG under stress, the utility of a laxity measurement alone is not clear as correlation of measurements is not excellent; hence, an upper limit of normal for the ulnohumeral gap under stress may be more useful. Further evaluation of this technique is required in patients with PLRI.

Immersive virtual reality vs. non-immersive distraction for pain management of children during bone pins and sutures removal: A randomized clinical trial protocol.

AIMS: To examine the efficacy of an immersive virtual reality distraction compared with an active non-immersive distraction, such as video games on a tablet, for pain and anxiety management and memory of pain and anxiety in children requiring percutaneous bone pins and/or suture removal procedures. DESIGN: Three-centre randomized clinical trial using a parallel design with two groups: experimental and control. METHODS: Study to take place in the orthopaedic department of three children hospital of the Montreal region starting in 2019. Children, from 7-17 years old, requiring bone pins and/or suture removal procedures will be recruited. The intervention group (N = 94) will receive a virtual reality game (Dreamland), whereas the control group (N = 94) will receive a tablet with video games. The primary outcomes will be both the mean self-reported pain score measured by the Numerical Rating Scale and mean anxiety score, measured by the Child Fear Scale. Recalls of pain and anxiety will be measured 1 week after the procedure using the same scales. We aim to recruit 188 children to achieve a power of 80% with a significance level (alpha) of 5%. DISCUSSION: While multiple pharmacological methods have previously been tested for children, no studies have evaluated the impact of immersive virtual reality distraction for pain and anxiety management in the orthopaedic setting. IMPACT: Improved pain management can be achieved using virtual reality during medical procedures for children. This method is innovative, non-pharmacological, adapted to the hospital setting, and user-friendly. TRIAL REGISTRATION: NCT03680625, registered on clinicaltrials.gov.

Supercharge End-to-Side Anterior Interosseous Nerve to Ulnar Motor Nerve Transfer for Severe Ulnar Neuropathy: Two Cases Suggesting Recovery Secondary to Nerve Transfer.

INTRODUCTION: The supercharged end-to-side (SETS) anterior interosseous nerve (AIN) to ulnar nerve transfer has been recently described for severe cubital tunnel syndrome. Previous studies have suggested that this technique augments or "babysits" the motor end plates until reinnervation occurs; however, it has more recently been suggested that reinnervation occurs by the donor nerve as evidenced in animal research. CASE REPORT: We present two cases of rapidly progressive ulnar neuropathy who underwent a SETS AIN to ulnar nerve transfer who demonstrated improvement in their electrodiagnostic studies in addition to improvement in their clinical and patient-reported outcome's scores postoperatively. CONCLUSION: Our findings provide further evidence that previously demonstrated in the literature that the SETS does more than "babysit" the motor end plates, but that there is axonal growth along the new pathway.