title: Quantification of humeral head deformity following neonatal brachial plexus palsy.
abstract: BACKGROUND
  Neonatal brachial plexus palsy frequently leads to glenohumeral dysplasia if neurological recovery is incomplete. Although glenoid retroversion and glenohumeral subluxation have been well characterized, humeral head deformity has not previously been quantified. Nonetheless, humeral head flattening is described as a contraindication to joint contracture release and external rotation tendon transfers. This study describes a novel technique for objectively quantifying humeral head deformity with use of magnetic resonance (MR) imaging and correlates the humeral head deformity with clinical and radiographic outcomes following joint rebalancing surgery.
  
  
  METHODS
  Magnetic resonance images of thirty-two children (age, 0.7 to 11.5 years) with neonatal brachial plexus palsy were retrospectively reviewed. Passive shoulder external rotation and Mallet scores were reviewed before joint rebalancing surgery and at a minimum clinical follow-up interval of two years. The humeral head skewness ratio on preoperative and postoperative axial MR images was defined as the ratio of anterior to posterior humeral head area, and this ratio was compared between affected and unaffected shoulders and with the glenoid version angle, posterior subluxation of the humeral head, and clinical parameters before and after surgery with use of paired t tests and Spearman correlation. Intraobserver and interobserver reliability of MR image measurements was determined.
  
  
  RESULTS
  Measurements of the skewness ratio on the affected side had moderate to substantial intraobserver reliability (0.53 to 0.72) and substantial interobserver reliability (0.65 to 0.71). Preoperatively, the skewness ratio of the affected humeral head (mean, 0.76; range, 0.54 to 1.03) differed significantly from the ratio in the contralateral shoulder (p<0.05) and was significantly associated with the glenoid version angle (p<0.05) and posterior subluxation of the humeral head (p<0.05). Remodeling of the affected humeral head was observed postoperatively, with a significant improvement in the skewness ratio (p<0.05). However, there were no significant correlations between the preoperative skewness ratio and postoperative clinical outcomes.
  
  
  CONCLUSIONS
  Humeral head deformity in neonatal brachial plexus palsy correlated with other measures of glenohumeral dysplasia and could be reliably and objectively quantified on MR imaging with use of the skewness ratio. The humeral head deformity can remodel following joint rebalancing surgery, and such a deformity alone does not preclude a successful outcome after surgical attempts to restore glenohumeral congruity.
authors.affiliation: Department of Radiology, Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
authors.forename: Brenton D
authors.initials: BD
authors.lastname: Reading
authors.forename: Tal
authors.initials: T
authors.lastname: Laor
authors.forename: Shelia R
authors.initials: SR
authors.lastname: Salisbury
authors.forename: William C
authors.initials: WC
authors.lastname: Lippert
authors.forename: Roger
authors.initials: R
authors.lastname: Cornwall
mesh_terms: D017677:Age Distribution; D001720:Birth Injuries / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery; D020516:Brachial Plexus Neuropathies / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D015897:Comorbidity; D017352:Echo-Planar Imaging / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D058430:Humeral Head / Q000002:abnormalities* / Q000473:pathology; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D016916:Joint Deformities, Acquired / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery; D008297:Male; D019637:Orthopedic Procedures / Q000379:methods; D010808:Physical Examination / Q000379:methods; D016059:Range of Motion, Articular / Q000502:physiology; D020127:Recovery of Function; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D017678:Sex Distribution; D012783:Shoulder Dislocation / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery; D016896:Treatment Outcome