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Comparison of Ultrasound and MRI for the Diagnosis of Glenohumeral Dysplasia in Brachial Plexus Birth Palsy
Kenneth W. Donohue, MD1; Kevin J. Little, MD2; Dan Zlotolow, MD3; Scott Kozin, MD3
1Orthopaedic Surgery, Baylor College of Medicine, Houston, TX; 2Department of Orthopaedic Surgery, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH; 3Shriners Hospital for Children Philadelphia, Philadelphia, PA

Hypothesis: Ultrasonography (US) for the diagnosis of humeral head subluxation and glenoid morphology will correlate with Magnetic resonance Imaging (MRI) findings in infants and toddlers with brachial plexus birth palsy (BPBP).

Methods: We performed a prospective investigation of 39 consecutive patients (14 male, 25 female) with BPBP at two separate institutions. All patients underwent both US and MRI for suspected glenohumeral dysplasia. The studies were obtained an average of 2 months apart (range 0 6 months). Patient age ranged from 6-53 months. Four blinded independent evaluators were given the entire US and MRI study of each patient and asked to perform measurements on the US and MRI for alpha-angle, percentage of humeral head displacement (PHHD), and glenoid version, as well as measurements only on the MRI for the percentage of humeral head anterior to the middle of the glenoid fossa (PHHA). Measurements were obtained on OsiriX software (Pixmeo Sarl).

Results: We found strong inter-rater reliability for alpha-angle on MRI, glenoid version on MRI, and alpha-angle on US (intra-class correlation coefficient, 0.83, 0.75, 0.78). Inter-rater reliability for PHHD on MRI and US was fair (0.70, 0.68), and inter-rater reliability for glenoid version on US and PHHA on MRI was poor (0.30, 0.57). A Bland- Altman analysis was used to evaluate measurement agreement between MRI and US in respect to each parameter. US was found to underestimate alpha angle and glenoid version by an average of 1323 degrees and 617 degrees respectively. US was found to overestimate PHHD by 412 degrees. There was a high degree of variability between measurements performed on MRI and US, which persisted despite modifications in measuring technique by the most senior author. This variability was maintained throughout all degrees of dysplasia.

Summary: We found both US and MRI measurements to be reliable and internally consistent. However, the poor correlation between MRI and US calls into question the validity of using US as a stand-alone examination for glenohumeral dysplasia in children with BPBP. To the author's knowledge, this is the first study to investigate the inter-rater reliability of ultrasound measurements in children over 1yr old and children with significant glenoid remodeling (Water's Type IV-V). Cartilage sensitive techniques on MRI remain the gold standard to fully evaluate the glenohumeral joint. The role of US may be as a screening tool for specific patient populations (Water's type VI) or as a way of evaluating glenohumeral joint reduction in real-time.

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