A survey-based study: assessing inpatient attending perspectives on teaching learners, feeling valued, and symptoms of burnout.

BACKGROUND: Physician burnout is rising, especially among academic physicians facing pressures to increase their clinical workload, lead administrative tasks and committees, and be active in research. There is a concern this could have downstream effects on learners' experiences and academic physician's ability to teach learners on the team. METHODS: A 29-question RedCap survey was electronically distributed to 54 attending physicians within an academic learning health system who oversaw the General Medicine inpatient teaching services during the 2022-2023 academic year. The aims were to assess this cohort of attending physicians' experiences, attitudes, and perceptions on their ability to effectively teach learners on the team, feeling valued, contributors to work-life balance and symptoms of burnout, Fisher's Exact Tests were used for data analysis. RESULTS: Response rate was 56%. Attendings splitting time 50% inpatient / 50% outpatient felt that team size and type of admissions model affected their ability to effectively teach learners (p = 0.022 and p = 0.049). Attendings with protected administrative time felt that non-patient care obligations affected their ability to effectively teach the learners (p = 0.019). Male attendings and attendings with ≤ 5 years of General Medicine inpatient teaching experience felt less valued by residency leadership (p = 0.019 and p = 0.026). 80% of attendings experienced emotional exhaustion, and those with > 10 weeks on a General Medicine inpatient teaching service were more likely to experience emotional exhaustion (p = 0.041). Attendings with > 10 weeks on a General Medicine inpatient teaching service and those who were a primary caregiver were more likely to experience depersonalization (p = 0.012 and p = 0.031). 57% of attendings had reduced personal achievement. CONCLUSIONS: Institutions should seek an individual and organizational approach to professional fulfillment. Special attention to these certain groups is warranted to understand how they can be better supported. Further research, such as with focus groups, is needed to address these challenges.

Impact of Bedside Rounding on Attending Teaching Evaluations.

OBJECTIVE: To examine associations between bedside rounding (BSR) and other rounding strategies (ORS) with resident evaluations of teaching attendings and self-reported attending characteristics. METHODS: Faculty from three academic medical centers who attended resident teaching services for ≥4 weeks during the 2018-2019 academic year were invited to complete a survey about personal and rounding characteristics. The survey instrument was iteratively developed to assess rounding strategy as well as factors that could affect choosing one rounding strategy over another. Survey results and teaching evaluation scores were linked, then deidentified and analyzed in aggregate. Included evaluation items assessed resident perceptions of autonomy, time management, professionalism, and teaching effectiveness, as well as a composite score (the numeric average of each attending's scores for all of the items at his or her institution). BSR was defined as spending >50% of rounding time in patients' rooms with the team. Hallway rounding and conference room rounding were combined into the ORS category and defined as >50% of rounding time in these settings. All of the scores were normalized to a 10-point scale to allow aggregation across sites. RESULTS: A total of 105 attendings were invited to participate, and 65 (62%) completed the survey. None of the resident evaluation scores significantly differed based on rounding strategy. Composite scores were similar for BSR and ORS (difference of <0.1 on a 10-point scale). Spearman correlation coefficients identified no statistically significant correlation between rounding strategy and evaluation scores. An exploratory analysis of variance model identified no single factor that was significantly associated with composite teaching scores (P > 0.45 for all) or the domains of teaching efficacy, professionalism, or autonomy (P > 0.13 for all). Having a formal educational role was significantly associated with better evaluation scores for time management, and the number of lectures delivered per year approached statistical significance for the same domain. CONCLUSIONS: Conducting BSR did not significantly affect resident evaluations of teaching attendings. Resident perception of teaching effectiveness based on rounding strategy should be neither a motivator nor a barrier to widespread institution of BSR.

Implementing a Second-Level Observation Unit at a Large Academic Medical Center.

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Use of adenosine to shorten the post ablation waiting period for cavotricuspid isthmus-dependent atrial flutter.

BACKGROUND: Dormant conduction unmasked by adenosine predicts clinical recurrences of cavotricuspid isthmus (CTI) dependent atrial flutter following catheter ablation. Conventional practice involves a waiting period of 20 to 30 minutes after achievement of a bidirectional line of block (BDB) to monitor for recovery of conduction. OBJECTIVE: Assess whether abolition of dormant conduction with adenosine immediately after CTI ablation and BDB can predict the lack of CTI conduction recovery during the following 30 minutes. METHODS: Consecutive patients undergoing catheter ablation for CTI-dependent atrial flutter were studied. Following the completion of CTI ablation and documentation of BDB, adenosine (≥12 mg IV) was administered immediately. In cases of dormant conduction, the CTI was ablated again until its abolition. After the achievement of BDB without dormant conduction, spontaneous CTI reconnection during the following 30 minutes and dormant conduction with adenosine at 30 minutes were evaluated. RESULTS: A CTI block was achieved in 171 patients. Nine patients (5.3%) had dormant conduction across the CTI immediately after ablation and BDB, and required further ablation. Two patients (1.2%) had subsequent spontaneous time-dependent reconnection within 30 minutes. Two other patients (1.2%) developed late dormant conduction with adenosine at 30 minutes. All 4 patients underwent further ablation. CONCLUSION: A negative adenosine challenge immediately after CTI ablation with bidirectional block, or after abolition of dormant conduction with further ablation, strongly predicted the absence of subsequent spontaneous reconnection within 30 minutes. Based on these results, the conventional waiting period is unnecessary in 97.6% patients without dormant conduction after CTI-dependent flutter ablation.

Disconnected Pancreatic Duct Syndrome: A Rare Complication of Pancreatitis.

Disconnected pancreatic duct syndrome (DPDS) is a rare complication of a common disease. Typically, DPDS occurs in acute necrotizing pancreatitis (ANP), chronic pancreatitis, abdominal surgery, or trauma. We present a case of DPDS from acute non-necrotizing pancreatitis (ANNP). A 41-year-old male with a history of alcohol use and prior AP presented with progressive, severe left-sided abdominal pain that was worse with movement. Labs revealed a lipase of 95 U/L (normal range 11-82 U/L). Computed tomography (CT) of the abdomen/pelvis (A/P) with IV contrast demonstrated a large left-sided pleural effusion, non-necrotic pancreatic pseudocysts, and a large subdiaphragmatic fluid collection. Thoracentesis of the pleural effusion revealed an amylase of 601 U/L confirming pancreatic etiology. A subsequent magnetic resonance cholangiopancreatography (MRCP) confirmed complex peripancreatic ascites, rapid subdiaphragmatic fluid accumulation, and a fistula from the pancreatic tail to retroperitoneum concerning for a rapidly dissecting pancreatic pseudocyst. He ultimately underwent endoscopic retrograde cholangiopancreatography (ERCP) with stent placement in the main pancreatic duct. His left-sided abdominal pain rapidly improved, and the patient was discharged. CT A/P one week after discharge showed a reduced size of subdiaphragmatic fluid collection. DPDS is usually seen in patients with a history of ANP. Our case demonstrates that it can also occur in ANNP, which has not previously been described in the literature. Therefore, a high index of clinical suspicion must be maintained for DPDS even in ANNP given its potential for severe complications.

Atypical Intrahepatic Cholestasis of Pregnancy: A Red Herring.

Intrahepatic cholestasis of pregnancy is an intrahepatic etiology of acute cholestasis commonly defined by pruritus and increased bile acids, liver transaminases, and, occasionally, bilirubin. Azathioprine is an immunosuppressive agent associated with various forms of hepatoxicity, ranging from transient rises in serum aminotransferase levels, acute cholestatic injury, and chronic hepatic injury. In this report, we present a 20-year-old pregnant woman who presented with cholestatic liver injury due to intrahepatic cholestasis of pregnancy with a clinical picture complicated by increased levels of azathioprine metabolites.

Sending a Signal: Evaluating the Impact of Program and Geographic Preference Signaling on the Internal Medicine Residency Match.

Background For over a decade, the number of residency applications has surged, a trend known as "application inflation." COVID-19 further intensified this trend, leading the Association of American Medical Colleges (AAMC) to address the issue by introducing a supplemental application in the 2021-2022 cycle, allowing programs to identify applicants with a connection to their program or geographic region. For the 2022-2023 cycle, the number of program signals increased from five to seven. The impact of the supplemental application and the increase in signals on the likelihood of an applicant matching with a program has yet to be evaluated. Methods This retrospective cohort study evaluated the impact of program signaling and geographic preference on the matching likelihood in our internal medicine residency program. Data from MyERAS® and the Supplemental Application for 640 applicants who applied to our large, urban, university-based program in the Southeastern United States during the 2020-2021 and 2022-2023 application cycles were included. Using univariate and multivariate analysis, we examined the correlation between program signal, geographic preference, and final match location. Results Applicants who sent a program signal had nearly three-fold higher odds of matching with our program. Geographic preference was numerically but not statistically associated with higher odds of matching. Both signaling a preference for matching with a program in an urban environment and couples matching correlated with decreased odds of matching with our program. Geography was an important predictor of match location as residing in our AAMC geographic region, our four-state area, and our specific state had increased odds of matching with our program. Conclusions Signaling our program was associated with increased odds of matching with our program. Geographic preferences were less predictive of a match with our program; however, they did predict the likelihood of a match at a program within that region. Future studies are needed to ensure external validity.

Meta-analysis of function after secondary shoulder surgery in neonatal brachial plexus palsy.

BACKGROUND: Shoulder internal rotation contracture, active abduction, and external rotation deficits are common secondary problems in neonatal brachial plexus palsy (NBPP). Soft tissue shoulder operations are often utilized for treatment. The objective was to conduct a meta-analysis and systematic review analyzing the clinical outcomes of NBPP treated with a secondary soft-tissue shoulder operation. METHODS: A literature search identified studies of NBPP treated with a soft-tissue shoulder operation. A meta-analysis evaluated success rates for the aggregate Mallet score (≥ 4 point increase), global abduction score (≥ 1 point increase), and external rotation score (≥ 1 point increase) using the Mallet scale. Subgroup analysis was performed to assess these success rates when the author chose arthroscopic release technique versus open release technique with or without tendon transfer. RESULTS: Data from 17 studies and 405 patients were pooled for meta-analysis. The success rate for the global abduction score was significantly higher for the open technique (67.4%) relative to the arthroscopic technique (27.7%, P<0.0001). The success rates for the global abduction score were significantly different among sexes (P=0.01). The success rate for external rotation was not significantly different between the open (71.4%) and arthroscopic techniques (74.1%, P=0.86). No other variable was found to have significant impact on the external rotation outcomes. The success rate for the aggregate Mallet score was 57.9% for the open technique, a nonsignificant increase relative to the arthroscopic technique (53.5%, P=0.63). Data suggest a correlation between increasing age at the time of surgery and a decreasing likelihood of success with regards to aggregate Mallet with an odds ratio of 0.98 (P=0.04). CONCLUSIONS: Overall, the secondary soft-tissue shoulder operation is an effective treatment for improving shoulder function in NBPP in appropriately selected patients. The open technique had significantly higher success rates in improving global abduction. There were no significant differences in the success rates for improvement in the external rotation or aggregate Mallet score among these surgical techniques.

Jejunal Leiomyosarcoma in a Young Adult: Distinguishing from Gastrointestinal Stromal Tumor through Radiographic, Histologic, and Epidemiologic Analysis - A Case Report.

Introduction: Primary small intestinal malignancies are rare with an incidence of less than 5% of all gastrointestinal malignancies and are more common in the middle-aged and elderly population. They are comprised either an adenocarcinoma, neuroendocrine tumor, gastrointestinal stromal tumor (GIST), lymphoma, and/or sarcoma. Case Presentation: Here we exhibit the case of a 23-year-old who presented with progressive nausea, weight loss, abdominal pain, and iron deficiency anemia and was diagnosed with leiomyosarcoma of the jejunum. Conclusion: We distinguish a GIST from leiomyosarcoma based on radiographic, histologic, and epidemiologic evidence and review the significance of prompt, accurate diagnosis as related to treatment.

The intrarater and interrater reliability of glenoid version and glenohumeral subluxation measurements in neonatal brachial plexus palsy.

BACKGROUND: Progressive and disabling glenohumeral dysplasia commonly occurs as a secondary deformity in children with neonatal brachial plexus palsy (NBPP). A number of methods for quantifying glenohumeral dysplasia are currently in use; however, the most commonly reported quantitative measures have yet to be validated. The present study assesses the intrarater and interrater reliability of the glenoid version angle (GVA) and percent of the humeral head anterior to the scapular line (PHHA) measurements on axial magnetic resonance images. METHODS: Axial magnetic resonance images of the shoulder girdle of 25 children with NBPP were selected to represent a wide range of glenohumeral dysplasia severity. An axial image was preselected for each measurement. Six examiners (3 orthopaedic surgeons, 2 musculoskeletal radiologists, and an epidemiologist) digitally measured the GVA and PHHA on each image twice, with each measurement separated by 2 to 14 days and the order of image presentation placed in a different arrangement for each measurement set. Intrarater and interrater reliability was assessed with the intraclass correlation coefficient (ICC). Measurement errors for the GVA and PHHA measurements and the variances associated with the scapular and glenoid lines were calculated. RESULTS: Using the Fleiss criteria, intrarater reliability was excellent, with ICCs averaging 0.909 (95% CI: 0.840, 0.940) for GVA and 0.891 (95% CI: 0.815, 0.921) for PHHA. Interrater reliability was excellent, with ICCs of 0.848 (95% CI: 0.788, 0.909) for GVA and 0.874 (95% CI: 0.815, 0.934) for PHHA. The GVA and PHHA measurement errors were ±6.4 degrees and ±7.2%, respectively. In a subset of 141 images measured, the between-image variance in the scapular line was greater than the glenoid line by a 1.61:1 ratio. CONCLUSIONS: : The present study demonstrates excellent intrarater and interrater reliability of standard measurements of glenohumeral dysplasia in NBPP. The measurement errors for both measurements were comparable with other standard measures (e.g., Cobb angle). The scapular line exhibited a greater variance than the glenoid line, which identifies an opportunity for improvement in the GVA measurement. LEVEL OF EVIDENCE: Diagnostic study; level III.

Documentation of postoperative pain in the neonatal brachial plexus palsy population.

AIMS AND OBJECTIVES: To assess postoperative pain management in neonatal brachial plexus palsy children who underwent a primary nerve repair, release only and/or a release and transfer procedure. BACKGROUND: Previous studies have noted pain management inadequacies in postoperative pain management in certain paediatric populations. However, this is the first study to focus on postoperative pain management in this particular population. METHODS: Seventy-five patients, who underwent a primary nerve repair, release only and/or a release and transfer procedures at our institution, were reviewed. Postoperative pain management was assessed on a patient and drug administration level through appropriate pain scale use; appropriate dosage for the medication prescribed; appropriate reassessment of pain following medication administration; and complications leading to a longer hospital stay. RESULTS: Based on our institution's guidelines following drug administration, 64 patients were not appropriately reassessed for pain. Based on the drug's duration following drug administration, 40 patients were not appropriately reassessed for pain. Twenty-eight per cent of all medication administrations were not properly reassessed for pain based on the drug's duration and 62% of the time based on our institution's guidelines. Fifty per cent of all medication administrations were not properly dosed and 51 patients were not appropriately dosed at least once during their hospital stay. Pain scales were documented incorrectly 20% of the time and administered improperly to 13 patients. CONCLUSIONS: Opportunities for improvement in postoperative pain management in the paediatric population - particularly those with neonatal brachial plexus palsy - exist. RELEVANCE TO CLINICAL PRACTICE: Findings from this study demonstrate that healthcare professionals may have (1) insufficient knowledge regarding pain and/or (2) inadequate direction and guidance to appropriately assess and document pain in the paediatric population. Improvements for these individual healthcare professionals and clinical settings are needed to overcome postoperative pain management issues in the future.

Arthroscopically assisted Sever-L'Episcopo procedure improves clinical and radiographic outcomes in neonatal brachial plexus palsy patients.

BACKGROUND: Muscle pathology resulting in internal rotation contractures in children with neonatal brachial plexus palsy places abnormal stresses on the glenohumeral joint and limits global shoulder function. The objective of this study was to assess the clinical and radiographic outcomes in children treated with an arthroscopic release with or without tendon transfer, the so-called arthroscopically assisted Sever-L'Episcopo procedure. METHODS: Fifty children with an average age of 5.1 years who underwent an arthroscopic release with or without tendon transfer were retrospectively reviewed. Clinical outcomes were assessed using Mallet classification scores, whereas glenoid retroversion and posterior humeral head subluxation were measured on magnetic resonance images to quantify radiographic outcomes. Mean clinical follow-up was 30 months (range: 24 to 65 mo) and mean radiographic follow-up was 24 months (range: 11 to 42 mo). RESULTS: Aggregate Mallet score improved significantly from 12.6 to 16.3 (P<0.0001), with shoulder abduction from 3.4 to 3.8 (P=0.0007), shoulder external rotation from 2.2 to 3.3 (P<0.0001), hand-to-neck from 2.3 to 3.2 (P<0.0001), and hand-to-mouth from 2.3 to 3.3 (P<0.0001). Hand-to-spine Mallet score did not significantly change from preoperative (2.4) to postoperative (2.6) (P=0.1348), although 4 patients experienced a loss in internal rotation function. Forty-eight percent of children improved by at least 4 points on the total Mallet score. Glenoid retroversion improved from 25 to 14.1 degrees (P<0.0001) and percent humeral head anterior to the central axis of the scapula increased from 30.5% to 38.8% (P=0.0001). Sixty-seven percent of patients demonstrated glenohumeral joint remodeling on magnetic resonance imaging. No child exhibited a worsening of glenohumeral anatomy. CONCLUSIONS: An arthroscopic release with or without tendon transfer is effective in reducing internal rotation contractures and increasing global shoulder function. Both clinical and radiographic outcomes were significantly improved at 2-year follow-up. Furthermore, in the majority of children, aggregate, abduction, and external rotation Mallet scores all increased without sacrificing internal rotation. LEVEL OF EVIDENCE: Therapeutic Level IV.

Salter-Harris type III fractures of the distal femur: plain radiographs can be deceptive.

BACKGROUND: Salter-Harris (SH) III fractures of the distal femur, although rare, can have devastating effects. The purposes of this study were to: (1) compare the intra-articular fracture displacement measured on plain x-ray and magnetic resonance imaging (MRI) or computed tomography (CT) scan and (2) report the outcomes of patients with a SH III fracture of the distal femur. METHODS: All SH III distal femur fractures treated at a large Children's Hospital with a Level I Pediatric Trauma Center between 1995 and 2006 were retrospectively reviewed. A total of 14 patients (average age: 13 y, 11 mo; range: 7 y, 8 mo to 17 y, 11 mo) with an average follow-up time of 21.50 months (range: 2 to 47 mo) were included in this study. Fracture displacement on plain x-ray was compared with the fracture displacement measured on MRI or CT scan. The average time between the initial plain x-ray and MRI or CT scan was 37.48 days (range: 3 h to 6 mo). RESULTS: Plain x-rays significantly underestimated the displacement of SH III fractures versus MRI or CT scan. Six patients who had both plain x-ray and MRI or CT scan had a measured displacement of 0.42 mm and 2.70 mm, respectively (paired Student t test, P=0.005). Ten of the 14 patients (71%) had no physical limitations and full knee motion at their most recent follow-up visit. The treatment of 4 patients (29%) was changed based on the findings of the additional MRI or CT scan. CONCLUSIONS: This study and earlier studies have shown a high rate of poor results with SH III fractures of the distal femur. This type of fracture pattern is extremely unstable and the true displacement is often underestimated by x-rays. Thus, it is strongly recommended that an MRI or CT scan be obtained on every SH III fracture of the distal femur. Moreover, any SH III fracture visible on plain radiographs should be treated with open reduction, internal fixation. LEVEL OF EVIDENCE: Level IV.

Central Nervous System Blastomycosis With Multiple Brain Abscesses Presenting as Right Upper Extremity Weakness.

Blastomycosis is a mycotic infection that typically affects the lung, but that can have dermatologic, orthopedic, genitourinary, and central nervous system manifestations. Blastomyces dermatitidis is a true human pathogen, which can produce disease in immunocompetent hosts. Risk factors for infection include residence in or travel to endemic areas and outdoor occupation, particularly those activities near open bodies of water and that disrupt soil. Immunosuppressed patients are also at increased risk for severe and disseminated disease. We present a case of a 79-year-old male who presented with a 2-week history of progressive right upper extremity weakness and severe odontogenic disease. He was found to have multiple brain abscesses with positive cultures from a cerebral abscess incision and drainage for B dermatitidis. He underwent an incision and drainage of the largest cerebral abscess and was treated with intravenous liposomal amphotericin B, which he tolerated poorly. He was subsequently switched to voriconazole, which was well tolerated, and his neurological deficits improved throughout his hospitalization.

Risk Factors for Brachial Plexus Birth Injury.

Over the course of decades, the incidence of brachial plexus birth injury (BPBI) has increased despite advances in healthcare which would seem to assist in decreasing the rate. The aim of this study is to identify previously unknown risk factors for BPBI and the risk factors with potential to guide preventative measures. A case control study of 52 mothers who had delivered a child with a BPBI injury and 132 mothers who had delivered without BPBI injury was conducted. Univariate, multivariable and logistic regressions identified risk factors and their combinations. The odds of BPBI were 2.5 times higher when oxytocin was used and 3.7 times higher when tachysystole occurred. The odds of BPBI injury are increased when tachysystole and oxytocin occur during the mother's labor. Logistic regression identified a higher risk for BPBI when more than three of the following variables (>30 lbs gained during the pregnancy, stage 2 labor >61.5 min, mother's age >26.4 years, tachysystole, or fetal malpresentation) were present in any combination.

Use of botulinum toxin type A in the management of neonatal brachial plexus palsy.

OBJECTIVE: To evaluate functional outcomes and the impact on surgical interventions after the use of botulinum neurotoxin type A (BoNT-A) for muscle imbalance, cocontractions, or contractures with neonatal brachial plexus palsy. DESIGN: A retrospective cohort study. SETTING: A brachial plexus center in a tertiary children's hospital. PARTICIPANTS: Fifty-nine patients with neonatal brachial plexus palsy (75 injection procedures, 91 muscles and/or muscle groups) received BoNT-A injections (mean age at injection, 36.2 months; range, 6-123 months; 31 boys; 30 right-sided injuries, 28 left-sided injuries, 1 bilateral injury). METHODS: Data collected retrospectively from medical records, from procedure notes and clinic visits before BoNT-A use, at ≤6 months follow-up (BoNT-A active [BA]) and at ≥7 months follow-up (BoNT-A not active [BNA]) included demographics, injection indication, side, and site(s), previous surgical history, occupational therapy and/or physical therapy plan, and outcome measurements. MAIN OUTCOME MEASUREMENTS: Outcomes assessed before and after injections included active and passive range of motion, Mallet and Toronto scores, parent comments about arm function, preinjection surgical considerations, and postinjection surgical history. RESULTS: Injection procedures included 51 to shoulder internal rotators, 15 triceps, 15 pronator teres, 9 biceps, and 1 flexor carpi ulnaris. Active and passive shoulder external rotation (SER) range of motion improved after shoulder internal rotator injections (P = .0003 and P = .002, respectively), as did Mallet scores with BA; the latter were sustained with BNA. Surgical intervention was averted, modified, or deferred after BoNT-A in 45% (n = 20) under surgical consideration before BoNT-A. Active elbow flexion improved in 67% (P = .005), sustained BNA (P = .004) after triceps injections; 2 of 7 patients averted surgery. Active supination improved with BA (P = .002), with gains sustained BNA (P = .016). Passive elbow extension improved after biceps injections by an average 17° (P = .004) BA, although not sustained BNA. CONCLUSIONS: BoNT-A is an effective adjunct to therapy and surgery in managing muscle imbalance, cocontractions, and contractures in neonatal brachial plexus palsy. Use of BoNT-A can result in averting, modifying, or deferring surgical interventions in a number of affected children.

Quantification of humeral head deformity following neonatal brachial plexus palsy.

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.