Congenital muscular torticollis

Question 1

What is torticollis?

Answer 1

• “Twisted neck”
• Unilateral shortening of the SCM
• Named for the side of the involved SCM

Question 2

What compensations are seen in torticollis?

Answer 2

• Shoulder elevation to the affected side
• Lateral head tilt towards the affected side

Question 3

Etiologies of torticollis

Answer 3

1. Prenatal
   * Ischemia
   * Compartment syndrome - head position in utero
   * Muscle rupture
   * Infective myositis
2. Perinatal
   * Birth trauma - breech presentation
   * Assisted deliveries
3. Postnatal
   * Hip dysplasia
   * Positional preference
   * Deformational plagiocephaly

Question 4

How does an SCM pseudotumor form?

Answer 4

• Tearing and bleeding in SCM forms scar tissue - fibrous mass
• Prevents SCM growth

Question 5

Contributing factors to torticollis

Answer 5

• Large infants
• Premature birth
• Assisted birthing - forceps/vacuum
• Uterus abnormalities

Question 6

Acquired non-traumatic causes of torticollis

Answer 6

• Inflammatory conditions - Osteomyelitis, RA, TB, tonsillitis, pharyngitis
• C1-C2 subluxation
• Ocular torticollis
• Gastroesophageal reflux disorder (GERD, Sandifer syndrome)
• Brachial plexus injuries
• Posterior fossa syndrome
• Arnold Chiari malformation
• Neonatal Abstinence Syndrome (NAS)

Question 7

Differential diagnosis of torticollis

Answer 7

• With limited ROM and tight SCM - rule out congenital structural osseous anomalies
• With no SCM tightness - contracture of other neck muscles, benign paroxysmal torticollis, congenital absence of cervical neck muscles or transverse ligament

Question 8

Associated anomalies with torticollis

Answer 8

• Scoliosis
• Hip dysplasia - ipsilateral to torticollis
• Metatarsus adductus
• Clubfoot
• Calcaneovalgus
• Flexible pes planus
• Hallux valgus
• Internal tibial torsion
• Brachial plexus injuries

Question 9

What is deformational plagiocephaly (DP)?

Answer 9

• Bossing of the forehead on flattened side
• Flattened back/side of the head (left or right)
• Misaligned ears (ear on flattened side will be pushed forward)
• Prominent cheek (flattened side)
• One eye may appear larger that the other
• Possible tilted jaw

Question 10

What is deformational brachycephaly (DB)?

Answer 10

• Entire back of head flattened
• Short (front to back) and wide (from side to side)
• Back/top of head appears higher than the front/top
• Less facial asymmetry – may see bulging forehead

Question 11

What is scaphocephaly?

Answer 11

• Elongated head
• Long front to back; narrow side to side
• Supine – difficult to maintain
• “Shelf” at back of head
• Often in babies born pre-term or with breech births

Question 12

What should be screened neurologically in a torticollis patient?

Answer 12

• Abnormal or asymmetrical tone
• Retained primitive reflexes
• Cranial nerve integrity
• Brachial plexus injury
• Temperament (irritability, alertness)
• Achievement of age-appropriate milestones
• Visual screen including tracking, field defects, nystagmus

Question 13

How should integumentary be screened in a torticollis patient?

Answer 13

• Skinfold symmetry in the hips and neck
• Color and condition of skin

Question 14

How should cardiopulmonary be screened in torticollis patients?

Answer 14

• Symmetrical coloration
• Rib cage expansion
• Clavicle movement
• Upper respiratory tract distress
• Alert and vocal without wheezing

Question 15

How should gastrointestinal be screened in torticollis patients?

Answer 15

• Reflux
• Constipation
• Preferential feeding from one side

Question 16

When should a torticollis patient be referred out?

Answer 16

• Vertebral anomalies
• Plagiocephaly
• Abnormal tone
• Late onset - after 6 months
• Visual abnormalities
• History of acute onset
• Suspected DDH
• > 12 months old on initial screening + facial asymmetry &/or 10-15 degrees difference in PROM or AROM
• > 7 months with SCM mass present

Question 17

Minimal, moderate, and severe skull asymmetry index

Answer 17

• Difference between two sides
• 3-10 minimal
• 10-12 moderate
• > 12 severe

Question 18

Torticollis CPG - 7 key body function and structure items

Answer 18

1. posture in supine, prone, sitting, standing with or without support
2. Bilateral active cervical rotation, lateral flexion & diagonal motions
3. PROM & AROM UEs & LEs – screen for tightness of other neck muscles, Ortolani & Barlow, Galeazzi, hip ABD
4. Bilateral passive cervical rotation & lateral flexion – arthrodial protractor
5. Pain/discomfort – (FLACC) scale
6. Integumentary – cervical & leg folds
7. Craniofacial assessment for asymmetries