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Pediatrics > Congenital Muscular Torticollis + Cranial Abnormalities > Flashcards

Congenital Muscular Torticollis + Cranial Abnormalities Flashcards

1
Q

Congenital Muscular Torticollis (CMT) Defined

A
  • Asymmetrical posturing of the head and neck resulting in a variable degree of lateral head tilt + rotation
  • “Wry neck”
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2
Q

Associated impairments/findings w/ CMT

A
  • Hip dysplasia→ incd risk w/ incd severity of torticollis (bc in-utero pos’ing)
  • Brachial Plexus injury (BPI), distal extremity deforms (Metatarsus Adductus, club foot), dev. delays, face/skull asymm, TMJ dysf
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3
Q

Primary issue resulting in CMT

A

Fibrosis of SCM

SCM→ IPSILAT flexion c/s, CONTRALAT rotation c/s

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4
Q

Fibrosis of ________=== primary issue in CMT

A

SCM

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5
Q

How is Torticollis named?

A

Named for side of HEAD TILT****

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6
Q

CMT Clinical Presentation:

A
  • Head tilt to IPSILAT (same) side, rotation to CONTRALAT (opp) side
  • NAMED FOR SIDE OF HEAD TILT***
    • Ex. Right torticollis
      • Right head tilt, left cervical rotation
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7
Q

Causes of CMT

A
  • True cause→ unknown
  • Risk factors→
    • Packaging issues/fetal crowding== MOST COMMON (esp first-born)
    • multiple births (twin A impacted most), tumor on SCM, breech pos (butt first), prolonged labor, LGA >8.5lbs, poor post-natal pos’ing
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8
Q

Breech===

A

Butt first

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9
Q

Differential Dx for CMT

A
  • Klippl-Fell Syndrome, bony abnorms, Neuro syndromes, Brachial plexus injury, ocular defects, auditory defects, GERD
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10
Q

Differential Dx for CMT

Klippl-Fell Syndrome

A

Rare dis. w/ congenital fusion of 2/7 cervical spine vertebrae

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11
Q

Differential Dx for CMT

Bony abnorms

A

Hemivertebra

bloc vertebra

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12
Q

Differential Dx for CMT

Neuro Syndromes: Benign Paroxysmal Positional Torticollis (BPPT)

A

Torticollis switches sides*

Self-limiting and resolves w/out intervention

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13
Q

Differential Dx for CMT

BPI

A

Can be w/ or w/out clavicular fx

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14
Q

Differential Dx for CMT

Auditory defects

A

Chronic ear infxs

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15
Q

Differential Dx for CMT

GERD

A

Baby tries to arch head/neck AWAY from sensation==> Torticollis

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16
Q

Tests/Imaging for Torticollis

A

US, Xrays,

Severe cases→ CT/MRI

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17
Q

Torticollis Prognosis

2 Key Things:

A
  1. Earlier referral=== better/faster resolution of sx’s
  2. MOST have full resolution of sx’s when RX started prior to age 1
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18
Q

Better outcomes for torticollis when?

A

EARLIER THE BETTER

If RX started prior to age 1

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19
Q

Torticollis prognosis

A
  • Earlier referral===better/faster resolution sx’s
    • prevents 2* impairs
  • MOST have full resolution when RX started prior to age 1
  • Residual head tilt may be present
  • May see re-emergence of head tilt posture when acquiring new motor skills
    • bc forget about it while learning/focusing on new skills***
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20
Q

We should see AND observe CMT by when for best outcomes?

A

3 months

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21
Q

Torticollis Exam:

The Hx

A
  • Age @ initial visit (we want <3mos), age of onset sx’s,
  • Pregnancy hx:
    • baby “stuck” in one pos, # of pregnancy
    • Delivery info:
      • Vag or C-section
      • cephalic or breech
      • forceps? suction?
      • how long did mom push (2nd stage labor)
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22
Q

Additional Subjective Info for CMT Exam:

A
  • Family hx?→ if yes==poor post-natal pos’ing
  • Head posture/preference, face changes
  • Dev. milestones not approp for age
  • med cond’s
  • pos’ing t/o day:
    • jumpers, car seats, strollers, swings, bouncers
    • Prone tolerance**→ poor in children w/ CMT
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23
Q

Screening Systems

MSK

A
  • Facial features/symmetry, posture in supine/upright, skull shape bc flat head, entire spine, shoulder, hips,
  • *palpation of entire length of mm belly for fibrosis or mass→ SCM
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24
Q

Screening Systems

Neuro

A
  • r/o more serious causes, look for abnorm tone, age approp reflexes, CN integrity,
  • Look for appearance of BPI→ abnorm mvmt/low mm tone of one UE
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25
Q

Screening Systems

Vision screen

A
  • Tracking ability, nystagmus, perceptual deficit→ posture in supine vs upright
    • Visual torticollis→ abnorm posture resolves in supine and returns in upright due to lack of horizon in supine
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26
Q

Screening systems

Auditory screen

A
  • Assess response to name, sound, music toys
  • Does child suffer from chronic ear infxs?
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27
Q

Screening Systems

Integumentary

A
  • Skin fold asymm→ neck and glutes
  • Color, cond of neck fold skin on side of torticollis bc head tilt compressing skin
    • maybe open/foul odor
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28
Q

Screening Systems

Cardiorespiratory

A
  • rib expansion, B/L clavicular mvmts, resp distress or accessory breath sounds i.e. wheezing
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29
Q

Screening Systems

GI

Torticollis + _______ go hand and hand****

A

Torticollis and reflux ******

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30
Q

Screening Systems

GI

A
  • Hx via parent report
    • constipation or reflux→ Reflux and torticollis go hand and hand****
    • preferential feeding one breast or side
    • arching behaviors
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31
Q

Torticollis Red Flags

*if hx or screening indicate any of the following a referral back to primary MD indicated

A
  • Suspected hip dysplasia
  • Plagiocephaly/skull deform and facial asymm.
  • Atypical presentation→ Tilt/Turn to SAME side OR plagiocephaly and torticollis SAME side***
  • Abnorm tone
  • Late onset >6mos→ maybe neuro impair
  • Visual abnorms→ gaze aversion, inconsist tracking
  • Hx of acute onset usually == trauma or acute illness
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32
Q

Musculoskeletal Exam:

A
  • Document→ posture + B/L CS AROM/PROM into rotation, LF, ext
    • likely resting head tilt w/ or w/out rotation, ipsilat shoulder elevation, anterior CS tight limits CS ext=poor prone skills, ROM/posture of entire length of spine bc trunk component present in severe cases
  • A/PROM all 4 extremities
  • Palpation of SCM + assoc’d structures
    • Tightness→ upper traps, levator scap, scalenes, hyoids
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33
Q

Assessing PROM in infant w/ CMT

A
  • Research says use→ arthrodial protractor
    • Goni/angle finder OK too
  • PROM/AROM cervical rotation
    • Position→ Supine
    • Stationary arm→ neutral
    • Moving arm→ follows child as they rotate in line w/ nose
    • Look down onto cranium from supine
  • PROM/AROM lateral flexion
    • Pos→ Supine
    • Stationary arm→ pointing towards belly button
    • axis @ chin
    • Moving arm→ middle of cranium
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34
Q

MSK Exam for CMT cont’d

Strength assessment:

A
  • Assess ability to laterally flex (should be 4mos) against gravity OR right their head to horizon→ Muscle Function Scale (MFS)
  • Time ability to hold pos.→ mm endurance
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35
Q

MSK Exam for CMT

Developmental Assessment:

A
  • Look for:
    • asymm in skills, delay in milestones,
    • Rolling (typ to see rolling to contralateral side first)
    • Delay in prone skills, SLOW to crawl/creep
    • Most w/ CMT enjoy standing sooner bc less stress on CS
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36
Q

MSK Exam for CMT

Approp. standardized assessments to use:

A

TIMP, AIMS, PDMS-2

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37
Q

Muscle Function Scale

A

Assesses ability to lateral flex against gravity OR right head to horizon

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38
Q

In general, CMT should NOT be painful

T/F????

A

TRUE!!!!!!!

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39
Q

MSK EXAM CMT

Pain

A
  • Assess discomfort @ rest→ FLACC scale should be used****
  • CMT should NOT be painful!!!
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40
Q

MSK Exam CMT

Cranial Anthropometrics:

A
  • Facial asymmetries
  • Skull deforms:
    • plagiocephaly
    • brachiocephaly
    • Combination***
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41
Q

Tx of CMT

A
  • Principle→ STRETCH tight side, STRENGTHEN weak side
  • CPG 3 categories:
    • “First Choice”→ most evidence*
    • “Supplemental”→ not as strong evidence
    • Interventions not supported by any
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42
Q

First Choice Interventions basic principle:

A

Strengthen weak side

Stretch tight side

43
Q

First Choice Interventions listed:

A
  • Neck/Trunk PROM and AROM
  • Developmental skills w/ emphasis on symmetrical mvmt
  • Parent/caregiver edu.
44
Q

First Choice Interventions:

Neck/Trunk PROM

A

Positioning or manual maneuvers

Should be comfortable → NO fighting stretch*** (remember example of older PTs doing this—-BAD!)

45
Q

FIRST CHOICE INTERVENTIONS

Neck and Trunk AROM

A

Rotation, LF, mvmt into upper quadrants

46
Q

First Choice Interventions:

Developmental skills→ emphasis on symmetrical mvmt

What is VERY EFFECTIVE for this?

A

TUMMY TIME!!!

47
Q

First Choice Interventions:

Developmental skills→ emphasis on symmetrical mvmt

A
  • Strengthen→ rotators, extensors, LFs
  • TUMMY TIME***
  • Devices→ theraball, swings, wobble boards, wedges, boppy pillows

NOTE: LF emerges 4mos***

48
Q

First Choice Interventions:

Parent/Caregiver Edu.

A
  • Environmental adaptations:
    • positioning, stretching/strengthening,
    • tips for carrying, feeding, room set up
    • Stress importance of daily HEP
      • *Routine-based activities into what they are already doing!!!
        • try to implement into routine so its not new and adherence will be higher!
49
Q

Interventions for Stretching***

A
  • Stretching/positioning
    • AVOID pressure to jaw, ear, cheek
    • *stabilize shoulder to prevent compensations
50
Q

Interventions: Strengthening

51
Q

Supplemental Interventions

*lower lvls of evidence to support use

A
  • Microcurrent e-stim, custom fabricated cervical orthoses, K-taping to contralat. neck to facilitate lateral righting rxns,
  • Tubular Orthosis for Torticollis (TOT collar)
52
Q

Additional Interventions W/OUT Supporting Evidence

*Documented and widely used in tx of CMT→ insuff. evidence to support use and further research indicated

A

STM

Cranial sacral techniques

Total Motion Release (TMR)

53
Q

Lapses in Improvement…..Why?

A

Illness, constipation, poor night’s sleep, teething, growth spurts*, gaining new skills (and forget about torticollis ex’s)

54
Q

When to Refer Back to PCP

A
  • Child NOT progressing after:
    • 4-6wks intense PT
    • 6mos of PT w/ only mod resolution
    • Infant >12 months @ IE and a 10-15* diff persists
    • Mass present in infants >7mos
  • may be more serious cond.
  • MAY be Indicated for Botox to tight SCM OR sx release of SCM***
55
Q

When to D/C

We want them to be doing what???

A

WALKING W/OUT HEAD TILT***

56
Q

WHEN TO D/C

A
  • When ROM is w/in 5* of uninvolved side***
  • On target for motor skills and no asymm of motor skills present
  • NO visible head tilt
  • Parents IND w/ HEP
  • *CPG recommends f/u screen 3-12mos after D/C

WANT THEM WALKING W/OUT HEAD TILT***

57
Q

Infants w/ postional head deforms are more likely to reach motor milestones ________ vs other babies

58
Q

Positional Plagiocephaly/Skull Deformity

A
  • Infants w/ pos’l head deforms likely to reach motor milestones LATER vs other babies
  • 3 Categories Skull Abnorms:
    • Plagiocephaly
    • Brachiocephaly
    • Scaphocephaly
59
Q

3 categories skull abnorms

A

Plagio, Brachio, Scaphocephaly

60
Q

This skull abnorm. is usually associated w/ Torticollis

A

Plagiocephaly

61
Q

Plagiocephaly cranial abnorm is usually associated w/…

A

Torticollis

62
Q

Plagiocephaly

Describe findings:

A

Ipsilateral ear shift

Ipsilateral frontal bossing (popping up)

Ear shift forward on ipsilateral side

Think “Paralellogram head”***

63
Q

Positional Plagiocephaly

“Parallelogram Head”

64
Q

This cranial abnorm IS NOT ASSOCIATED W/ CMT

A

Brachycephaly

*developmentally delayed→ supine too much

65
Q

Brachycephaly

Findings:

A
  • Brachycephaly→ Bilateral forehead bossing, incd posterior vault, bilateral protrusion of parietal bone above ears
  • CI of >81%
  • dev. delayed→ supine too much, NOT assocd w/ CMT***
66
Q

Scaphocephaly (AKA- Dolichocephaly)

Findings:

A
  • ScAphocephaly→ long, nArrow skull shape
  • NOT assocd w/ CMT***
67
Q

Facial Asymmetry

Ex.

68
Q

Craniosynostosis

Defined

A

Abnormal premature closure of skull sutures; does not allow brain growth

  • *Typical→ babys skull fuses @ 8mos, full closure of sutures @ 2 yrs
69
Q

Craniosynostosis

Findings:

A
  • Typ. presents w/ palpable ridge on suture lines, contralateral bossing and posterior shift of IPsilateral ear
  • Helmets DO NOT improve head shape→ likely reqs sx
70
Q

How to tell difference bw:

Plagiocephaly vs Craniosynostosis

A
  • Plagio→ “Parallelogram head”
    • Contralat occ. bossing
    • Ipsilat ear displaced ANT.
    • Ipsilat frontal bossing
  • Craniosynostosis→ “Trapezoid head”
    • Ipsilat occ bossing
    • Ipsilat ear displaced POST
    • Contralat parietal bossing
71
Q

Plagiocephaly vs Craniosynostosis

Shapes drawn out

A

Plagio→ Parallelogram head

Cranio→ Trapezoid head

72
Q

Positioning Programs for Plagiocephaly/Skull Deforms

A
  • Parent edu, STRESS TUMMY TIME+alleviating stress on back of head while awake,
  • Still have child sleep on back***
  • Bumbos, devices to relieve/prevent posturing→ Tortle, work closely w/ MD
73
Q

How to determine course of Rx for Cranial Deformity

A
  • Monitor head shape
    • → measurement of cranial anthropometrics: Calipers and tape measures
  • No tools+ mod-severe==> refer to orthotist for head scan
74
Q

Measurement/Important Landmarks

ALL

A
  • Glabella (g): most prom. point bw supraorbital ridges (bw eyebrows)*
  • Opisthocranion (op): most prom point of occiput
  • Eurion (eu): most lateral point either side of head
  • Frontotemporale (ft): most med. point of temporal crest (palpate, typ. @ lateral point of eyebrow)
  • Lambdoideal point (ld): junction bw occiptal and parietal bones
75
Q

Glabella

A

most prom. point bw supraorbital ridges (bw eyebrows)*

76
Q

Opisthocranion

A

most prom point of occiput

77
Q

Eurion

A

Most lateral point on either side of head

78
Q

Frontotemporale

A

Most medial point on temporal crest (palpate, typ @ lateral point of eyebrow)

79
Q

Lambdoideal point

A

Junction bw occipital and parietal bones

80
Q

Head Length

A

Glabella→ Opisthocranion

81
Q

Head Width

A

Eurion→ Eurion

82
Q

Head Circumference

A

Encircle tape measure around head covering glabella and opisthocranion

83
Q

Obliques:

A

Left frontotemporale to Right lambdoideal

Right frontotemporale to Left lambdoideal

84
Q

Cranial Vault Asymmetry Index

CVAI

A

CVAI== (A-B)x100/A or B (whichever larger)

A and B are obliques

85
Q

Cranial Index aka Cranial Ratio

CI or CR

A

CI==M/L/A/P x 100

86
Q

5 Levels of Severity

*Things to KNOW!

A
  • Lvl 3: mod-severe== recommend orthotist
  • Severity dictates recommendation for helmet***
    • BEST TIME bw _4-8_mos
87
Q

Best time for helmet

88
Q

Argenta Scale

A

rec’d by CPG- easy/no equip

Via observation of skull shape

89
Q

Helmets

2 main types:

A
  1. Star Band -→ “fixin my flat”
  2. Doc Band
90
Q

Helmets best to rx bw____ and ______ and WHY?

A

4 and 8mos of age*****

*CAN HOLD HEAD UP!!!

91
Q

HELMETS

A
  • Best to rx b/w 4 and 8mos of age
    • Best window for improve.
    • can hold head up***
  • Duration→ 23/24 hrs/day, length depends on severity
  • Night only once improve. obtained***
92
Q

Name that Torticollis!

93
Q

Name that Torticollis!

94
Q

Name that Torticollis!

95
Q

Name that Torticollis!

96
Q

Name that Torticollis!

97
Q

Name that Torticollis!

TOUGH ONE

Remember named for lateral tilt

SCM– ipsilat LF, contralat ROT.

98
Q

Name that Head Shape!

A

Parietal Plagiocephaly

99
Q

Name that Head Shape!

A

R. Anterior Plagiocephaly

100
Q

Name that Head Shape!

A

Scaphocephaly

Long, nArrow skull

101
Q

Name that Head Shape!

A

R. Parietal Plagiocephaly

102
Q

Name that Head Shape!

A

Brachiocephaly

*easy to remember, supine too much→ flat in back

103
Q

Name that Head Shape!

A

Craniosynostosis

104
Q

Name that Head Shape!

A

R. Parietal Plagiocephaly

Pediatrics (27 decks)

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