Congenital Muscular Torticollis + Cranial Abnormalities Flashcards
Congenital Muscular Torticollis (CMT) Defined
- Asymmetrical posturing of the head and neck resulting in a variable degree of lateral head tilt + rotation
- “Wry neck”
Associated impairments/findings w/ CMT
- 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
Primary issue resulting in CMT
Fibrosis of SCM
SCM→ IPSILAT flexion c/s, CONTRALAT rotation c/s
Fibrosis of ________=== primary issue in CMT
SCM
How is Torticollis named?
Named for side of HEAD TILT****
CMT Clinical Presentation:
- 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
- Ex. Right torticollis
Causes of CMT
- 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
Breech===
Butt first
Differential Dx for CMT
- Klippl-Fell Syndrome, bony abnorms, Neuro syndromes, Brachial plexus injury, ocular defects, auditory defects, GERD
Differential Dx for CMT
Klippl-Fell Syndrome
Rare dis. w/ congenital fusion of 2/7 cervical spine vertebrae
Differential Dx for CMT
Bony abnorms
Hemivertebra
bloc vertebra
Differential Dx for CMT
Neuro Syndromes: Benign Paroxysmal Positional Torticollis (BPPT)
Torticollis switches sides*
Self-limiting and resolves w/out intervention
Differential Dx for CMT
BPI
Can be w/ or w/out clavicular fx
Differential Dx for CMT
Auditory defects
Chronic ear infxs
Differential Dx for CMT
GERD
Baby tries to arch head/neck AWAY from sensation==> Torticollis
Tests/Imaging for Torticollis
US, Xrays,
Severe cases→ CT/MRI
Torticollis Prognosis
2 Key Things:
- Earlier referral=== better/faster resolution of sx’s
- MOST have full resolution of sx’s when RX started prior to age 1
Better outcomes for torticollis when?
EARLIER THE BETTER
If RX started prior to age 1
Torticollis prognosis
- 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***
We should see AND observe CMT by when for best outcomes?
3 months
Torticollis Exam:
The Hx
- 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)
Additional Subjective Info for CMT Exam:
- 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
Screening Systems
MSK
- 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
Screening Systems
Neuro
- 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
Screening Systems
Vision screen
- 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
Screening systems
Auditory screen
- Assess response to name, sound, music toys
- Does child suffer from chronic ear infxs?
Screening Systems
Integumentary
- 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
Screening Systems
Cardiorespiratory
- rib expansion, B/L clavicular mvmts, resp distress or accessory breath sounds i.e. wheezing
Screening Systems
GI
Torticollis + _______ go hand and hand****
Torticollis and reflux ******
Screening Systems
GI
- Hx via parent report
- constipation or reflux→ Reflux and torticollis go hand and hand****
- preferential feeding one breast or side
- arching behaviors
Torticollis Red Flags
*if hx or screening indicate any of the following a referral back to primary MD indicated
- 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
Musculoskeletal Exam:
-
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
Assessing PROM in infant w/ CMT
- 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
MSK Exam for CMT cont’d
Strength assessment:
- 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
MSK Exam for CMT
Developmental Assessment:
- 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
MSK Exam for CMT
Approp. standardized assessments to use:
TIMP, AIMS, PDMS-2
Muscle Function Scale
Assesses ability to lateral flex against gravity OR right head to horizon
In general, CMT should NOT be painful
T/F????
TRUE!!!!!!!
MSK EXAM CMT
Pain
- Assess discomfort @ rest→ FLACC scale should be used****
- CMT should NOT be painful!!!
MSK Exam CMT
Cranial Anthropometrics:
- Facial asymmetries
- Skull deforms:
- plagiocephaly
- brachiocephaly
- Combination***
Tx of CMT
- Principle→ STRETCH tight side, STRENGTHEN weak side
-
CPG 3 categories:
- “First Choice”→ most evidence*
- “Supplemental”→ not as strong evidence
- Interventions not supported by any