Orthopaedic Assessment and Intervention in infancy Flashcards
what percentage of births have major congenital disorder
2-3%
what is congenital muscular torticollis
latin for twisted neck
clinical sign of asymmetric neck posture - could be a result of multiple underlying disorder
how does congenital muscular torticollis typically present itself
presents with head tilted to one side and
rotated to the other
what are the three types of congenital muscular torticollis (CMT)
- Sternomastoid tumour (SMT)
- Muscular torticollis (MT)
- Postural Torticollis (PT)
Describe sternomastoid tumour
a type of congenital muscular torticollis
shortening of the SCM muscle due to a fibrotic mass
Describe Muscular torticollis
a type of Congenital muscular torticollis
shortening of the SCM
muscle but without a fibrotic mass
causes unilateral contracture of SCM muscle
Describe Postural Torticollis
a type of Congenital muscular torticollis
asymmetry of neck ROM,
following persistent positional preference of the head
what are the causes of SMT
true aetiology unknown
now thought to be damage of shortening of SCM due to intrauterine positioning/constraint - leads to venous occlusion
what is the typical presentation of SMT
palpable mass
develops around 2-3wks and resolves from ~4 months
size can range from less than 1cm to 4cm in diameter
contracture of SCM muscle causes neck to tilt to same side and rotate opposite side
describe rate of incidence of SMT
Incidence 0.4 - 3.9% of new-borns
3M:2F
What is muscular torticollis
results from the resolution of SCM mass after around 4/12
a non-contractile band of muscle is present
what would be observed in an objective assessment of a patient with muscular toticollis
non contractile band of muscle => shorterning and thickening of muscle on palpation
limited ROM
What is postural Torticollis
mildest form of CMT
a positional preference
what can cause postural torticollis
Can develop secondary weakness/tightness due to asymmetrical use and positional preference
this positional head preference develops near end of pregnancy
usually prefer R>L
Neonates don’t have enough head control to turn head so head preference persists
what would be observed in an objective assessment of a patient with postural torticollis
No morphological changes to SCM and full/almost full passive ROM CSp, but asymmetrical active CSp ROM
describe rate of incidence of postural torticollis in new borns
Incidence 16% of new-borns
what can be a by-product of postural torticollis
Babies’ skulls are soft, so this head preference can
lead to flattening of the skull on one side
(plagiocephaly) before or after birth
what is the origin of the word plagiocephaly
oblique head - greek
what is plagiocephaly
it is the flattening of the skull on one side before or after birth
what types of positional plagiocephaly
Occipital flattening
Ipsilateral ear pushed forward
Ipsilateral forehead bossing
Ipsilateral fuller cheek and eye
Parallelogram shape
what is plagiocephaly associated with
intrauterine constraint
and prematurity
whay percentage of the brain is at adult volume once at birth, by 2 years old and by 5 years old
25% adult volume at birth
77% adult volume at 2 years old
90% adult volume at 5
what are sutures of the skull
fibrous bands of tissues, that connect the bones of the cranium, and meet at the fontanelles
why are the sutures of the skull fibrous
Being fibrous allows for some movement of
the bones of the skull (this enables an infant’s
skull to pass more easily through the birth canal and also allows for rapid brain growth
describe rate of incidence of plagiocephaly
38% of healthy full-term babies
what equipment can influence plagiocephaly
changes in
baby equipment / handling
what may be discovered in an infant with plagiocephaly during an objective assessment
No morphological changes to neck muscles
* But can develop secondary weakness/
tightness due to asymmetrical use
* This leads to further positional preference
of the head
craniosynostosis
a congenital anomaly with premature closure of one or more sutures between cranial bones
what are the possible consequences of craniosynostosis
It has the potential for negative neurologic and cognitive effects
what is the rate of incidence of craniosynostosis
6 per 10,000 births
types of craniosynostosis
metopic
sagittal
bicoronal
unicoronal
lambdoid
https://www.cincinnatichildrens.org/health/c/craniosynostosis
what are the features of lambdoid synostosis
frontal protuberance
mastoid protuberance
posterior protuberance
ear displaced posteriorly
closed lambdoid suture
what are the features of synostic plagiocephaly
hx of misshapened head at birth
palpable ridge over suture
ipsilateral ear is posterior and displaced inferiorly (anterior in deformational)
* becomes more severe with time
neck massess detected in infants could also mean?
cysts e.g. branchial cyst
Lymphadenopathies
Lymphangiomas
Tumours
signs of neurological disturbance in infants
head tilt
vomiting in the am
headache in the am
loss of balance
regression of milestone
change in gait
weakness
behaviour change
ocular change
what signs of spinal changes can be present in infants
head tilt/scoliosis
pain
weakness
anasthesia/parasthesia
loss of bladder/bowel conrol
what is grisel syndrome
Atlanto-axial subluxation due to periligamentous inflammation following
infection/inflammation in the area
after what surgery can grisel syndrome arise in infants
tonsillectomy/adenoidectomy
what infection/inflammation is commonly present before grisel syndrome
Pharyngitis, tonsillitis, mastoiditis,otitismedia, retro-pharyngeal abscess
what infections can affect protective posturing
infections in head or neck region e.g. osteomyelitis of CxSp or otitis media
what is benign paroxysmal torticollis
episodes of torticollis (head tilts)
can last minutes (10mins) to months (2 months)
episodes become less frequent with age and stop by age 5
what other signs and symptoms are associated with benign paroxysmal torticollis
pallor
vomiting
ataxia
irritability
what is sandiers syndrome
By tilting head / arching back,
stretches oesophagus and relieves
pressure
CAN BE MISTAKEN FOR SEIZURE
what is sandifer’s syndrome associated with
gastro-esophageal reflux disease(GERD)
What are the signs of sandifers syndrome
irritable, coughing, breathholding, poor feeding, poor sleeping
what are red flag signs for severe pain
Fractures,
osteomyelitis,
retropharyngeal abscess
what are red flags of raised ICP
Sunset phenomenon
Bulging fontanelle
Vomiting
Headache
Drowsy
What are may an acute onset of symptoms be a red flag for
Infection, abscess, Grisel Syndrome
what is acid reflux a possible red flag for in infancy
GERD
Sandifer syndrome
what is fever a possible red flag for in infancy
Infection, abscess
what is dysmorphic features a possible red flag for in infancy
syndrome
what is lymphadenopathy a possible red flag for in infancy
infection
what is increasing head tilt a possible red flag for in infancy
Infection, tumour
what is recurrent episodes tilt a possible red flag for in infancy
Benign paroxysmal torticollis
what is recent change in function tilt a possible red flag for in infancy
Acute neurological event
what topics should be covered whilst taking a subjective history in ortho infants
birth/medical history
asymmetry in head/neck, spine, hips, feets
development hx - asymmetry in sucking hand, feeding, rolling
investigation - depends on source of referral
what is observed in the objective assessment
posture in different positions - supine, prone, upright
neonata asymmetry
baby most symmetrical by 4/12
what milestones must an infant at 6/12 accomplish in supine
turn head either side
rolling on either side
what milestones must an infant at 6/12 accomplish in prone
should have extended head and arms
head in midline or rotating either side
how is the head tilt assessed
in supine, prone, upright
no head midline until 4 months but is normal for some tilting at young age
head midline should be present by 4 months in prone
what should be assessed in objective assessment of infant
head preference of positioning - to check for positional torticollis
check for head tilt in supine, prone, upright for all sorts of torticollis, sandifers syndrome
check cranio facial features for craniosynostosis
observe and palpate neck for SMT, SCM tumour or nodes,
hearing vision abnormalities
check for other conditions - look for asymmetries in spine, hips, feet
how is the cervical spine rom assessed in infants
make sure baby is relaxed and in age appropriate positions and stimulation
if PROM try and have the head over the edge of surface
stabilise trunk, block shoulder, support head
bring the babys hand to mouth
what is the estimated degree of cervical rotation if an infant can get their chin past their shoulder
100 degrees
what is the estimated degree of cervical rotation if an infant can get their chin to their shoulder
90 degrees
what is the estimated degree of cervical rotation if an infant can get their chin to mid-clavicle
70 degrees
what is the estimated degree of cervical rotation if an infant can get their chin to nipple line
45 degrees
how is passive side flexion of CxSp completed in infants
in supine
stabilise shoulder
palmar surface of hand should make contact with posterior aspect of skull and finger tips should make contact with temples of the infant
how is muscle strength assessed in infants
righting response
head always wants to stay upright
test by holding baby and tilting trunk side to side as age appropriate
look for functional Ax - pull to sit, rolling over, supine to sit up, reach up
what is the muscle function scale
Measures lateral head righting while holding the infant horizontally
what does the muscle function scale score 0 mean?
if head below horizontal
what does the muscle function scale score 1 mean?
head horizontal
The child must hold head at least 5 sec to score that level
what does the muscle function scale score 2 mean?
2 slightly above horizontal <45degrees
The child must hold head at least 5 sec to score that level
what does the muscle function scale score 3 mean?
2 slightly above horizontal >45degrees
The child must hold head at least 5 sec to score that level
what does the muscle function scale score 4 mean?
4 holding very high above horizontal nearly vertical
The child must hold head at least 5 sec to score that level
what is the physio management of CMT/plagiocephaly
CSp and trunk active ROM
PROM (if AROM not full)
Development of age-appropriate,
symmetrical movement
Environmental adaptations
Parent/carer education
