Torticollis, Plagiocephaly, and Brachial Plexus Injury Flashcards
What is Congenital Muscular Torticollis (CMT)?
Unilateral shortening of the sternocleidomastoid (SCM)
What is the position of a child’s head that has CMT?
- Laterally flexed/side-bending to ipsilateral side
- Rotated to contralateral side
What cervical limitations do you see in a child with CMT?
- Contralateral sidebending and ipsilateral rotation
- Limited ext/flex but b/c of short neck it is hard to discern
An infant exhibits left lateral neck flexion and rotation of the head toward the right, what do they have?
Shortening of the left SCM
-Left Congenital Muscular Torticollis
What are some things you can look at to assess asymmetry of an infant/baby?
- Measure distance from ear to shoulder on both sides
- Look at occiput to see if a slant is present
- Look at spine and hips
- Visual tracking
- Equilibrium (vestibular system)
- Typical positions during activities (sleeping, feeding, etc)
- Reflexes
If the child has a left CMT, what is happening in the pelvis and face?
- Left CMT = Left sidebending, Right rotation
- More weight bearing on left hip/pelvis
- Left fascial drooping
- Left mandible has decreased muscle development
What is a prenatal deformation?
Normal responses of the tissue to abnormal mechanical forces.
what are 2 things that can cause prenatal deformations?
- Extrinsic forces - intrauterine constraint (baby may be laterally flexed and SCM will start to shorten)
- Intrinsic forces
What is the proposed etiology for CMT?
Specific causation is unknown.
- Can be associated with how the fetus is positioned in utero or from complicated delivery
- -> From babies being in breech position during delivery instead of vertex (“normal”) position
What are does CMT cause?
A palpable mass or fibrotic tumor is often observed
- Hypothesized occlusion of blood vessels with resultant anoxic injury to the SCM
- Could be from intrauterine malposition or trauma at birth
Is fibrosis present in all CMT children?
YES - Fibrosis of the SCM muscle is present in all children with CMT and ranges on a continuum of no palpable mass to a firm palpable mass
What is the Brachial Plexus Outcome Measure?
- evaluated quality of UE movement upon completion of 11 movements
- graded on a 5 point ordinal scale
- demonstrates good internal consistency and construct validity
- best used in adjunct w/Active movement scale
What are some PT goals for a brachial plexus injury?
- ideal outcome is complete return of motor control and sensation w/o limitations
- increase shoulder abd. to greater than 90 degrees
- correct internal rotation of arm
- increase flex/ext against resistance in elbow
- increase flex/ext against resistance in wrist and fingers
- improve sensation in arm and hand
- prevent deformities in arm and hand
- achieve developmental milestones
What are 3 CMT types
SCM Tumor Muscular Torticollis (MT) Positional Torticollis (POST)
Define SCM tumor
definitive mass or tumor PALPABLE withing SCM muscle
Define Muscular Torticollis (MT)
Contracture of SCM muscle is present but NO PALPABLE MASS present
Define Postitional Torticolis (POST)
Contracture of SCM muscle and PALPABLE MASS ABSENT.
This may be due to reflex
Positional reflex
What is some Conservative Congenital Muscular Torticollis Managment
-Prolonged passive stretching of SCM muscle
-POSITION AND HANDLING (Biggest challenge in babies)
-AROM in cervical with subsequent strengthening exercises
-Symmetric developmental activities to correct head position
Success of conservative management during first year
What is the TOT collar?
- Orthotic device that may be beneficial to help maintain Rom
- Soft tubular collar with struts of varying lengths that are positioned to elongate targeted muscles and limit motion in opposite direction
What is the criteria for a TOT collar
Recommended for infants at least 4 months old with consistent head tilt of 5 degrees or more for more than 80% of day who perform all movement with head tilt
When is surgical treatment indicated?
- When conservative tx has failed after 6 months
- Feeding is inhibited d/t ROM impairments
- Developmental milestones are delayed d/t torticollis
- Deficit of passive rotation and lateral flexion of neck >15 d
- *Symmetry is incredibly important!!**
What is plagiocephaly used for?
Should be treated in early infancy with cranial orthosis aimed at correcting cranial-facial asymmetry
What is Dynamic Orthotic Cranioplasty (DOC) band?
Cranial band that applies pressure to anterior and posterior prominences of cranium but allows growth in flattened areas
When is Dynamic Orthotic Cranioplasty recommended (AGE) and how often is it worn
- Recommeneded between 3 and 4 and below 12 months of age
- After that is difficult to modify development
- Worn 23-24 hours/day initially
Brachial Plexus Outcome Measure
- evaluated quality of UE movement upon completion of 11 movements
- graded on a 5 point ordinal scale
- demonstrates good internal consistency and construct validity
- best used in adjunct with the Active Movement Scale
Physical Therapy Goals (8)
- Ideal outcome is complete return of motor control and sensation without limitations
- Increase shoulder abduction to greater than 90 degrees
- Correct internal rotation of arm
- Increase flexion and extension against resistance in elbow
- Increase flexion and extension against resistance in wrist and fingers
- Improve sensation in the arm and hand
- Prevent deformities of the arm and hand
- Achieve developmental milestones
What are the procedural interventions for a brachial plexus injury?
- family education: rest period of 7-10 days to let inflammation decrease
- HEP development
- Active movement: relate to developmental appropriateness, humeroscapular rhythm, facilitate normal movement patterns, positioning techniques, developmental activities
What should you do for ROM and sensory in a brachial plexus injury?
- ROM: refrain from overstretching, adhesion prevention
- Sensory Awareness: reduce neglect (things that make noise, bright colors)
What should you do for splinting and positioning in a brachial plexus injury?
- place the child’s arm in optimal position, promotes soft tissue mobility
- intermittent splinting of the wrist and fingers to preserve tendons and reduce contractures
- utilize restraining splints to promote activity of the involved limb
What position should you put a child in who has suffered a brachial plexus injury?
shoulder abduction and ER, elbow flexion, forearm supination
What splints should you use for a child with a brachial plexus injury?
- intermittent wrist and finger splint until motor function returns
- resting night splints prevent finger contractures
- restraining air splints to promote use of involved hand
what three phenomena can occur to the nerves from a brachial plexus injury?
Neurotmesis, Axonotmesis, Neurpraxia
Neurotmesis
complete rupture of nerve
Axonotmesis
disruption of the axons with intact neural sheath; best prognosis
Neurpraxia
temporary nerve conduction block with intact axons
Name 3 locations of which a brachial plexus injury can occur.
- Rootlet attached to spinal cord, 2. Anterior or posterior rootlets, 3. Distal to rootlet attachment leaving vertebral canal
Name 3 risk factors for developing a brachial plexus injury
- Shoulder dystocia, 2. Maternal diabetes –> Large gestational size, 3. Difficult delivery
What kind of delivery may lead to bilateral brachial plexus injuries?
Breech delivery
What injuries can traction on newborn’s shoulder during delivery of the head in a breech delivery produce?
injure the cervical roots, fracture the clavicle or humerus, or sublux the shoulder.
Associated C4 damage will cause..
ipsilateral hemiparesis of the diaphragm
What is the most important risk factor for brachial plexus injury?
birth weight
The most common injury is to the
upper roots of C5-C6 (Erb’s Palsy)
Changes that occur usually resulting from the upper roots of C5-C6:
The shoulder is usually held in extension, IR, and adduction.
The elbow is extended, the forearm is pronated and the wrist and fingers are flexed (“waiter’s tip” position).
Grasp is intact (may be weakened) but sensory loss may be present.
If C7 is involved ____ & ____ _____is compromised.
elbow & finger extension
Erb-Klumpke palsy results in
injury to C5-T1, in total arm paralysis and loss of sensation
Horner’s syndrome
deficient sweating, recession of eyeball, abnormal pupillary contraction, etc.
Horner’s syndrome occurs with
Erb-Klumpke palsy
Klumpke’s palsy by definition involves only
lower roots C7-T1
What is affected in Klumpke’s?
- Shoulder and elbow movements are not impaired but the resting position of the forearm is in supination
- Paralysis of the wrist flexor and extensor muscles and intrinsic muscles of wrist/hand
Observation/Examination Findings of Erb-Klumpke Palsy.
Upper Extremity Neglect
Soft tissue Contractures
Abnormal Bone Growth
Orthopedic Abnormalities of Erb-Klumpke
Flattening of humeral head (not used to articulating)
Shortened clavicle
Hypoplasia of humeral head
Abnormal glenoid fossa (no WB and pushing from humeral head)
