Congenital Muscular Torticollis PDF

CONGENITAL MUSCULAR TORTICOLLIS Congenital Muscular Torticollis (CMT): Presentation: Unilateral shortening of the sternocleidomastoid (SCM) muscle. Limited cervical ROM. The infant's head is laterally flexed toward the shortened muscle, with the chin rotated to the opposite side. A...

CONGENITAL MUSCULAR TORTICOLLIS Congenital Muscular Torticollis (CMT): Presentation: Unilateral shortening of the sternocleidomastoid (SCM) muscle. Limited cervical ROM. The infant's head is laterally flexed toward the shortened muscle, with the chin rotated to the opposite side. An infant with shortening of the right SCM muscle exhibits a posture of right lateral neck flexion with rotation of the head toward the left. Congenital Muscular Torticollis (CMT): The term torticollis comes from the Latin for twisted neck. Facial asymmetry and plagiocephaly (flattening of the skull) often develop secondary to the persistent asymmetric positioning of the head. While the SCM may be the primary muscle involved, secondary shortening of other cervical muscles such as scalenes, levator scapulae, or upper trapezius occurs. It is the third most common congenital musculoskeletal condition after hip dislocation and clubfoot.  Infant with left congenital muscular torticollis. Note the facial asymmetry in the region of his mandible.  CMT is associated with mandibular asymmetry, craniofacial asymmetry including deformational plagiocephaly, eye and mouth displacement, scoliosis, brachial plexus injury, pelvic asymmetry, congenital hip dysplasia, foot deformity, muscle and functional asymmetry. Synonyms for CMT include fibromatosis colli, wry neck, or twisted neck. (Cranial Deformation) CD is a coexisting impairment in up to 90% of infants with CMT and increases the risk of facial, ear, and mandibular asymmetry. Up to 75% of infants with CD exhibit SCM imbalance or CMT. Synonyms for CD include positional deformation, deformational cranial flattening, or nonsynostotic head asymmetry.  Child with right CMT and CD, left asymmetrical brachycephaly. Note the right lateral flexion, chin turned to the left, asymmetry of the ear pinnae, eyebrows, mandible, and neck folds, wider forehead, right shoulder elevation, and trunk rotation. Anatomy of SCM CMT Causes:  A palpable mass or fibrotic tumor is often observed.  Hypothesized occlusion of blood vessels with resultant anoxic injury to the SCM muscle  Could result from intrauterine malposition or trauma at birth  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.  CMT is usually noted in the first 2 to 3 weeks after birth, with a reported incidence of 0.4% to 1.9% CMT incedence ---> 16% Dolichocephaly СМТ --> contralateral DP (post. flattening) A mass or fibrotic pseudotumor is often observed or is palpable within the belly of the SCM muscle and appears within the first few weeks after birth and then gradually disappears. Infants with CMT have a higher incidence of breech presentations and associated congenital musculoskeletal diagnoses, such as hip dysplasia and foot deformities. The "Back to Sleep" program, initiated by the American Academy of Pediatrics in 1992 to reduce the incidence of sudden infant death syndrome (SIDS), recommended sleeping in supine for infants. Since the inception of this program, SIDS rates have declined more than 50%, but the incidence of plagiocephaly and POST has increased dramatically. Positional (postural) torticollis Motor development is inversely associated with CD. Postnatal positioning factors associated with CD: 1-Supine sleeping. 2-Infrequent tummy time. 3-consistent bottle feeding on the same arm. 4-consistent positioning in a crib. CMT causes: 1-Prenatal factors: ischemic injury, intrauterine malposition, rupture of the muscle, infective myositis & hereditary. 2-Perinatal factors: birth trauma from breech presentations or assisted deliveries. 3-Postnatal factors: hip dysplasia, positional preference & deformational plagiocephaly. Histologic changes of SCM include fibrosis, hyperplasia & atrophy. SCM nodule (mass) Cranial deformation (CD) as a result of persistent asymmetrical pressure DD for CMT: Differential Diagnosis  CMT Types: SCM tumor (SMT): -A definitive mass/ tumor/ fibrous bands is palpable within the SCM muscle, with limitation of PROM. Muscular torticollis (MT): -Contracture of the SCM muscle (limitation of PROM) is present but no palpable mass is present. Positional (postural) torticollis (POST): -Contracture of the SCM muscle and a palpable mass are absent.  CMT Plagiocephaly Postural CMT is the mildest form. CMT severity can also be classified with US images based on the degree of fibrosis & fiber orientation.  Types of cranial deformation (CD): 1) Typical. 2) Plagiocephaly: ipsilateral occipital flattening. 3) Brachycephaly: central occipital flattening. 4) Dolichocephaly: long and narrow skull. Deformational plagiocephaly DP -→> ipsilateral ear ant. & inf. CMT Changes in Body Structure and Function: Presence of tight band or nodule. Limited ROM. Muscle weakness. Asymmetrical posture. Red, irritated skinfolds: Redness and deeper skinfolds along the anterior lateral side of the neck are characteristic of SCM tightness. Redness and deeper posterior neck skinfolds are an indication of tightness in the upper trapezius muscle. Pain during stretches. facial asymmetry mandibular hypoplasia C1-C2 subluxation Cervical and thoracic scoliosis Possible hip dysplasia Anterior and posterior views of characteristic asymmetric postural deformities shown in a 3-month-old infant (A-B), an 8- month-old infant (C-D), and an untreated 8-year-old child (E-F). All have left congenital muscular torticollis (CMT) and deformational plagiocephaly (DP). (A) 3-month-old in supine with incurvation of the entire vertebral column. (B) Same 3- month-old infant in prone. Note little change in the postural alignment. (C) 8-month-old in sitting exhibiting postural asymmetry. (D) 8-month-old in sitting exhibiting ipsilateral shortening of the posterior cervical muscles, shoulder elevation, and rotation of the thorax. (E-F) Untreated 8-year- old in standing with long-term functional consequences of CMT and DP, including postural asymmetries. contralateral shoulder forward. ipsilateral 1/2 of the face smaller. Possible activity limitations associated with CMT: decreased tolerance to prone positioning Asymmetrical propping on upper extremities Asymmetrical movements and transitions: rolling, sitting, quadruped, kneel, one-half kneel, and standing Asymmetrical or delayed protective and righting reactions of the head, neck, and trunk decreased visual tracking toward the ipsilateral side For most children, the delays resolve by 10 months, but for others, delays may persist into early childhood Possible participation restrictions associated with CMT: Prefers bottle feeding to one side or difficulty breastfeeding equally on both sides. Reduced tolerance of prone positions for play. Possible delays in development. Difficulty cleaning infant's neck. Possible activity limitations associated with CD: Asymmetrical visual tracking in supine. Difficulty fitting eyeglasses. Possible participation restrictions associated with CD: Teasing by peers due to craniofacial asymmetry Difficulty bottle or breastfeeding equally on both sides DB -> bilateral shoulder hiking, reduced cervical flexion, reflux dolichocephaly --> difficulty maintaining the head in midline when supine/ reclined sitting Craniofacial asymmetries. (A) Submental view of an 8-month-old infant with left congenital muscular torticollis (CMT) and deformational plagiocephaly (DP). Note recession of the frontal bone, eyebrow, and zygoma on the ipsilateral side and inferiorly and posteriorly positioned ipsilateral ear. (B) En face view shows hemihypoplasia of the face, decreased vertical facial height on the left, asymmetry of the eyes with the ipsilateral eye smaller, inferior orbital dystopia, canting of the mandible, and deviation of chin and nasal tip. (C) Submental view of an 8-year-old with untreated left CMT and DP demonstrating the same facial asymmetries as the 8-month-old infant. (D) En face view of same 8-year-old demonstrates similar cranial facial asymmetries and shortening of the left sternocleidomastoid muscle. Physical Therapy Examination for CMT: Limitation PT Measurement Arthrodial protractor or seated swivel test Cervical AROM Arthrodial protractor measurement of PROM Cervical PROM Time per episode and episodes per day in prone Prone tolerance TIMP for < 4 months old; AIMS for > 4 months Gross motor function to 1 year Test of Infant Motor Performance (TIMP) Alberta Infant Motor Scale (AIMS) Faces, Legs, Activity, Cry, Consolability (FLACC) Pain scale Cervical strength Muscle Function Scale N.B. In examination: start with activity & participation  AROM Assessment Active rotation should be measured in supine for infants under 3 months; for infants > 3 months, it should be measured while sitting on the parent's lap using the rotating stool test, by enticing the infant to follow toys or sounds in all directions. Active neck extension and rotation should be assessed in prone.  A-Position of the arthrodial protractor for measuring neck rotation B-Placement of the protractor for measuring lateral neck flexion  Muscle Function Scale: To assess lateral flexion by holding the infant vertically in front of a mirror and tipping her horizontally 90° to each side, observing for the amount of active neck righting from the horizontal line. 0 = with the head below horizontal, 1 = with the head on the horizontal line, 2 = with the head slightly over the horizontal line, 3 = with the head high over the horizontal line, and 4 = with the head very high over the line approaching vertical  CMT Prognosis The prognosis for full resolution of CMT is 100% for infants < 3 months of age, if they are referred early and caregivers are adherent with conservative intervention. The prognosis for full resolution drops to 75% for infants referred between 3 to 6 months of age, and 30% for toddlers between 6 to 18 months of age. The potential for surgical release increases with later ages of referral.