congenital_torticollis4

- Congenital Muscular Torticollis
     - see: diff dx in infants
     - results from fibrosis of sternal head;
     - can result from unilateral shortening of sternocleidomastoid, commonly associated
            with fibrosis of the muscle; (may also involve the platysma and scalene muscles);
            - birth trauma, occlussion of venous flow, or hematoma results in fibrosis
                    of muscle & palpable mass noted w/in first 4 wks of life;
     - mass usually resolves within the first year of life (90% resolve);
     - nontender enlargement may be palpated in body of sternocleidomastoid

- Grisel's Syndrome:
     - Atlantoaxial Rotary Subluxation in association w/ pharyngeal infection,
          occurs predominantly in children;
     - it results in severe torticollis, resistant to manual therapy;
     - > 5 mm of anterior displacement of arch of C-1 (Fielding type III) indicates
            disruption of both facet capsules as well as transverse ligament;
     - reduction w/ skeletal traction, followed by atlantoaxial fusion, is recommended;

- Rigid Torticollis:
     - see: diff dx
     - may also present as rigid deformity, & sternocleidomastoid is not
            contracted or in spasma;
            - torticollis most often follows an injury to the C1-C2 articulation;
            - frx of the odontoid in young child may not be apparent on initial x-rays;

- Associatted Anomalies:
     - congenital atlanto-occipital abnormalities;
     - bony anomalies of the Cervical Spine, esp involving C1 & C2;
     - congenital webs of skin along the side of the neck, pteygium colli;
     - DDH: (20%);
     - plagiocephaly:
            - w/ persistent contracture of sternocleidomastoid, deformities of face
                   and skull result and are apparent w/ in first year of life;
            - flattening of face is noted on side of contracted sternocleidomastoid
                   and is probably caused by child's sleeping position;
     - metatarsus adductus:

- Non Operative Treatment:
     - 90% will respond to passive stretching within the first year of life;
     - in first yr of life, rx consists of stretching sternocleidomastoid
           muscle by trying to rotate the head to opposite position.
     - stretching exercises should include not only lateral rotation,
           but also side bending to the opposite shoulder;

- Indications for Surgery:
     - failure of non operative treatment after 12 to 24 months of age, surgical
           intervention is needed to prevent further facial deformity;

- Operative Treatment:
     - involves resection of portion of distal sternocleidomastoid muscle from its
            sternal and clavicular attachments through transverse incision in the
            normal skin fold of the neck;
     - skin incisions immediately adjacent to clavicle may result in unsightly
            hypertrophic scars.
            - transverse skin incisions in skin folds 1.5 cm proximal to clavicle result
                  in imperceptible scars;
     - uncommonly, distal resection is insufficient and proximal release of
           sternocleidomastoid is needed;