Congenital Muscular

Torticollis
Referat Pedi 2 - Reza Devianto

Consultant
Prof. Dr. dr. Yoyos Dias Ismiarto, SpOT(K)., M.Kes., CCD
dr. Fathurachman Sp.OT., M.Kes.

Pediatric Division
Orthopaedi and Traumaology department
Hasan Sadikin Hospital / Padjadjaran University
 Introduction

 Congenital Muscular Torticollis (CMT) is a congenital deformity characterized by

the head is tilted toward the side with the shortened muscle and the chin rotated
toward the opposite side

 It is a relatively common recognized infantile abnormality and its incidence varies

from 0.3% to 2.0% live births

 CMT is recorded as is the third most common congenital musculoskeletal anomaly

after dislocation of the hip and clubfoot
Etiology

 The hypothesis of birth injury

 The ischaemic hypothesis
 The hypothesis of intra uterine malposition
 The hereditary hypothesis
 The hypothesis of infection
 The nervous hypothesis
Pathology
 Clinical features

 The head is tilted toward the side of the

affected muscle, and the chin is rotated to
the opposite side.
• A mass of tumor may be palpable in the neck (non
tender, soft enlargment beneath the skin)
• Contractures of the sternocleidomastoideus muscle

• Skull and face deformities can develop

(plagiocephaly)
• The level of the eyes and ears becomes
unequal and can result considerable
cosmetic deformity
 Radiographs of cervical spine are normal
 MRI: abnormal signal in the sternocleidomastoid muscle
 USG : fusiform enlargement
Classification

 Sternomastoid tumor group (SMT);

 Muscular torticollis without palpable tumor group (MT);
 Postural torticollis group (POST), clinical features of CMT without sternomastoid tumor
or muscle tightness
 Diagnosis

 Diagnosis is based mainly on past medical history and clinical

examination of the infant
 All sign above
 It should be distinguish from postural torticollis
 Every patient should have radiograms of the cervical spine made to exclude
congenital anomalies of the vertebrae
 In the differential diagnosis, one should also consider of traumatic disorder of
cervical spine
 Management

 Non Operative Management

 Manual passive stretching : before the age of 12 months is the most

effective mode of physical therapy
 A program of gentle stretching exercise should include flexion extension, lateral
bending away from involved side and rotation toward it
 Streching exercise shoud be continued until full neck rotation achieved
 Cervical orthosis may be an adjunct and support for children whose lateral head
tilt dosesn’t resolve with exercise or older children with no longer tolerate
strecthing

 Botulinum toxin (Botox) could enhance the effectiveness of stretching on the side
of the contracture and allow strengthening of overstretched and weakened muscles
on the opposite side of the neck. 
Operative Management

 Surgical release may be considered in children older than 12-18 months of age with CMT
resistant to conservative treatment or in case of facial asymmetry and plagiocephaly
development
 Surgery is highly recommended when a restriction of movement up to thirty degrees is
present, as well in cases complicated with deformities of facial bones
 Surgical techniques to lengthen tight SCMs include unipolar release and bipolar release
TECHNIQUE
 Pre Operative Planning

 Cervical spine should be reviewed– bony anomalies or cervical scoliosis

 In fixed deformities, positioning of the head can be difficult for anestesiologist. Flexible fiberoptic
intubation shoud be considered
 The ear taped anteriorly and hair around the mastoid process is shaved
Positioning

 Supine postion , General anestesia

 Sanbag placed to elevate the shoulder on the affected side
 Draping should permit correction to be evaluated by bending the neck. The neck is bent
toward the unaffected side and the head rotated to affected side - the SCM muscle kept
under tension and the origin and insertion can be clearly identified
 Incision and dissection

 For release the distal pole SCM, Tranverse incision 3-

4long incision 1 cm superior the clavicle and the two
head the SCM Muscle
 The subcutaneus tissue and platysma muscle are
divided inthe lline incission and the tendon sheats of
clavicular and sternal head exposed
 For proximal pole exposure , 2-3 cm horizontal
incisision is made just distal the tip of mastoid process
 The dissection is carried deeper until the periosteum of
mastoid process exposed. Inserton of muscle exposed
subperiosteally
 Unipolar Release
 Release the sternal , some times clavicular head the SCM Muscle
 A transverse incision placed pararelly and 1 cm proximal to the
clavicle between calvicular and sternal head of the SCM
 Two head OF SCM Identified. Surrounding fascia is cleared and
sternal head or both head is undermined with curved clamp
 The muscle are elevated with the help of clamp and divide with
cautery. Alternatively sternal head can be lengthened by Z Plasty
 Check bending neck contralateral and rotating lateral side while
palpating area with finger tip to identified remaining tight
 Bipolar Release

 Bipolar release include the release of the

mastoid insertion of SCM Muscle along with
the distal released
 The procedure start with a distal incision
 The insertion of the muscle is identified
anteriorly and posterorly
 Dissection starts subperiosteally from mastoid
processus to avoid facial nerve anteriorly and
the anterior branch of the great auricular nerve
inferiorly
 Release the clavicular head with lengthening of
the sternal head by z plasty may appropriate in
older children and provide simetrical
appeareance post operative
PEARL & PITFALLS
 Post operative Care

 Immobilization the head and neck a slightly over corrected position with braces,
head halter traction or cervical collar for 3 weeks
 The brace is removed 3 weeks and passive stretching is recommeded as well as
active strengthening exercise
 Exercised continued for 3-6 weeks
 Outcome

 Early conservative mangement succesful in over 90 % children with CMT who are
younger than 1 year
 Cheng et al – excellent result operation at age 6 monts to 2 years with bipolar release
 Canale et al better with bipolar release, although the difference not significant
 Wirth et al reported satisfactory result in 48 of 55 patient with bipolar release with low
reccurence
Complication

 Wound breakdown
 Neurovascular damage
 Hypertrophic scar
Thank You