CONGENITAL MUSCULAR

TORTICOLLIS
A PAEDIATRICS UNIT PRESENTATION
BY

OGBUJI MAC-DONALD C.

27/09/2023
CONTENTS
• Introduction Conclusion
• Relevant Anatomy References
• Prevalence
• Predisposing factors
• Causes
• Pathophysiology
• Signs and Symptoms
• Complications
• Assessment
• Management
• Recommendation
INTRODUCTION
• Torticollis is a problem involving the muscles of the neck that causes the
head to tilt down. The term comes from two Latin words: tortus, which
means twisted, and collum, which means neck. Sometimes it’s called
“wryneck.” (Shroff 2022).
• It is a rare condition in which the neck muscles contract, causing the head to
twist to one side.
• In general, torticollis is classified as either congenital (present at birth) or
acquired (occurring later in infancy or childhood).
• By far the most common type is congenital muscular torticollis. Although
children have this when they are born, parents may not notice it until
children are several weeks old, as they start to gain more control of their
head movement.
RELEVANT ANATOMY
• The sternocleidomastoid muscle has a sternal and clavicular head.
• The sternal head originates at the manubrium sterni moving superiorly,
laterally and posteriorly.
• The clavicular head originates at the medial third of the clavicle and
runs vertically upward.
• It inserts at the mastoid process and enables ipsilateral lateral flexion
and contralateral rotation.
• SCM also extends the upper part of the cervical spine and flexes the
lower part.
PREVALENCE
• Torticollis in infants is most commonly caused by congenital muscular
torticollis.
• Congenital muscular torticollis is the third most common congenital
musculoskeletal condition in newborns - its prevalence ranges from
0.3% to 19.7%
• It has been associated with upper cervical spine dysfunction and has
been called a "kinetic imbalance due to suboccipital strain"
• Acquired torticollis is posttraumatic 10 to 20% of the time.
• Generally, there is a female to male predilection of 2 to 1.
(Physiopedia, 2010)
PREDISPOSING FACTORS
• Factors associated with congenital torticollis are, but not
limited to;
• plagiocephaly.
• breech delivery.
• cesarean section delivery.
• twin A (lower in utero)
• complicated deliveries (forceps or vacuum)
• birth trauma.
CAUSES
• The shortening of one of your baby’s sternocleidomastoid muscles
(SCMs) causes congenital torticollis.
• Your SCMs are two large muscles in your neck, they connect the back of
your skull to your breastbone (sternum) and collarbone (clavicle).
• Researchers aren’t sure why one of these muscles shortens in some babies. It
may be due to:
• The way your baby was positioned in your womb (uterus).
• An abnormal development in the SCM.
• A collection of blood in your baby’s neck muscles (hematoma).
• Abnormal thickening of your baby’s muscle tissue (fibrosis).
• Klippel-Feil syndrome, a rare birth defect that causes the vertebrae in your
baby’s neck to fuse.
PATHOPHYSIOLOGY
• Congenital muscular torticollis is rare (< 2%) and is believed to be caused
by local trauma to the soft tissues of the neck just before or during delivery
(Canale,1994).
• The most common explanation involves birth trauma to the
sternocleidomastoid (SCM) muscle, resulting in fibrosis or that intrauterine
malpositioning leads to unilateral shortening of the SCM, (Robin NH 1996).
• There may be resultant hematoma formation followed by muscular
contracture, these children often have undergone breech or difficult forceps
delivery.
• The fibrosis in the muscle may be due to venous occlusion and pressure on
the neck in the birth canal because of cervical and skull position.
PATHOPHYSIOLOGY(CONT’D)
• Another hypothesis includes malposition in utero resulting in
intrauterine or perinatal compartment syndrome.
• Other causes of congenital torticollis include postural torticollis,
pterygium colli (webbed neck), SCM cysts, vertebral anomalies,
odontoid hyperplasia, spina bifida, hypertrophy or absence of cervical
musculature, and Arnold-Chiari syndrome.
• It can also be seen with clavicular fractures, especially in neonates
secondary to birth trauma.

(Stevens P et al., 2007)

SIGNS AND SYMPTOMS
• Symptoms of congenital torticollis may include:
• Your baby’s head tilts to one side and chin tilts to the other side.
• Limited movement of your baby’s head and neck.
• One of your baby’s shoulders is higher than the other.
• Neck muscle tightness or stiffness.
• Swollen neck muscles.
• Small pea-sized lump in one of your baby’s neck muscles.
• Uneven (asymmetrical) facial features.
COMPLICATIONS

• If the problem is not fixed, the baby will be unable

to move their head normally. It will lead to
permanent muscle tightening. It will cause the neck
and face to develop unevenly.
ASSESSMENT
• Congenital muscular torticollis can assessed right from the clinical presentation
which includes;
• reduced neck range of motion
• palpable SCM mass
• head position preference
• plagiocephaly
• However, some cases will require complementary diagnostic tests.
• Ultrasonography (US) is the most frequently used form of imaging, especially for
neonates
• it is useful for assessing neck masses, pseudo-tumour
• useful for monitoring/evaluation post-treatment
• Magnetic resonance imaging (MRI) may be used to rule out non-muscular causes
ASSESSMENT CONT’D
• Further assessment for CMT includes:
• passive cervical range of motion with arthrodial goniometer
• active range of motion
• global assessment
• neurological, auditory and visual function assessments to rule out other
conditions
• Identification of red flags is essential. These include: poor visual
tracking; abnormal muscle tone; other features inconsistent with CMT;
poor progress with treatment. If you identify these features, appropriate
onward referral is necessary.
MANAGEMENT
• There is no standardised treatment for CMT, but with appropriate
interventions, it has been found that 90 to 95% of infants will improve
before the age of 1 year. If treatment is commenced before 6 months, 97% of
infants will improve,(Gundrathi J et al.,2023)
• Physiotherapy (stretching, strengthening and developmental facilitation) and
aggressive repositioning are first-line treatments. Helmet therapy may be
considered for infants with moderate to severe and persisting asymmetry.
• Education, guidance and support can reassure and help parents. It is
important to educate parents/caregivers on positioning and handling skills to
encourage active neck rotation towards the affected side and to discourage
side flexion to the affected side (e.g. during feeding).
MANAGEMENT CONT’D
• Manual stretches are an important part of treatment. Manual stretches include side
flexion and lateral rotation. It is necessary to show the caregiver how to stabilise and
correctly position their hands for each stretch. Please note that stretching techniques are
contraindicated in infants diagnosed with Klippel-Feil syndrome.
• Passive ROM Lateral Neck Flexion
• The following stretch is useful to encourage lateral flexion of the neck:
• hold infant's shoulder
• perform side tilt until you feel a gentle stretch
• never force the stretch
• infant should not be crying, but might be fussy, so try to keep them distracted
• can perform supine, or lying on your lap
• hold stretch for 30 seconds
Passive ROM Cervical Rotation
• The following stretch is useful to encourage cervical rotation:
• rotate to the infant's non-preferred side
• place your hand on their cheek
• block their opposite shoulder and rotate them
• the goal is to get their chin over the top of their shoulder
• can be performed supine or while being held.
KINESIO TAPING;
• Kinesio taping is an alternative intervention for CMT.
• It has been suggested that kinesio taping might decrease treatment duration for
CMT and that it can have an immediate effect on muscular imbalance in children
with CMT.
MANAGEMENT CONT’D
Home Programme
• There are certain measures that caregivers can take at home to help their child with CMT:
• place toys/decorations to encourage infant to turn to other side
• position the crib or changing table, so the infant must turn to the other side to see /
interact with caregivers
• Tubular Orthosis for Torticollis (T.O.T) collar
Medical Management;
• If conservative treatment is not successful, botox] or surgical options may be considered.
• Surgical may be indicated for the following:
• no improvement after six months of manual stretching
• there is a deficit of more than 15 degrees in passive rotation and lateral bending
• tight muscular band is present
• there is a tumour in SCM
RECOMMENDATION
• Physical therapy is the recommended treatment for torticollis.
• Craniofacial asymmetry is a long-term complication if the contracted
sternocleidomastoid muscle is not released. Efforts should be made to
correct torticollis to prevent the progression of facial asymmetry.
• Its recommended to also know about assessement, and management of
acquired torticollis.
CONCLUSION
• Torticollis is a clinical sign that might signify an underlying disorder.
• In newborn infant with CMT, ultrasound is preferred and often
diagnostic.
• In older children CT is used to diagnosed traumatic insult, neck
infection and vertebral anomalies.
• MRI is used to diagnosed inflammatory and infectious spinal disorders
and in which CNS or neck malignancy is suspected.
REFERENCES
• Macias C, Gan V. Congenital torticollis in children [database online]. Waltham, Mass:
UpToDate; 2007.
• Tindall GT, Cooper PR. Spasmodic torticollis. Tindall GT,. Cooper PR, Barrow DL,
eds. Practice of Neurosurgery. Philadelphia, Pa: Lippincott, Williams & Wilkins; 1996.
Vol 3: 2636, 2807, 2969, 3236-7.
• Wilkins RH, Rengachary SS. Spasmodic torticollis. Wilkins RH, Rengachary SS,
eds. Neurosurgery. 2nd ed. New York, NY: McGraw-Hill; 1996. 4159-61.
• Gundrathi J, Cunha B, Mendez MD. Congenital Torticollis. 2023 Jan 31. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 31747185.
• Haque S, Shafi BB, Kaleem M. Imaging of Torticollis in Children. RadioGraphics. Mar
2012; 32(2): 558-571
• ↑ Petronic I, Brdar R, Cirovic D, Nikolic D, Lukac M, Janic D, et al.
Congenital muscular torticollis in children: distribution, treatment duration and out co
me