Pediatric Orthopedics

Torticollis

The term torticollis is derived from the Latin words tortus for twisted and collum for neck. while the head is tilted to effected side, it faces to opposite side.

How many types are available in Torticollis?

Torticollis has many types. Congenital muscular torticollis is the most common type. It can also be secondary to cervical bony deformities, ocular problems and neurologic diseases.

What causes the deformity?

The cause of congenital muscular torticollis is unclear. In congenital muscular torticollis etiology, there are several theories. One hypothesis blames birth trauma as causing the bleeding into the sternocleidomastoid muscle. According to this theory, fibrosis, a scar tissue formation is seen  following the bleeding and this fibrous tissue lead the SCM muscle shorten.  Another theory advocates that a kind of compartment syndrome causes the SCM muscle fibrosis. Also, repetitive intrauterine micro trauma are believed to cause   SCM muscle shortening.

What are the clinical signs? 

Parents notice the twisted neck and sometimes facial and head asymmetry. An olive sized nodule can be palpable in the sternocleidomastoid muscle. Typically, the head is tilted one side and face turned to the opposite direction. Patients should be evaluated for following conditions:

1- Klippel -Feil Syndrome is characterized with short neck, cervical vertebral abnormalities.

2- Ocular torticollis, certain eye muscle disfunction  may cause the deformity.

3- Neurological diseases like dystonia may be underlying problem.

Facial asymmetry and plagiocephaly should be evaluated and particularly for plagiocephaly, a pediatric neurosurgery consultation may be called. One should also keep in mind the increased co-incidence  with developmental hip dysplasia. Thus, all children with torticollis should be evaluated by physical examination and hip ultrasonography.

Which diagnostic tests are required?

Physical examination and ultrasonography may show a nodular lesion within the SCM muscle as well as muscle thickening. Those finding confirm the diagnosis of muscular torticollis. A cervical spine radiography is helpful to rule out the cervical vertebral anomalies. An MRI study may be required to rule out the neurological diseases like syringomyelia.

Treatment

The main pathology in muscular torticollis is Sternocleidomastoid muscle. I encourage the parents to do stretching exercises as advised. Most cases are resolved with regular stretching exercises. I recommend to continue the exercises up to two years of age. Children over 2 years of age may require surgical release. I perform either unipolar or bipolar release depending on the age and the severity of torticollis. In unipolar surgery, distal clavicular and sternal parts of muscles are cut, whereas in bipolar surgery also proximal attachment to the mastoid is severed.

 

About the author

Prof.Dr. Seref Aktas