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Torticollis refers to lateral tilt and rotation of the head and neck. The most common form of torticollis is known as congenital muscular torticollis and is due to “over pull” of the sternocleidomastoid muscle to the side of head tilt. So, for example, a right-sided sternocleidomastoid muscle contracture would result in head tilt to the right and rotation of the chin to the left (Fig. 216-1). This deformity is seen at birth and is often associated with a very tight sternocleidomastoid muscle (SCM) that often has a small mass or swelling in its midsubstance which is palpable but not painful. The incidence of congenital muscular torticollis is 3 to 5 per 1000 births. The etiology is not completely understood but is associated with breech presentation and difficult forceps delivery and occurs more commonly in first-born children. It is important to remember that this is a painless torticollis. Other associated orthopedic conditions are associated with torticollis including hip dysplasia and metatarsus adductus. These conditions should be evaluated as part of the normal orthopedic examination with specific focus placed on the examination of the hips and feet, as well as the spine in patients with muscular torticollis.1

Figure 216-1.

Congenital muscular torticollis in a young boy. The tight right sternocleidomastoid causes the right head tilt and rotation to the left.

The clinical presentation typically demonstrates a predisposition to tilting the head to one side with rotation to the opposite side. A small mass in the midportion of the sternocleidomastoid is palpable on the affected sternocleidomastoid muscle and has the feel and size of an olive. The face on the ipsilateral side of the SCM lesion demonstrates some flattening with loss of roundness of the back of the head (plagiocephaly) on the opposite side.

The differential diagnosis of congenital muscular torticollis includes congenital cervical vertebral anomalies, inflammatory atlantoaxial rotatory displacement, central nervous system (CNS) tumors of the posterior fossa or cervical spinal cord, or visual abnormalities. When the sternocleidomastoid is contracted with the palpable olive with a consistent head tilt to the ipsilateral side with rotation to the opposite side, the diagnosis is nearly confirmed. Treatment consists of stretching exercises to rotate the infant’s chin to the ipsilateral shoulder, while tilting the head toward the contralateral shoulder. This should be performed several times during the day and generally results in outstanding correction of this deformity over a 6 to 12 month period of time. Other modalities such as positioning the child in their crib so as to look at objects opposite to his or her restricted motion are appropriate. Early nonoperative treatment is usually successful with restoration of full motion.

The plagiocephaly seen with congenital muscular torticollis is due in large part to the abnormal head tilt and rotation, as well as the supine position that has been recommended by the American Academy of Pediatrics ...

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