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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
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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.
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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.
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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 ...