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Torticollis (wryneck) is a head position whereby the ear is tilted to 1 shoulder and the chin is rotated to the opposite shoulder. The most common form of torticollis is known as congenital muscular torticollis and is due to overpull of the sternocleidomastoid (SCM) muscle. This deformity is typically noted within the first 2 to 4 weeks of life and almost always by 6 months of age. The incidence of congenital muscular torticollis is reported to be approximately 3 to 5 per 1000 births. Although its etiology is not completely understood, the condition has been previously linked to breech presentation, increased infant size, difficult forceps delivery, and first-born children. Orthopedic disorders associated with torticollis include hip dysplasia, clubfoot, and metatarsus adductus.

Clinical presentation of congenital muscular torticollis ranges from a benign postural preference without range of motion limitation to severely restricted mobility with a very tight SCM. In some cases of congenital muscular torticollis, the SCM may have a palpable, painless, olive-like swelling in its mid-substance (fibromatosis colli). Physical examination demonstrates a tilt of the head to 1 side with rotation to the opposite side. For example, a left-sided SCM muscle contracture would result in head tilt to the left and rotation of the chin to the right (Fig. 213-1). It should be noted that chin rotation toward a tight SCM is atypical for congenital muscular torticollis and should prompt further evaluation of other nonmuscular causes. Although rare, head tilt may be absent with involvement of both SCMs. Craniofacial asymmetry is noted in as many as 90% of patients with congenital muscular torticollis at initial presentation.

Figure 213-1

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

Due to the persistence of abnormal head positioning, particularly for prolonged periods in the supine position, skull abnormalities including plagiocephaly can result. In general, plagiocephaly will improve over time with the correction of torticollis as the asymmetric pressure is alleviated. There is some evidence that use of an orthotic helmet can improve plagiocephaly when compared with traditional repositioning techniques.

The differential diagnosis of congenital muscular torticollis includes vertebral anomalies, atlantoaxial rotatory displacement, central nervous system (CNS) tumors of the posterior fossa or cervical spinal cord, and visual abnormalities (eg, strabismus). Diagnosis is based on characteristic clinical findings including head positioning and asymmetry, tightness of the SCM, and restricted neck range of motion. Routine imaging is not recommended, although neurologic and visual examination can help to narrow the differential.

Treatment for congenital muscular torticollis consists of stretching exercises to reverse the direction of the deformity (ie, rotating the infant’s chin and tilting the head toward the opposite shoulder). These exercises should be performed several times throughout ...

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