1. Torticollis

2. Causes :
1. Developmental defect in sternomastoid muscle. 2. Malposition of neck in the uterus. 3. Difficult labour, breech and forceps delivery. 4. Muscle ischaemia : pathological changes similar to VIC. Ischaemia is due to arterial obstruction. 5. Venous ischaemia : venous occlusion caused by persistent lateral flexion and rotation of the head before birth.

3. Incidence is more common in girls.
It can be unilateral or bilateral.
There may be shortening of scalenii, platysma, splenius or trapezius muscles.
Shortening of sternomastoid muscle is the principle causative factor.

4. Two types:
Congenital postural torticollis : it is transient in nature and does not require operative treatment.
2. Congenital muscular torticollis : it appears 2 weeks after birth and is associated with development of a tumour in sternomastoid muscle. (controversies related to etiology)

5. Sternocleidomastoid tumour
Ischemic etiology : sternocleidomastoid branch of Superior thyroid artery
Theory not supported by evidence; vascularity observed in the tumor
Biopsy findings not consistent with Volkman’s ischemic contracture
Hematoma due to injury at birth:
Not supported by evidence.
A fibrotic patch is observed in 15 to 25% of the muscle – seen with in 2 weeks after birth; not expected in a tissue injured 2 weeks back.
Tumor also observed in babies delivered of C-Section
Developmental anomaly: the most likely etiology

6. Clinical features.
Swelling appears after 10 days of birth in sternomastoid . It is tender and painful if the muscle is stretched. The tumour disappears by about 7th month and there is shortening of sternomastoid muscle.
Head is fixed in side flexion to one side i.e; the affected side and rotated to the opposite side.
shoulder on the affected side is raised.
Scoliosis with convexity to the unaffected side is present in the cervical region.

8. Facial asymmetry is present ( due to cranio vertebral torsion)
Smaller eye, lowering of the corners of the mouth and eye.
Deviation of nose on the affected side.
Facial palsy may be present in postural torticollis due to pressure on the facial nerve.
In bilateral affection, both sternocleidomastoid are contracted.
The head is protruded forward with associated kyphosis.
Sometimes torticollis develops a few months after birth with no steromastoid tumour and is due to congenital vertebral anomalies.

9. Treatment: Objectives:
1. To correct the deformity by release of the contracted soft tissues.
2. To maintain the correction.
3. To prevent recurrence

10. Evaluate the range of motion.
Massage can help in relaxation of muscle prior to stretching.
Hot packs can assist in relaxation.
Passive movements by placing the head in extension with the help of a pillow under the thoracic region.
Slow relaxed passive movments of the cervical spine followed by sustained stretching.

11. When Rt. Sternocleidomastoid is involved the head is bent in side flexion to the left, and later rotated to the right.
Apply traction to gain further stretching. Maintenance of over correction by passively holding or placing a sand bag.
Active correction: the child is encouraged to move the head in arc of correction.
Vestibular ball exercises, head righting reactions encouraged.

12. The mother should be trained to move the child’s head towards the affected side and the child is encouraged to look back over the right shoulder.
Proper positioning during sleep with the help of sand bags is important. The child is made to sleep on the opposite side of lesion.
There are 2 advantages:
Correction is maintained
There is natural relaxation of the muscles..

14. Surgical treatment Z lengthening of the sternal head.
Bipolar sternomastoid tenotomy: open tenotomy of the mastoid and clavicular attachments, release of the cervical fascia and z plasty of the sternal head.
Resection of muscle: for removal of tumors. ( earlier performed in the 1st few weeks of life)

15. Possible complications:
Subcutaneous tenotomy: injury to Jugular vein
Division of upper end of the muscle: Injury to spinal accessory nerve

16. In older children and adults the deformity gets organised and surgical correction is necessary.
The head is immobilised in plaster cast for 2 to 4 weeks followed by mobilisation as soon as the cast is removed.

17. Post surgery PT management:
Hot packs for pain relief.
Active movements of sternocleidomastoid to prevent post surgery weakness.
Free active movements in the direction of correction followed by resistive exs.
Self correction in front of mirror.
Specially moulded cervical collar and maintenance of correction during sleep.

18. Cervical Rib

19. Fibrous or bony development of the costal process of seventh cervical vertebra.
Unilateral or bilateral.
Congenital and asymptomatic in early years.
In adult life person develops depressed and rounded shoulders.

20. Neurological complications :
The lowest trunk of brachial plexus may be pressed against the rib.
Complete sensory anaesthesia in the forearm and hand over the area supplied by the lowest trunk of brachial plexus.
Pain and paraesthesia – ulnar aspect of the forearm and hand.
Weakness of the finer movements of the hand may be present.
Atrophy – interossei, and the muscles of the thenar and hypothenar eminence.

21. Vascular symptoms : Absence or feeble radial pulse.
Dusky cyanosis of the forearm and hand.

22. Differential diagnosis :
Important to rule out PVD like Raynaud’s disease.
Syringomyelia, MND, Poliomyelitis and Muscular dystrophy.

23. Surgical treatment :
Indicated in patients with vascular and neurological signs.
Removal of the cervical rib and the associated fibrous bands and occasionaly dividing the scalenii muscles.

24. PT management : Postural guidance. Hot packs for pain relief.
exercises to improve distal circulation of hand and fingers.
Improve tone , power, endurance of the upper extremity.
Identify the movements which relieve symptoms.
Shoulder girdle elevation, retraction and raising the arm overhead brings spontaneous relief.

25. Therefore following exs are very important:
Edgelow’s protocol : progress as symptoms resolve
Self resisted scapular elevation.
Self resisted scapular adduction( shrugging ).
Endurance training to shoulder girdle muscles.
Progressive resisted exs with therabands.

26. Klippel Feil Syndrome

27. Clinical features: Absence or shortness of the neck.
Limitation or absence of neck movements.
Low hair line at the base of neck.
Facial asymmetry.
Elevation of scapula, associated sprengel’s shoulder.
Cervico thoracic scoliosis.
Abnormalities of the upperlimb such as syndactyly, supernumerary digits, renal anomalies, impairment of hearing, congenital heart disease.

29. Appearance of the patient is characteristic:
There appears almost no neck
The trapezius muscles are tensed and produce winged appearance or pterygium colli.

30. Radiological findings :
Fusion of some or all of the cervical and upper thoracic vertebrae.
Vertebral body segmentation.
Atlanto occipital fusion.
Cervical spina bifida.

32. Neurological complications:
Radiculopathy, myelopathy or quadriplegia due to compression of spinal cord or nerve roots may arise in older children or later in life.
These changes may be due to hypermobility of the unfused segments adjacent to fused segments.

33. Surgical treatment : Local spine fusion.
Wire fixation carries a risk of neural injury when there are anomalous vertebrae and recommend delicate exposures.
Decortication using an air drill and the placing of autogenous cancellous iliac grafts with external immobilisation with a halo cast.
Cervical traction should be avoided.
Webbing of the skin is corrected by plastic surgery.
Short neck appearance is improved by partial thoracoplasty of the upper ribs.

34. PT management : After the period of immobilisation:
Strengthening of postural muscles
Neurodynamic mobilisation with close attention to signs of irritation
Breathing exercises.
Postural training in front of the mirror.

35. Sprengel’s deformity Also called ‘High Scapula’
Abnormally raised scapula on one or both sides
Scapular muscles poorly developed, may be represented by fibrous bands
May be assoc. with scoliosis with convexity towards affected side
Movement of scapula restricted due to fibrous bands or bony bar ( restricted shoulder abduction)

36. Management Corrective exercises not effective
Functional disability is minimal to moderate
Surgical: excision of the fibrous bands or bony bar leading to change in position of the scapula.

37. Physiotherapy ( post surgical):
Gradual relaxed passive mobilisation of shoulder and scapula
Pain relief
Strengthening
Postural correction with increased sensory awareness of the newly acquired posture.

38. THANK YOU