1. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
In the name of god
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

2. Congenital muscular torticollis
Mohammad reza etemadifar MD
St Zahra hospital
Isfahan university of medical sciences
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

3. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
terminology
The term torticolis is derived form two Latin words, tortus, meaning “twisted,” and collum, meaning “neck,.”
Wryneck is a lay term is used to describe torticollis arising from any cause.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

4. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
definition
Congenital muscular torticollis is an asymmetrical deformity of the head and neck
the head is tilted toward the side with the shortened muscle
the chin rotated towards the opposite side.
This is caused by unilateral contracture of the sternocleidomastoid muscle.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

5. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
etiology
The exact cause of fibrosis of the sternocleidomastoid muscle in congenital muscular torticollis is not known.
Intrauterine malposition is commonly associated with the deformity and possibly it is due to a local ischemic process resulting from intrauterine malposition.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

6. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
etiology
The immediate cause of the deformity is fibrosis within the sternocleidomastoid muscle, which subsequently contracts and shortens.
The exact pathogenesis of the fibrosis is unknown. Edema, degeneration of muscle fibers and acute inflammation lead to fibrosis.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

7. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
Pathology
On section, the “tumor” appears white and glistening, in gross appearance resembling a soft fibroma.
Microscopic study shows that it consist of dense fibrous tissue.
In an older child, after the disappearance of the tumor, tissue excised from sternocleidomastoid muscle shows that the muscle has been replaced fibrous tissue
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

8. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
Pathology
If the deformity is not corrected the soft tissues of the affected side undergo adaptive shortening as growth proceeds.
The deep cervical fascia becomes thickened and contracted.
The scalenus anterior and medius muscles become shortened.
Later, the carotid sheath and the enclosed vessels contract.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

9. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
clinical Findings
The deformity may be present at birth or it may become evident about the second or third weeks.
The condition is more common in girls than in boys.
The head is tilted towards side of the affected muscle, and the chin is rotated to the opposite side.
Rotation of the neck to the side of the deformity and lateral motion to the opposite side are limited
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

10. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
clinical Findings
Palpation reveals a hard, nontender, fusiform swelling, or tumor, in the sternocleidomastoid muscle. Usually both the sternal and clavicular heads are involved.
Occasionally only the sternal head is affected.
The superior portion of the muscle close to its mastoid attachment is rarely, if ever, involved.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

11. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
clinical Findings
If the contracture is not treated secondary deformities of the face and head develop. The face on the side of the contracted muscle becomes flattened because of external pressure. The infant usually sleeps in prone posture.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

12. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
clinical Findings
Spontaneously, as it is more comfortable, the neck is rotated so that the affected side is down.
Ipsilaterally, the face is flattened by remodeling to conform to the bed.
A word of caution is appropriate plagiocephaly can be congenital owing to synostosis of the coronal fissures; this is ruled out by radiograms of the skull.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

13. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
clinical Findings
With skeletal growth, asymmetry of the face increase.
The levels of the eyes and ears change, defects that are less noticeable when the head is tilted to one side and more obvious when the head and neck are straight in the midline.
Eye strain may result from ocular imbalance.
A lower cervical-upper dorsal scoliosis with concavity towards the affected side may develop.
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برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

14. Right side congenital muscle torticollis
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

15. Left sided congenital muscle torticollis
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

16. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
diagnosis
Recognition of congenital muscular torticollis is not usually difficult because of the characteristic cordlike contracture of the sternocleidomastoid muscle. The early fusiform tumor may escape notice. Postural torticollis should be distinguished from congenital muscular torticollis.
The postural deformation is caused by intrauterine malposture, and the deformity is less severe. Although the sternocleidomastoid muscle is shortened, there is no true fibrotic replacement of the muscle. Often there are other findings associated with intrauterine malposture such as pelvic obliquity with abduction-adduction contracture of the hips, or postural metatarsus varus or valgus.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

17. Differential Diagnosis of Congenital Muscular Torticollis
Congenital Anomalies
Postural torticollis
Hemivertebra, cervical-superior dorsal spine
Unilateral atlanto-occipital fusion
Klippel-Feil syndrome
Unilateral congenital absence of sternocleidomastoid muscle
Pterygium colli
Trauma-particularly C1, C2
Rotatory subluxation
Fracture
Inflammatory conditions unilateral
Cervical lymphadenitis
Spontaneous hyperemic subluxation of the atlas
Rheumatoid arthritis
Neurologic Disorders
Visual disturbances
Syringomyelia
Cervical spinal cord tumor
Brain tumor, posterior fossa
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

18. Evaluation of torticollis
Diagnostic algorithm
Evaluation of torticollis
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برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

19. Imaging Algorithm for Acute Torticollis
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برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

20. Type 1 Atlanto-axial Rotatory Fixation
Axial CT image with head rotated to left shows widened space between dens and right C1 lateral mass which persists with rotation of head to right (arrowheads) compatible with AARF. The atlanto-dental interval is normal making this a type 1 AARF.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

21. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
Treatment
Treatment should be begun as soon as the diagnosis is made.
Manipulations consisting of passive stretching of the contracted sternocleidomastoid muscle should be performed by the parents after adequate instruction.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

22. Manipulation technique
First the head is bent laterally so that the ear on the side opposite the shortened muscle approaches the shoulder, then the head is rotated so that the chin approaches the shoulder of the affected side.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

23. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
An additional method of stretching the sternocleidomastoid muscle is to make use of gravity by placing the infant supine on the mother’s lap with the head hanging into hyperextension. One hand stabilizes the shoulders and chest, and the other hand tilts the head laterally away from the contracted muscle so that the contra lateral ear touches the opposite shoulder. The chin is then rotated toward the contracted muscle.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

24. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
Prone posture during sleep should be avoided, as it will aggravate the facial deformities and the contracture.
Ordinarily, if the stretching exercises are begun at a very early age and performed faithfully and correctly every day, the contracture of the sternocleidomastoid muscle will corrected and surgery will not be necessary.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

25. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
It is unlikely that the fibrous cord that replaces the sternocleidomastoid muscle can be stretched by manipulation after the age of one year.
This is especially true if restriction of rotation of the neck is greater than 30 degrees and there is an established facial asymmetry.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

26. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
Surgery
In 10% of children, surgery may be needed to correct the torticollis. This is an outpatient surgery to lengthen the short muscle.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

27. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
Surgery is indicated
when the torticollis does not respond to conservative measures up to one year of age
in cases in which the condition is neglected until the child is a year old or when the parents have not complied in performing an effective exercise regimen
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برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

28. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
Age considerations
Only conservative treatment is indicated during infancy (scar is a problem)
the operation should be delayed until the child is between the ages of 1 and 4 years.
Some recommend surgery after 3 years
bipolar release should be considered as the treatment of choice in patients older than 6 years of age
Surgery performed before the age of 6 to 8 years may allow remodeling of any facial asymmetry and plagiocephaly
In older ages also it is better to operate
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

29. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
Satisfactory results are usually obtained by division or partial excision of the muscle, provided the head is kept in the corrected position for a sufficient length of time after the operation, and active and passive exercises are carried out to prevent any recurrence of the deformity.
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

30. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
Surgical techniques
Unipolar release of the muscle distally is appropriate for mild deformity.
Bipolar release proximally and distally may be indicated for moderate and severe torticollis or recurrent cases
LENGTHENING?
Endoscopic release ??
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

31. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
AFTERTREATMENT
manual stretching ,muscle strengthening, and active range-of-motion exercises of the neck three times daily for 3 to 6 months
The use of plaster casts or braces usually is unnecessary
Head-halter traction or a cervical collar?
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

32. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
prognosis
Good or excellent results in 60 to 80 % of surgically treated cases
The younger the patient the better surgical results
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

33. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
summary
CMT is a deformity caused by fibrosis of sternomastoid muscle
Usually is diagnosed in early infancy
More common in girls
Stretching exercises is recommended in 1st year of life (about 9o% will improve)
Surgery is recommended after infancy(2-3 years)
Unipolar release for mild and bipolar release for severe deformity
Up to 8 years head and facial deformity will improve very well after surgery
In older ages also it is better to operate
Surgical outcome usually is satisfactory
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

34. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
A woman brought her three-month-old infant to the physician for an examination because she was concerned about the position of the infant's head. The pregnancy and delivery were unremarkable. Physical examination revealed that the head and body were in an asymmetrical position otherwise, the infant appeared normal. Passive range of motion in the neck was almost normal with no tightness. There was no palpable tumor of the sternocleido-mastoid muscle. Neurologic examination and an ultrasound scan of the neck muscles were normal
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

35. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
Question
Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?
A. Benign, paroxysmal torticollis.
B. Neurogenic torticollis.
C. Osseous torticollis.
D. Postural torticollis
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

36. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان
Postural torticollis is a painless condition that typically presents during infancy. The condition usually resolves within a few months without the need for operative treatment. Potential complications include cervical scoliosis with compensatory thoracic scoliosis, facial asymmetry, and plagiocephaly.
After a child is diagnosed with postural torticollis, the family may be educated about a home stretching program and positional cues to encourage functional stretching and use of the muscle. Stretching helps resolve torticollis, but follow-up is needed to assess progress
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

37. Thank you for your attention
4/16/2017
برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان