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COMMENTARY
Year : 2014  |  Volume : 7  |  Issue : 5  |  Page : 588-589  

Congenital muscular torticollis in children


Department of Surgery, Padmashri Dr. Dnyandeo Yashwantrao Patil Medical College Hospital and Research Center, Pune, Maharashtra, India

Date of Web Publication10-Sep-2014

Correspondence Address:
Bharat Bhushan Dogra
Department of Surgery, Padmashri Dr. D. Y. Patil Medical College Hospital and Research Center, Pune - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Dogra BB, Kataria M. Congenital muscular torticollis in children. Med J DY Patil Univ 2014;7:588-9

How to cite this URL:
Dogra BB, Kataria M. Congenital muscular torticollis in children. Med J DY Patil Univ [serial online] 2014 [cited 2021 Oct 19];7:588-9. Available from: https://www.mjdrdypu.org/text.asp?2014/7/5/588/140410

We have read the article titled "Outcome of bipolar release of sternocleidomastoid muscle in neglected congenital muscular torticollis" with lot of interest and would like to add few comments. Congenital torticollis, also known as wryneck, is a deformity of the neck that is present at birth. Congenital torticollis is mainly due to shortening of the neck muscles resulting in tilting of the head to the side on which the neck muscles are shortened, so that the chin points to the other side. This deformity is rare (<2%) and is believed to be caused by local trauma to the soft tissues of the neck just before or during delivery. [1] The most common explanation offered is that birth trauma occurs to the sternocleidomastoid (SCM) muscle, resulting in fibrosis or that intrauterine mal-positioning leads to unilateral shortening of the SCM. [2] Because of the association of congenital muscular torticollis with other intrauterine positioning disorders, Davids et al. postulated that head positioning in utero can selectively injure the sternocleidomastoid muscle, leading to development of a compartment syndrome. Magnetic resonance imaging (MRI) scans of 10 infants with this condition showed signals in the sternocleidomastoid muscle similar to those observed in the forearm and leg after compartment syndrome. [3] Other causes of congenital torticollis include postural torticollis, pterygium colli (webbed neck), vertebral anomalies, odontoid hyperplasia, spina bifida, hypertrophy or absence of cervical musculature, and Arnold-Chiari syndrome. It can also be seen with clavicular fractures, especially in neonates secondary to birth trauma. Atlantoaxial rotary subluxation of C1 on C2 is important to consider and leads to a presentation similar to torticollis.

Although no racial predominance is reported for torticollis, females are affected twice as often as males and congenital muscular torticollis occurs in less than 0.4% of newborns. [1] Ninety percent of patients with congenital muscular torticollis respond to passive stretching within the first year of life. Patients with this deformity often have a firm, non-tender, palpable soft-tissue mass in the sternocleidomastoid muscle shortly after birth. By 4-6 months of age, the mass is usually absent, and the only clinical finding is the contracture of the sternocleidomastoid muscle and the torticollis posture. The head characteristically tilts toward the side of the mass with the chin rotated in the opposite direction. Oleszek et al. suggest that botulinum toxin type A may be a safe and effective treatment option for children with congenital muscular torticollis who are unresponsive to stretching exercises and physiotherapy. [4] In resistant cases, the extent of sternocleidomastoid tightness determines the choice of unipolar or bipolar lengthening, Z-lengthening or radical resection. Akazawa et al. preferred partial resection of sternocleidomastoid and reported acceptable results. [5] Distal unipolar lengthening is sufficient for most cases, but secondary or bipolar lengthening may be needed in a case with recurrence. Bipolar release as described by Ferkel et al., involves making a short transverse proximal incision behind the ear and dividing the sternocleidomastoid muscle insertion transversely just distal to the tip of the mastoid process. Next, a distal incision is made 4-5 cm long in line with the cervical skin crease 02 cms proximal to the medial end of the clavicle and the sternal notch to divide the subcutaneous tissue and platysma muscle, exposing the clavicular and sternal attachments of the sternocleidomastoid muscle. The clavicular portion of the muscle is cut transversely, and a Z-plasty is performed on the sternal attachment in order to preserve the normal V-contour of the sternocleidomastoid muscle in the neckline. [6]

Post-operatively, physiotherapy in the form of muscle stretching and strengthening should be started early. A cervical collar may be used for the first 6-12 weeks after surgery.

 
  References Top

1.Canale ST. Congenital muscular torticollis. In: Canale ST, Daugherty K, Jones L, editors. Campbell′s Operative Orthopaedics. 9 th ed. St. Louis, Missouri: Mosby-Year Book; 1998. p.1064-7.  Back to cited text no. 1
    
2.Robin NH. Congenital muscular torticollis. Pediatr Rev 1996;17:374-5.  Back to cited text no. 2
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3.Davids JR, Wenger DR, Mubarak SJ. Congenital muscular torticollis: Sequela of intrauterine or perinatal compartment syndrome. J Pediatr Orthop 1993;13:141-7.  Back to cited text no. 3
    
4.Oleszek JL, Chang N, Apkon SD, Wilson PE. Botulinum toxin type a in the treatment of children with congenital muscular torticollis. Am J Phys Med Rehabil 2005;84:813-6.  Back to cited text no. 4
    
5.Akazawa H, Nakatsuka Y, Miyake Y, Takahashi Y. Congenital muscular torti-collis: Long-term follow-up of thirty-eight partial resections of the sternocleidomastoid muscle. Arch Orthop Trauma Surg 1993;112:205-9.  Back to cited text no. 5
    
6.Ferkel RD, Westin GW, Dawson EG, Oppenheim WL. Muscular torticollis. A modified surgical approach. J Bone Joint Surg Am 1983;65:894-900.  Back to cited text no. 6
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