In the name of god

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

2. Congenital muscular torticollis Mohammad rezaetemadifar MD St Zahra hospital Isfahan university of medical sciences برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

3. 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. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

4. 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. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

5. 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. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

6. 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. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

7. 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 برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

8. 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 scalenusanterior and medius muscles become shortened. • Later, the carotid sheath and the enclosed vessels contract. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

9. 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 برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

10. 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. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

11. 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. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

12. 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. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

13. 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. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

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

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

16. 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. 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 برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

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

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

21. 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. 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. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

23. 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. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

24. 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. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

25. 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. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

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

27. 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 برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

28. 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 برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

29. 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. برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

30. 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 ?? برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

31. 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? برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

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

33. 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 برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

34. 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 برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

35. 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. Neurogenictorticollis. • C. Osseous torticollis. • D. Postural torticollis برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

36. 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 برنامه مدون ارتوپدی 2 تا 4 اسفند 91 اصفهان

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