wry neck, torticollis, cervical rib treatment causes and pathology. congenital torticollis, muscular torticollis

1. Torticollis
( Wry neck)
Dr saurabh agrawal
Assistant professor
Deptt of orthopedics
AIIMS

3. So what is “Torticollis” ?
– Torticollis, also known as wry neck, is a
dystonic
condition defined by an abnormal, asymmetrical
head or neck position, which may be due to a
variety of causes.
– The term torticollis is derived from the
Latin words tortus for twisted and collum
for neck

4. Presentation of
Torticollis :-
– Torticollis is a fixed or dynamic tilt, rotation,
with flexion or extension of the head and/or
neck. The type of torticollis can be described
depending on the positions of the head and
neck:-
– LATEROCOLLIS : the head is tipped
toward the shoulder
– ROTATIONAL TORTICOLLIS : the head
rotates along
the longitudinal axis
– ANTEROCOLLIS : forward flexion of the
head and neck
– RETROCOLLIS : hyperextension of head

5. Signs and Symptoms
– Torticollis can be a disorder in itself as well as a
symptom in other conditions.
– Other symptoms include:
– Neck pain
– Occasional formation of a mass
– Thickened or tight sternocleidomastoid muscle
– Tenderness on the cervical spine
– Tremor in head
– Unequal shoulder heights
– Decreased neck movement

6. Types of Torticollis
:-
1
Congenit
al
muscular
torticolli
s (CMT)
2
Postura
l
torticolli
s
3
Ocular
torticolli
s
(Trochle
ar
torticolli
4
Spasmo
dic
torticolli
s
(wryneck
5
Acute
torticolli
s

7. Congenital muscular torticollis
The congenital
muscular torticollis is
the most common
torticollis which is
present at birth. The
cause of congenital
muscular torticollis is
unclear.
Supposed causes
include :-
Birth trauma
•Intrauterine malposition
•Repetitive microtrauma
within the womb to the
SCM
• Sudden change in
calcium concentration
in body,
causing prolonged period
of muscle
Congenital
Torticollis is
presented at 1–4
weeks of age and a
hard mass usually
develops.
It is normally
diagnosed using
ultrasonography and
a colour histogram or
clinically through
evaluating the infant's
passive cervical range
of motion.

8. Acquired torticollis
Non-congenital muscular
torticollis may result from
:-
• Scarring Or Disease Of
Cervical
Vertebrae
• Adenitis
• Tonsillitis,
• Rheumatism
• Enlarged Cervical Glands
• Retropharyngeal Abscess
• Cerebellar Tumors
Type
s
Spasmod
ic
(Clonic)
Permanent
(Tonic)

9. Acquired
T
orticollis:
Types
Self- Limiting : One or more of
the neck muscle is painful
It resolves in 1-4 weeks
SCM or upper Trapezius is usually the most
involved Draughts or cold or abnormal posture
is implicate
Tumors of the Posterior
Fossa
These can compress the nerve
supplying the neck muscle and
have to be treated surgically
Infection
s
Pharyn
x Ear
Adenectomy – cam cause Grisel’s syndrome which
can cause subluxation of the upper cervical joints.
Drug induced : Antipsychotics &
Antiemetics
Fibrodysplasia ossificans
progressiva (FOP)

10. Other Types of
Torticollis
– Spasmodic Torticollis
– Recurrent or transient
contraction of the muscles
of the neck muscles.
– SCM is mostly involved
– Cervical dystonia,
idiopathic cervical
dystonia, intermittent
torticollis"
– Trochlear torticollis
(Congenital fourth nerve
palsy)
– This is unrelated to the
SCM
– Caused by damage to the
Trochlear nerve (CN IV)
that supplies the Superior
Oblique muscle of the eye.

11. Torticollis may
lead to
additional
problems :-
– Flattening of the skull (plagiocephaly or
brachycephaly)
in infants.
– Movement that favors one side of the body,
affecting the arms, trunk, and hips. This can lead
to strength imbalances, such as an elevated
shoulder and side- bending of the trunk. This
movement pattern can lead
to delayed gross motor development.
– Developmental hip dysplasia.
– Scoliosis.
– Limited ability to turn the head to see, hear, and
interact with surroundings, which can lead to
delayed cognitive development.
– Delayed body awareness or lack of self-
awareness and interaction.
– Difficulty with balance.
– Asymmetrical vision changes.

12. Additional
Problem

13. Diagnosis
–General History
taking
–Birth History
–History of Trauma
–Neurological examination
–X-ray of cervical spine
–MRI
–USG – Muscular tissue,
Color Histogram
–Optometrist evaluation

14. Assessment :
– Observation of any asymmetries including facial, cranial,
neck and positional preference and presence of
plagiocephaly.
– Observation of skin creases.
– Observation of infant in developmentally appropriate
positions to
detect asymmetry and screen developmental milestones.
– Cervical active and passive range of movement testing.
– Upper and lower limb ROM screen, checking for hip dysplasia,
which can be associated with CMT, and spine asymmetry.
– Pain at rest and during movements.
– Palpation of sternocleidomastoid for size and elasticity and
presence of mass.
– Screen of visual tracking.
– Screen muscle tone.
– Identification of Red flags and appropriate onward referral:
– poor tracking
– abnormal muscle tone
– other features inconsistent with CMT
– poor progress with treatment

15. Management :
Physical Therapy (Goals)
To correct the
deformity by
release of the
contracted
soft tissues
and
To maintain the
correction by
suitable
exercise
regime;
avoiding
recurrence.

16. Physiotherapy
Management
– Early mild cases
– Children with a mild degree of deformity
reporting early for the treatment can be
managed with physiotherapy.
– The physiotherapy procedures employed are:
– I. Evaluation: Careful evaluation of ROM and
the
degree of deformity.
– II. Massage: Massage can relax the muscle
preceding the stretching maneuvers.
– III. Thermo Therapy Modality: Carefully
administered thermo-therapy modality induces
relaxation.
– IV. Passive movements: The child is placed in
supine position with head beyond the edge of
the table with the neck in extension by
positioning a pillow under the thoracic region;
Shoulders are stabilized by an assistant.

17. Physiotherapy Management
– To attain relaxation, all the movements of the
cervical spine are done in a form of slow relaxed
passive movements.
– This should be followed by sustained passive
stretching to the affected sternomastoid. E.g.
when the right sternomastoid is involved the head
should be gradually bent inside flexion to the left,
held there for a while and then rotated gradually to
the right. Try to gain as much overcorrection as
possible by applying gradual traction to gain further
stretching.

18. Physiotherapy
Management
– Maintenance of Correction: Once the correction is
achieved. It has to be maintained by passively
holding or keeping a sandbag.
– E.g: Kineso taping, Cervical Brace, Cervical collars
– The same maneuver can be repeated
during the subsequent visits.
– Active correction: Active correction is best
achieved by assisting the child head to follow an
object moved in the proper arc of correction. The
bright-colored sound producing object is ideal to
attract the child attention.
– PNF: patients with neck extension can be used
to an advantage with emphasis on stretch and
traction.

20. Surgical Management
– Subcutaneous tenotomy, open tenotomy, bipolar tenotomy,
and radical resection of a sternomastoid tumor or the
SCM.
– The sterna and the clavicular heads of sternomastoid are
divided close to the origin along with the release of the tight
fascia. The head is then immobilized in a plaster cast in
over-corrected position for 2 to 4 weeks. Mobilization is
begun as soon as the cast is removed.

21. Post surgical
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 exercises.
– Self correction in front of mirror.
– Specially molded cervical collar and
maintenance of correction during
sleep.

22. Cervicalrib

24. • Definition:It is basically a congenital condition in which
supernumerary (Extra rib)usually arising from 7th cervical
vertebrae.
• Usually bilateral

25. Patholog
y
• Persistent ossification of C7 lateral costal element which
gets reabsorbed.

26. Clinicalpresentation
• Asymptomatic
• Pain(Dull aching) and parasthesia in ulnar aspect of hand and little
fingers.
• Tingling Of forearm and Hand-”Falling asleep” due to
circulatory insufficiency.
• Diminished sensations in medial 11/2 digits
• Symptoms are accentuated in downward displacement of
shoulder girdle(heavy weight lifting)

27. Sign
s
• 1)Thoracic outlet syndrome
• 2)Pallor
• 3)Cyanosis
• 4)Trophic changes-Glossy skin,brittle
nails,ulcer
• 5)Gangrene
• 6)Adsons test positive
•

28. Differentialdiagnosis
• 1) Herniated cervical disc
• 2) Hyperabduction syndrome
• 3) Costoclavicular compression
syndrome

29. Investigations
• 1)Plain x-ray cervical
spine
• 2)Chest x-ray
•

31. Treatment
• Conservative
• 1)Pain medications-NSAIDS
•
• 2)Avoid heavy weight lifting
• 3)Physio-Self resisted elevation and adduction of
scapula.Endurance trailing for sports.

32. Surger
y
• If symptoms
persist
• Remove surgical
rib .