case study 4200

1. Emerson Hart
HLTH 4200
Fall 2016
Case Study of Patient with Cranial Remolding Orthosis
Introduction:
Deformational plagiocephaly is a deformity of the cranium in infants that can
occur pre- or post-natally. Plagiocephaly means “oblique head”. The incidence of
plagiocephaly has increased recently partially due to the promotion of infants
sleeping on their backs to reduce Sudden Infant Death Syndrome and the use of
child carriers that increase supine positioning (Plank, 2006). Positional
plagiocephaly is when a flat area develops from a child spending too much time
lying on that one spot of its head. Some plagiocephaly is caused by a condition called
Torticollis, where one side of the neck is tight, causing a child to look primarily one
direction, when means the child spends most of its time on that side of the head and
can develop flatness there. Flatness does not mean anything is wrong with the
child’s brain, but that there is a pressure opposing the force of growth that normally
rounds out the skull. As the brain grows, it presses outwards on the skull, causing
the skull to grow round.
If a child is diagnosed with plagiocephaly, their head size and symmetry is
evaluated using a STARscanner, which collects 3-D head shape data for custom
cranial remolding orthoses (helmets). The scanner takes less than 2 seconds to
make a full scan, which can then be reviewed by the practitioner and emailed to
Orthomerica, who will fabricate a custom STAR cranial remolding orthosis

2. (ORTHOMERICA, 2008). Normal ranges for the differences between the two
diagonal head measurements taken are between 0 and 6 mm. Anything over 10 is
recommended for a cranial remolding orthosis. The best time for a child to wear a
helmet is between 4 and 7 months, when there is a lot of growth able to be captured.
During the 4-7 month age, the brain is growing rapidly, which means the skull is
growing. Helmets work to distribute the growth to the flat areas, so the head
appears more evenly rounded. They do this by fitting closely around the prominent
parts of the head, but leaving space around the flat parts, so that the growth is
redirected to those areas where there is room to grow into. Every few weeks, the
child is brought back to make adjustments to the helmet as the head grows and the
fit changes. The overarching idea of a helmet is to inhibit growth where the skull is
protruding, but to allow growth where there is flatness.
Case Presentation:
The patient is a 3-month-old male referred by his pediatrician for a Helmet
Evaluation. The pertinent medical diagnosis for the child is plagiocephaly. He has
already been participating in a repositioning program for 4 weeks to attempt to
correct the plagiocephaly without a helmet. His plagiocephaly is on the right, with
flattening in the right posterior and bossing in the right frontal. His right ear has
shifted anteriorly, and he has no facial asymmetry and no palpable ridging. He
presents with neck tightness, and his plagiocephaly is moderate to severe, with a
difference of 15 mm. At initial evaluation, the plan was to continue with
repositioning program and re-evaluate in 3-4 weeks.

3. Management and Outcome:
After 4 weeks, the patient returned, and had grown over 12 mm in head
circumference. He meets the criteria for a cranial remolding orthosis, and the
mother wants to pursue treatment, expressing concern that his head shape has not
changed and that he tends to look to the right. Patient was rescanned, and will
return in one week for helmet delivery.
The patient was fitted with a STARband Cranial Remolding Orthosis. The
STARband was trimmed and modified according to Orthomerica recommendations.
Patient wore for 20 minutes without redness, and with proper fit. The patient’s
caregiver was given verbal instructions, demonstration and printed material
regarding wear schedule, proper fit, how to put on and take off the helmet, follow up
schedule, cleaning, and all related precautions and concerns for orthosis. She
demonstrated independence with putting on and taking off the helmet, and
verbalized understanding of instructions. The orthosis was verified for structural
integrity and safety. The goal of the orthosis is to improve cranial symmetry and
proportion. The patient will come back for follow-up in one week.
After one week of wearing the helmet full-time, the patient came in for a
follow-up. Redness was noted near the right parietal corner, left parietal
prominence, and near the base of the neck. Adjustments were made where the
redness was observed. The patient will follow-up in 2 weeks or earlier if needed. At
his next follow-up, the helmet was snug at the right parietal and left frontal, so
growth adjustments were made. The patient will follow-up in 2 weeks for a re-scan.

4. At the next appointment, after 5 weeks of wearing the helmet, patient was scanned
and had a CVA of 5 mm, originally at 13-15 mm. The patient’s caregiver expressed
contentment with the patient’s head size. The helmet was adjusted to allow more
growth, and the patient will return in 2 weeks for follow-up.
At the follow-up appointment, more growth adjustments were made and the
patient will return in 2 weeks for a final scan to hopefully discontinue sue of
STARband cranial remolding orthosis. Overall, the patient has changed from a 15
mm difference between diagonals down to a 5 mm difference. The patient was
officially discharged and discontinued use of the helmet with a final difference
between diagonals of 4-5 mm.
Discussion:
This patient presented with moderate to severe plagiocephaly, was treated
with a custom cranial remodeling orthotic, and after 2 months of wearing the helmet
full-time, is being discharged with less than 5 mm difference between his diagonal
measurements. He is an ideal patient because of how early he started with the
helmet, as well as how successful the helmet was in improving head shape. His final
difference of 5 mm is within the normal range and is much improved from the
original 15 mm difference. The patient’s caregiver expressed satisfaction with the
patient’s current head shape and he will not need to be seen again.

5. References:
Orthomerica. (2008). STARscanner Laser Data Acquisition System. [Brochure]. N.c.:
Orthomerica: the Global Orthotic Solution.
Plank, Laura H., Brian Giavedoni, Janet R. Lombardo, Mark D. Geil, and Andrew
Reisner. "Comparison of Infant Head Shape Changes in Deformational
Plagiocephaly Following Treatment With a Cranial Remolding Orthosis Using
a Noninvasive Laser Shape Digitizer." Journal of Craniofacial Surgery 17.6
(2006): 1084-091.

6. Pictures and Charts:

7. *scan of patient’s head after 7 weeks in helmet – midforehead cross section.

8. *Scan of patient’s head after 7 weeks in helmet – above eyebrows/ear cross section.