This document discusses congenital muscular torticollis (CMT), which is the most common cause of torticollis in infants. CMT is caused by fibromatosis within the sternocleidomastoid muscle (SCM) that develops prenatally or shortly after birth. It presents as a palpable mass in the SCM that usually resolves within a year with stretching exercises, but can become permanent without treatment. Surgical release of the SCM may be needed for severe, persistent cases. Diagnosis is made by physical exam identifying the SCM mass. Treatment involves stretching exercises during infancy and possible surgery if deformity persists.

1. 
CONGENITAL MUSCULAR
TORTICOLLIS
Dr. Gaurav Singh
Central Institute Of Orthopaedics
VMMC & SJH

2. OSSEOUS
•Occipitocervical
synostosis
•Basilar
impression
•Odontoid
anomalies
NonOsseous •Congenital
Muscular
Torticolis
Neurogenic
•Tumors(post
fossa or spinal
cord)
•Syringomyelia
•Arnold chiari
malformation
•Ocular
dysfunction
•Paroxysmal
torticollis of
infancy
TORTICOLIS is combined head tilt and
rotatory deformity

3.  (twisted neck”) or wry neck most common cause of torticollis in
infancy and young child @ median age of 2 mnths
 Congenital muscular torticollis (CMT) is caused by fibromatosis
within the SCM
 It may involve the muscle diffusely, but more often it is
localized near the clavicular attachment of the muscle. A mass
either is palpable at birth or becomes so, usually during the first
2 weeks. The mass attains maximal size within 1 or 2 months
and may remain the same size or become smaller; usually, it
diminishes and disappears within 1 year.
 If it fails to disappear, the muscle becomes permanently fibrotic
and contracted and causes torticollis, which also is permanent
unless treated.

4. 
 condition likely results from local compartment
syndrome or ischemia involving the neck that produces
the fibrotic muscle.
 Increased incidence of associated musculoskeletal
disorders, such as metatarsus adductus, DDH (7-20%),
and talipes equinovarus.
 cause of CMT include malposition of the fetus in utero,
birth trauma, infection, and vascular injury.
 More common on the right side than on the left side.
 It may involve the muscle diffusely, but more often it is
localized near the clavicular attachment of the muscle.

5. 
 A palpable nodule is typically present in the affect SCM at
birth or within the first few weeks of life.. The presence of
the characteristic fibrotic nodule typically confirms the
diagnosis.
 The patient may also have associated plagiocephaly and
facial asymmetry.
 The head becomes inclined toward the affected side and
the face toward the opposite side thus producing the
“cock robin”appearance.
 If the deformity is severe, the ipsilateral shoulder
becomes elevated and the frontooccipital diameter of the
skull may become less than normal
Clinical feature

6. 
 Flattening of the face on the ipsilateral side of the
SCM lesion can be worsened by the prone position
during sleep.
 The infant may also have a “bat” ear as a result of
folding in utero. If infants are placed supine for
sleeping, reverse modeling of the contralateral side
of the skull can occur.

7. 
 The diagnosis is made on physical examination by
detecting a mass or knot on the involved side of the neck.
 When the diagnosis remains in doubt, cervical spine
radiographs are appropriate.
 Lin and Chou reported that ultrasonography was useful
in predicting which infants would require surgical
treatment. Those patients in whom fibrotic change was
limited to only the lower third of the sternocleidomastoid
muscle recovere without surgery, whereas 35% of patients
with whole muscle involvement required surgical release
Diagnosis

8.  Only conservative treatment is indicated during infancy.
 CMT typically resolves with a home stretching program
during the first year of life.
 The child’s chin is rotated toward the shoulder on the side of
the affected sternocleidomastoid muscle while the head is
tilted toward the opposite shoulder.
 surgery should be delayed until evolution of the
fibromatosis is complete, and then, if necessary, the muscle
can be released at one or both ends.
 Ideally, surgery is performed just before school age so that
sufficient growth remains for remodeling of facial
asymmetry while giving enough time for the growth of the
structures to make surgical dissection and release easier.
treatment

9. 
 Regardless of the type of treatment, established facial
asymmetry and limitation of motion of more than 30
degrees at the beginning of treatment usually
precluded a good result.
 Unipolar release of the muscle distally is appropriate
for mild deformity. Bipolar release proximally and
distally may be indicated for moderate and severe
torticollis

10.  incision 5 cm long just superior to and parallel to the
medial end of the clavicle.
 tendon sheath longitudinally.
 superior and inferior to the hemostat; clamp them and
resect 2.5 cm of their inferior ends.
 explore the wound digitally for any remaining bands of
contracted muscle or fascia;
 Avoid damaging the spinal accessory nerve.
 tethering of the scar to the deep structures, reattachment
of the clavicular head or the sternal head of the
sternocleidomastoid muscle, loss of contour of the muscle,
failure to correct the tilt of the head, or failure of facial
asymmetry to correct.
Unipolar release

11. 
 Surgical correction in children with severe deformity
or after failed operation usually requires a bipolar
release of the sternocleidomastoid muscle.
 Ferkel et al. described a modified bipolar release and
Z-plasty of the muscle for use in these circumstances.
 Make a short transverse proximal incision behind the
ear and divide the sternocleidomastoid muscle
insertion transversely just distal to the tip of the
mastoid process.
Bipolar release

12. 
 Make a distal incision 4 to 5 cm long in line with the
cervical skin creases, a fingerbreadth proximal to the
medial end of the clavicle and the sternal notch.
 Cut the clavicular portion of the muscle transversely,
and perform a Z-plasty on the sternal attachment so
as to preserve the normal V-shaped contour of the
sternocleidomastoid muscle in the neckline.
 Alternatively, release the clavicular head directly
from the clavicle while transecting the sternal head
proximal to its insertion by 1 to 2 cm. Then suture
the two ends together side to side or end to end .