CONGENITAL MUSCULAR TORTICOLLIS What is congenital muscular torticollis?

Congenital muscular torticollis is a condition in which an infant's neck muscle is shortened causing the neck to twist. This condition is sometimes called wryneck. What causes congenital muscular torticollis? The cause of congenital muscular torticollis is not known. However, there are several prominent theories: 1. 2. 3. 4. Injury to the neck during the delivery process Intrauterine pressure on the neck due to positioning in the uterus (womb) Abnormalities of blood vessels and blood flow in the fetus These abnormalities result in the formation of a small scar inside the muscles of the neck. It is this scar that is felt as the neck "mass." The scar tissue prevents the muscle involved from working normally. 5. Hypertrophy Pathophysiology Congenital muscular torticollis is believed to be caused by local trauma to the soft tissues of the neck just before or during delivery.2 The most common explanation involves birth trauma with resultant hematoma formation followed by muscular contracture. These children often have undergone breech or difficult forceps delivery. The fibrosis in the muscle may be due to venous occlusion and pressure on the neck in the birth canal because of cervical and skull position. Another hypothesis includes malposition in utero resulting in intrauterine or perinatal compartment syndrome. Up to 20% of children with congenital muscular torticollis have congenital dysplasia of the hip as well. Clinical Manifestation In the congenital form, the first sign may be a firm nontender enlargement of the sternocleidomastoid muscle visible at birth. This mass, which is more often localized near the clavicular attachment of the sternocleidomastoid muscle, usually enlarges during 4-6 weeks of life and then gradually decreases in size. By age 4-6 months, the mass is usually absent, and the only clinical finding is the contracture of the sternocleidomastoid muscle and the torticollis posture.

Diagnostic Procedures Clinical examination The entire length of the muscle must be palpated to determine if fibrosis or an area of fibrosis is present along the entire length of the muscle.

The anterior border of the muscle must be palpated. It generally stands out as a tight band. This may be difficult to detect in small infants because the neck is relatively short. Alternative differential diagnoses must be considered if the muscle is neither short nor prominent.

Laboratory Examination Generally, physical examination of the infant may show the characteristic tilting of the head and tension of the sternocleidomastoid muscle, as well as presence of a mass in the middle portion of the muscle. In addition to a complete medical history and physical examination, diagnostic procedures for congenital muscular torticollis may include the following:

x-rays - to check for abnormalities in the bones of the neck and shoulders; a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film. ultrasound examination - to evaluate the muscle around the mass; a diagnostic imaging technique which uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to view internal organs as they function, and to assess blood flow through various vessels.

Medical Intervention Medical therapy involves conservative treatment. Sternocleidomastoid fibrosis spontaneously resolves in the vast majority of infants. Physiotherapy may be recommended; however, no evidence shows that this alters the course of the condition. Botulinum toxin type A has been injected into the sternocleidomastoid muscle for the treatment of congenital muscular torticollis in pediatric and adult patients. However, modest benefits with improved range of motion has been observed in very few patients. May need Halter traction or Philadephia collar.

Surgical Intervention Surgery is performed with the patient under general anesthesia. A 3- to 4-cm transverse skin incision is made about 1 cm over the sternal and clavicular origins of the affected muscle. The platysma is carefully divided along the line of incision to avoid injury to the external jugular vein. The 2 heads of the sternocleidomastoid muscle are dissected free. The muscle is divided using diathermy to prevent bleeding. The platysma is then sutured with absorbable 4-0 skin suture, and the skin is closed with continuous 4-0 nonabsorbable skin suture.

Nursing Consideration Promote patient comfort by giving an anti-inflammatory and an analgesic, as needed. Assist the patient to find positions that make him most comfortable. Prepare him for diagnostic tests, such as X-rays, a computed tomography scan, blood tests, and cerebrospinal fluid analysis.

NURSING CARE PLAN ASSESSMENT DIAGNOSIS A n anxious parents with a 2y/o child arrive at the clinic. our child is having difficulty of moving her affected neck, and we are very much concern to our Childs physical appearance, what if she grows to have this abnormal neck apprarance, it might affect her social interaction. -fear and anxiety possibly evidenced by expressed concerns regarding to the perceived appearance. -Impaired physical mobility possibly evidenced by limited range of motion. -deficient knowledge regarding the pathophysiology of the condition, long term therapy needs, activity restriction, and prevention of complications, possibly evidenced by statements of concern. OBJECTIVES -The parents will demonstrate reduced anxiety regarding of their childs appearance. PLANNING INTERVENTION EVALUATION -provide appropriate information regarding the neck disorder of their child at the end of the shift. -Refer to the physical therapist to develop the individual mobility. -the parents are showing reduced feling of anxiety regarding to their childs condition.

-The will demonstrate improved range of motion.

-recommend -Long leg cast initial with the foot in treatment. maximum plantar flexion and iversion for a month. -provide information regarding the different measures needed to correct the deformity. -surgery to the foot which is needed inevitably to correct the deformity.

-the child is able to demonstrate improvement regarding her condition. The parents are now has reduced anxiety regarding their childs condition.

-the family will be familiar to the nature of their childs musculoskeletal disorder.