Musculoskeletal · Congenital Muscular Torticollis
The facts most likely to be tested
Congenital muscular torticollis is caused by unilateral fibrosis and shortening of the sternocleidomastoid (SCM) muscle.
Infants typically present with the head tilted toward the affected side and the chin rotated away from the affected side.
Physical examination reveals a palpable, non-tender SCM mass or fibrotic cord in the lower third of the muscle.
Associated conditions frequently include developmental dysplasia of the hip (DDH), metatarsus adductus, and plagiocephaly.
First-line treatment for infants is conservative management consisting of passive stretching exercises and physical therapy.
Surgical release of the SCM is reserved for patients who fail to improve with physical therapy by 6 to 12 months of age.
Acute acquired torticollis in children requires evaluation for atlantoaxial subluxation, often following minor trauma or upper respiratory infection (Grisel syndrome).
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A 3-month-old infant is brought to the clinic by his mother due to a persistent head tilt. On physical examination, the infant holds his head tilted to the right and prefers to look toward the left. A firm, non-tender 2-cm mass is palpated within the right sternocleidomastoid muscle. The infant has full passive range of motion of the cervical spine, though resistance is noted with left lateral flexion. The remainder of the physical exam, including hip stability, is unremarkable.
What is the most appropriate initial management for this patient?
Passive stretching exercises and physical therapy
The patient presents with classic findings of congenital muscular torticollis; the first-line treatment is conservative therapy to prevent permanent deformity and plagiocephaly.
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Etiology / Epidemiology
Congenital muscular torticollis (CMT) is the most common form, often linked to intrauterine malposition or birth trauma.
Clinical Manifestations
Infant presents with wry neck; head is tilted toward and rotated away from the affected sternocleidomastoid (SCM) muscle.
Diagnosis
Diagnosis is clinical; ultrasound is the gold standard to rule out structural anomalies or fibromatosis colli.
Treatment
First-line is physical therapy (stretching); surgical release is reserved for refractory cases after 1 year of age.
Prognosis
Early intervention yields >90% success rate; delayed treatment risks permanent facial asymmetry.
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Epidemiology & Etiology
CMT is frequently associated with breech presentation and oligohydramnios. Acquired torticollis in older children may result from atlantoaxial subluxation or Grisel syndrome following upper respiratory infections.
Pertinent Anatomy
The sternocleidomastoid (SCM) muscle is the primary culprit. Unilateral shortening causes the chin to point toward the contralateral shoulder while the head tilts toward the ipsilateral shoulder.
Pathophysiology
Fibrosis of the SCM leads to muscle shortening and restricted cervical range of motion. If untreated, the infant develops plagiocephaly (asymmetric flattening of the skull) due to consistent positioning. Chronic tension can lead to secondary cervical scoliosis.
Clinical Manifestations
Infants exhibit a palpable mass in the lower third of the SCM, known as fibromatosis colli. Red flags include fever, neurological deficits, or sudden onset, which mandate imaging to rule out retropharyngeal abscess or cervical spine fracture.
Diagnosis
Diagnosis is primarily clinical based on restricted neck rotation. Ultrasound is the gold standard to confirm SCM thickening and exclude other masses. If neurological symptoms are present, cervical spine MRI is required to rule out syringomyelia or tumors.
Treatment
Initial management is physical therapy focusing on passive stretching and positioning. If no improvement occurs by 6-12 months, surgical release of the SCM is indicated. Avoid aggressive manipulation in patients with suspected cervical instability.
Prognosis
Most cases resolve with conservative therapy within 6 months. Permanent facial asymmetry and cervical spine deformity are the primary long-term complications if the condition remains untreated beyond the first year of life.
Differential Diagnosis
Klippel-Feil syndrome: congenital fusion of cervical vertebrae
Sandifer syndrome: torticollis associated with GERD
Retropharyngeal abscess: acute onset with fever and dysphagia
Atlantoaxial subluxation: history of recent URI or trauma
Ocular torticollis: head tilt secondary to strabismus