Congenital muscular torticollis: Clinical features and diagnosis
- Charles G Macias, MD, MPH
Charles G Macias, MD, MPH
- Associate Professor of Pediatrics
- Baylor College of Medicine
- Vanthaya Gan, MD
Vanthaya Gan, MD
- Clinical Professor of Pediatrics
- University of Texas Southwestern Medical Center
Torticollis is the term for the clinical finding of a twisted or rotated neck. In Latin, the word "tortus" means "twisted" and "collum" means "neck." Torticollis, also called wryneck, is a common complaint in children and may be congenital or acquired.
The clinical features and diagnosis of congenital muscular torticollis will be reviewed here. The management and prognosis of congenital muscular torticollis, acquired torticollis in children, and neck stiffness in children are discussed separately. (See "Congenital muscular torticollis: Management and prognosis" and "Acquired torticollis in children" and "Approach to neck stiffness in children".)
TERMINOLOGY AND CLASSIFICATION
●Congenital torticollis – Congenital torticollis is a postural deformity of the neck that develops prenatally (though presentation to medical attention may be delayed); congenital torticollis has muscular and nonmuscular causes (table 1). (See 'Differential diagnosis' below.)
●Congenital muscular torticollis – Congenital muscular torticollis is a postural deformity of the neck that is usually evident by two to four weeks of age; it is characterized by lateral neck flexion (head tilted to one side) and neck rotation (chin pointed to the opposite side) (picture 1).
There are three types, in order of increasing severity [1-3]:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Cheng JC, Tang SP, Chen TM, et al. The clinical presentation and outcome of treatment of congenital muscular torticollis in infants--a study of 1,086 cases. J Pediatr Surg 2000; 35:1091.
- Kaplan SL, Coulter C, Fetters L. Physical therapy management of congenital muscular torticollis: an evidence-based clinical practice guideline: from the Section on Pediatrics of the American Physical Therapy Association. Pediatr Phys Ther 2013; 25:348.
- Boere-Boonekamp MM, van der Linden-Kuiper LT LT. Positional preference: prevalence in infants and follow-up after two years. Pediatrics 2001; 107:339.
- Cheng JC, Au AW. Infantile torticollis: a review of 624 cases. J Pediatr Orthop 1994; 14:802.
- Chen MM, Chang HC, Hsieh CF, et al. Predictive model for congenital muscular torticollis: analysis of 1021 infants with sonography. Arch Phys Med Rehabil 2005; 86:2199.
- Stellwagen L, Hubbard E, Chambers C, Jones KL. Torticollis, facial asymmetry and plagiocephaly in normal newborns. Arch Dis Child 2008; 93:827.
- Cheng JC, Wong MW, Tang SP, et al. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of eight hundred and twenty-one cases. J Bone Joint Surg Am 2001; 83-A:679.
- Davids JR, Wenger DR, Mubarak SJ. Congenital muscular torticollis: sequela of intrauterine or perinatal compartment syndrome. J Pediatr Orthop 1993; 13:141.
- Lin JN, Chou ML. Ultrasonographic study of the sternocleidomastoid muscle in the management of congenital muscular torticollis. J Pediatr Surg 1997; 32:1648.
- Engin C, Yavuz SS, Sahin FI. Congenital muscular torticollis: is heredity a possible factor in a family with five torticollis patients in three generations? Plast Reconstr Surg 1997; 99:1147.
- Thompson F, McManus S, Colville J. Familial congenital muscular torticollis: case report and review of the literature. Clin Orthop Relat Res 1986; :193.
- Hsieh YY, Tsai FJ, Lin CC, et al. Breech deformation complex in neonates. J Reprod Med 2000; 45:933.
- Kuo AA, Tritasavit S, Graham JM Jr. Congenital muscular torticollis and positional plagiocephaly. Pediatr Rev 2014; 35:79.
- Littlefield TR, Kelly KM, Pomatto JK, Beals SP. Multiple-birth infants at higher risk for development of deformational plagiocephaly: II. is one twin at greater risk? Pediatrics 2002; 109:19.
- Wei JL, Schwartz KM, Weaver AL, Orvidas LJ. Pseudotumor of infancy and congenital muscular torticollis: 170 cases. Laryngoscope 2001; 111:688.
- Ohman A, Nilsson S, Lagerkvist AL, Beckung E. Are infants with torticollis at risk of a delay in early motor milestones compared with a control group of healthy infants? Dev Med Child Neurol 2009; 51:545.
- Öhman A, Beckung E. Children who had congenital torticollis as infants are not at higher risk for a delay in motor development at preschool age. PM R 2013; 5:850.
- Tufano RP, Tom LW, Austin MB. Bilateral sternocleidomastoid tumors of infancy. Int J Pediatr Otorhinolaryngol 1999; 51:41.
- Torticollis. In: Signs and symptoms in pediatrics, 3rd ed, Tunnessen WW, Roberts KB (Eds), Lippincott Williams & Wilkins, Philadelphia 1999. p.353.
- Kustos T, Magdics M. [Bilateral torticollis]. Orv Hetil 1993; 134:2817.
- Boricean ID, Bărar A. Understanding ocular torticollis in children. Oftalmologia 2011; 55:10.
- Watemberg N, Ben-Sasson A, Goldfarb R. Transient Motor Asymmetry Among Infants With Congenital Torticollis-Description, Characterization, and Results of Follow-Up. Pediatr Neurol 2016; 59:36.
- Tien YC, Su JY, Lin GT, Lin SY. Ultrasonographic study of the coexistence of muscular torticollis and dysplasia of the hip. J Pediatr Orthop 2001; 21:343.
- Walsh JJ, Morrissy RT. Torticollis and hip dislocation. J Pediatr Orthop 1998; 18:219.
- Slate RK, Posnick JC, Armstrong DC, Buncic JR. Cervical spine subluxation associated with congenital muscular torticollis and craniofacial asymmetry. Plast Reconstr Surg 1993; 91:1187.
- Hollier L, Kim J, Grayson BH, McCarthy JG. Congenital muscular torticollis and the associated craniofacial changes. Plast Reconstr Surg 2000; 105:827.
- Pazonyi I, Kun A, Czeizel A. Congenital postural deformity association. Acta Paediatr Acad Sci Hung 1982; 23:431.
- Rogers GF, Oh AK, Mulliken JB. The role of congenital muscular torticollis in the development of deformational plagiocephaly. Plast Reconstr Surg 2009; 123:643.
- Pollack IF, Losken HW, Fasick P. Diagnosis and management of posterior plagiocephaly. Pediatrics 1997; 99:180.
- Jones MC. Unilateral epicanthal fold: diagnostic significance. J Pediatr 1986; 108:702.
- Mulliken JB, Vander Woude DL, Hansen M, et al. Analysis of posterior plagiocephaly: deformational versus synostotic. Plast Reconstr Surg 1999; 103:371.
- Joiner ER, Andras LM, Skaggs DL. Screening for hip dysplasia in congenital muscular torticollis: is physical exam enough? J Child Orthop 2014; 8:115.
- de Chalain TM, Park S. Torticollis associated with positional plagiocephaly: a growing epidemic. J Craniofac Surg 2005; 16:411.
- Hervey-Jumper SL, Justice D, Vanaman MM, et al. Torticollis associated with neonatal brachial plexus palsy. Pediatr Neurol 2011; 45:305.
- Demirbilek S, Atayurt HF. Congenital muscular torticollis and sternomastoid tumor: results of nonoperative treatment. J Pediatr Surg 1999; 34:549.
- Petronic I, Brdar R, Cirovic D, et al. Congenital muscular torticollis in children: distribution, treatment duration and out come. Eur J Phys Rehabil Med 2010; 46:153.
- Ballock RT, Song KM. The prevalence of nonmuscular causes of torticollis in children. J Pediatr Orthop 1996; 16:500.
- Snyder EM, Coley BD. Limited value of plain radiographs in infant torticollis. Pediatrics 2006; 118:e1779.
- Boyko N, Eppinger MA, Straka-DeMarco D, Mazzola CA. Imaging of congenital torticollis in infants: a retrospective study of an institutional protocol. J Neurosurg Pediatr 2017; 20:191.
- Haque S, Bilal Shafi BB, Kaleem M. Imaging of torticollis in children. Radiographics 2012; 32:557.
- Kwon DR, Park GY. Diagnostic value of real-time sonoelastography in congenital muscular torticollis. J Ultrasound Med 2012; 31:721.
- Shah SA, Song K. Congenital scoliosis. In: Lovell and Winter's Pediatric Orthopaedics, 7th ed, Weinstein SL, Flynn JM (Eds), Lippincott Williams & Wilkins, Philadelphia 2014. p.698.
- Gray GM, Tasso KH. Differential diagnosis of torticollis: a case report. Pediatr Phys Ther 2009; 21:369.
- Williams CR, O'Flynn E, Clarke NM, Morris RJ. Torticollis secondary to ocular pathology. J Bone Joint Surg Br 1996; 78:620.
- Marmor MA, Beauchamp GR, Maddox SF. Photophobia, epiphora, and torticollis: a masquerade syndrome. J Pediatr Ophthalmol Strabismus 1990; 27:202.
- Dörner L, Fritsch MJ, Stark AM, Mehdorn HM. Posterior fossa tumors in children: how long does it take to establish the diagnosis? Childs Nerv Syst 2007; 23:887.
- O'Brien DF, Caird J, Kennedy M, et al. Posterior fossa tumours in childhood: evaluation of presenting clinical features. Ir Med J 2001; 94:52.
- Tomczak KK, Rosman NP. Torticollis. J Child Neurol 2013; 28:365.
- Nuysink J, van Haastert IC, Takken T, Helders PJ. Symptomatic asymmetry in the first six months of life: differential diagnosis. Eur J Pediatr 2008; 167:613.
- Adams SB Jr, Flynn JM, Hosalkar HS, et al. Torticollis in an infant caused by hereditary muscle aplasia. Am J Orthop (Belle Mead NJ) 2003; 32:556.
- Vajramani A, Witham FM, Richards RH. Congenital unilateral absence of sternocleidomastoid and trapezius muscles: a case report and literature review. J Pediatr Orthop B 2010; 19:462.
- Raman S, Takhtani D, Wallace EC. Congenital torticollis caused by unilateral absence of the sternocleidomastoid muscle. Pediatr Radiol 2009; 39:77.
- The neck. In: Pediatric diagnosis: Interpretation of symptoms and signs in children and adolescents, 6th ed, Green M (Ed), WB Saunders, Philadelphia 1998. p.63.
- Huang MH, Gruss JS, Clarren SK, et al. The differential diagnosis of posterior plagiocephaly: true lambdoid synostosis versus positional molding. Plast Reconstr Surg 1996; 98:765.
- Raco A, Raimondi AJ, De Ponte FS, et al. Congenital torticollis in association with craniosynostosis. Childs Nerv Syst 1999; 15:163.
- Linz C, Collmann H, Meyer-Marcotty P, et al. Occipital plagiocephaly: unilateral lambdoid synostosis versus positional plagiocephaly. Arch Dis Child 2015; 100:152.
- TERMINOLOGY AND CLASSIFICATION
- CLINICAL FEATURES
- Physical examination
- Associated conditions
- Clinical diagnosis
- DIFFERENTIAL DIAGNOSIS
- Head tilt/postural preference
- Limited range of motion
- Neck mass
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS