High Yield Overview
TORTICOLLIS IN CHILDREN
Congenital Muscular Torticollis | Head Tilt | Sternocleidomastoid | Stretching vs Surgery
0.4-2%Incidence at birth
90%+Resolve with stretching
20%Associated hip dysplasia
12-18mSurgical age if conservative fails
MANAGEMENT APPROACH
0-6 months
PatternStretching program
TreatmentParent-directed PT, positioning
6-12 months
PatternIntensive physiotherapy
TreatmentTherapist-guided stretching
Greater than 12-18 months
PatternSurgical consideration
TreatmentSCM release if persistent
Critical Must-Knows
- Classic triad: Head tilt to AFFECTED side, chin rotation to OPPOSITE side, palpable SCM mass (pseudotumor)
- Screen for DDH: 20% association with congenital muscular torticollis (CMT) - always examine hips
- Early stretching is key: Greater than 90% resolve with physiotherapy started before 1 year
- Plagiocephaly: Positional head flattening from persistent tilt - contributes to cosmetic concerns
- Surgical release: Consider if no improvement by 12-18 months, releases SCM at clavicular origin
Examiner's Pearls
- "Tilt is toward the TIGHT SCM (affected side), chin points AWAY
- "Pseudotumor (SCM mass) present in first weeks, usually resolves by 4-6 months
- "Facial asymmetry and plagiocephaly develop if untreated
- "Differential: congenital cervical spine anomaly, ocular torticollis, Sandifer syndrome
Critical Torticollis Exam Points
Clinical Pattern
Head tilts TOWARD tight SCM, chin rotates AWAY. If right SCM is tight: head tilts RIGHT, chin points LEFT. Palpable "pseudotumor" (fibromatosis colli) in the SCM in early infancy, usually gone by 4-6 months. Passive rotation limited to opposite side.
Associated Conditions
Screen ALL torticollis patients for DDH - 20% association. Also check for plagiocephaly (flattening of ipsilateral occiput), facial asymmetry, and cervical spine anomalies. If atypical features, consider C-spine X-ray or MRI.
Physiotherapy Program
Passive stretching is first-line treatment. Stretch SCM by tilting head OPPOSITE to tight side and rotating chin TOWARD tight side. Do during every diaper change. Also positioning: encourage looking toward affected side. Greater than 90% success if started early properly.
Surgical Indications
Consider surgery if: No improvement by 12-18 months, significant residual rotation deficit (greater than 15-20 degrees), significant residual tilt, cosmetic/functional concerns. Open or endoscopic SCM release at clavicular origin. Post-op stretching and bracing crucial.
Quick Decision Guide - Pediatric Torticollis
| Feature | Congenital Muscular Torticollis | Cervical Spine Anomaly | Ocular Torticollis |
|---|---|---|---|
| Onset | Birth or shortly after | Birth | Often noted later, intermittent |
| SCM mass | Present early (pseudotumor) | Absent | Absent |
| Range of motion | Limited passive rotation away from tilt | Variable, may be fixed | Full passive ROM |
| X-ray | Normal | Abnormal (Klippel-Feil, hemivertebra) | Normal |
| Treatment | Stretching, surgery if fails | Depends on anomaly | Ophthalmology referral |
Mnemonic
TILTTILT - Torticollis Features
T
Toward tight muscle (head tilt)
Head tilts to the affected SCM
I
Investigate hips (DDH)
20% have associated hip dysplasia
L
Limited rotation (opposite side)
Cannot turn chin toward affected side
T
Tumor (pseudotumor) early
Palpable SCM mass in first weeks
Memory Hook:The head TILTs toward the tight SCM - same side as the problem.
Mnemonic
STRETCHSTRETCH - Treatment Principles
S
Start early (before 1 year)
Best outcomes with early treatment
T
Tilt head opposite
Stretch by tilting to opposite side
R
Rotate chin toward tight side
Complete the stretch maneuver
E
Every diaper change
Frequent repetition is key
T
Tummy time
Prone positioning helps
C
Consider surgery if fails
12-18 months if no improvement
H
Hips examined
Screen for DDH in all cases
Memory Hook:STRETCH the SCM by tilting opposite and rotating toward - start early for best results.
Mnemonic
DDHDDH - Screen in Torticollis
D
Develop dysplasia in 20%
Significant association
D
Do ultrasound or exam
Screen all torticollis babies
H
Hips and head together
CMT and DDH share intrauterine crowding etiology
Memory Hook:DDH in 20% - Don't forget to check hips in all CMT patients.
Overview and Epidemiology
Congenital Muscular Torticollis (CMT) is the most common cause of torticollis in infants and young children. It is characterized by unilateral shortening or fibrosis of the sternocleidomastoid muscle (SCM), leading to a head tilt toward the affected side with chin rotation to the opposite side.
Epidemiology:
- Incidence 0.4-2% of live births
- Third most common congenital musculoskeletal condition (after DDH and clubfoot)
- Right side more commonly affected (75%)
- Male slightly more often than female
- Associated with difficult delivery, breech presentation, first-born
CMT vs Other Causes
CMT accounts for 80% of pediatric torticollis. The remaining 20% includes osseous abnormalities (Klippel-Feil, atlantoaxial rotatory subluxation), tumors (posterior fossa, spinal cord), ocular causes, and Sandifer syndrome (GERD). Consider imaging if no palpable SCM mass, atypical presentation, or failure to improve with stretching.
Etiology Theories:
- Intrauterine compartment syndrome of SCM (most accepted)
- Birth trauma and ischemia to muscle
- Venous occlusion and edema leading to fibrosis
- Associated with breech, oligohydramnios, multiple pregnancy
Pathophysiology and Mechanisms
Sternocleidomastoid Muscle
SCM Anatomy
| Feature | Details | Clinical Relevance |
|---|---|---|
| Origin | Sternal head: manubrium. Clavicular head: medial clavicle | Surgical release usually at clavicular end |
| Insertion | Mastoid process and lateral superior nuchal line | Rarely released proximally |
| Innervation | Spinal accessory nerve (CN XI) | At risk in surgery |
| Action | Ipsilateral tilt, contralateral rotation | Explains clinical pattern in CMT |
Biomechanics of Torticollis
Muscle Contracture Effects
- Unilateral SCM shortening pulls head into tilt
- Head tilts toward affected (tight) side
- Chin rotates away from affected side
- Limited passive rotation toward affected side
- Over time: facial asymmetry, plagiocephaly
Secondary Deformities
- Plagiocephaly: Flattening of ipsilateral occiput (lies on that side)
- Facial asymmetry: Ipsilateral face appears smaller
- Frontal bossing: Contralateral forehead more prominent
- These changes drive urgency for early treatment
Plagiocephaly and Timing
Positional plagiocephaly develops within months if torticollis is untreated. While mild cases improve with treatment, severe plagiocephaly may require helmet therapy. This underscores the importance of early stretching to prevent secondary skull deformity.
Classification Systems
CMT Subtypes (by SCM characteristics)
| Subtype | Clinical Finding | Characteristics | Prognosis |
|---|---|---|---|
| Sternomastoid tumor (Pseudotumor) | Palpable mass in SCM | Most common, present in first weeks, resolves by 4-6 months | Excellent with stretching |
| Muscular torticollis | Tight SCM without mass | No palpable mass, just tight muscle | Good with stretching |
| Postural torticollis | Positional preference, no tightness | Mildest form, normal ROM | Resolves with positioning |
All three subtypes generally respond well to conservative treatment if started early.
Clinical Assessment
Systematic Examination
Step 1History
- Birth history: Breech, prolonged labor, forceps/vacuum
- Onset: When noticed head tilt
- Progression: Worsening, stable, improving
- Prior treatment: Any stretching program, PT
- Feeding: Any difficulty (may relate to Sandifer)
- Vision: Any concerns (ocular torticollis)
Step 2Inspection
- Head position: Tilt direction, chin position
- SCM palpation: Mass (pseudotumor), tightness
- Plagiocephaly: Flattening of occiput
- Facial asymmetry: Ipsilateral face smaller
- Neck webbing: May indicate Klippel-Feil
Step 3Range of Motion
- Passive rotation: Should be symmetric, check deficit
- Passive lateral flexion: Head tilt to each side
- Active ROM: Observe when child looks around
- Compare sides - asymmetry is diagnostic
Step 4Associated Conditions
- Hip examination: Barlow/Ortolani, asymmetry (DDH in 20%)
- Foot examination: Metatarsus adductus, clubfoot
- Spine examination: Scoliosis, congenital anomalies
- General exam: Dysmorphic features if atypical
Always Screen for DDH
20% of CMT patients have developmental dysplasia of the hip. Both conditions share the etiology of intrauterine crowding and malpositioning. Hip examination (and ultrasound if indicated) is mandatory in all CMT patients.
Investigations
When to Image
X-ray cervical spine if: atypical features, no palpable SCM mass, failure to respond to stretching, restricted ROM in multiple planes, or concern for bony anomaly. Most routine CMT with classic features does not require imaging.
Imaging in Torticollis
| Investigation | When Used | What to Look For |
|---|---|---|
| Cervical spine X-ray | Atypical presentation, no improvement, bony abnormality suspected | Klippel-Feil, hemivertebra, atlantoaxial anomaly |
| Ultrasound SCM | Early, if diagnosis uncertain | Muscle thickening, echogenicity changes |
| Hip ultrasound | All CMT patients less than 6 months | DDH screening |
| MRI cervical spine | Neurological signs, severe or atypical | Cord abnormality, tumor |
| CT cervical spine | Suspected atlantoaxial rotatory fixation | AARF diagnosis |
When to Consider Non-CMT Causes:
- No palpable SCM mass or tightness
- Multiple planes of restriction
- Onset after first few months of life
- Neurological signs
- Failure to improve with proper stretching
Management Algorithm
Physiotherapy-Based Management
| Age | Approach | Key Elements | Expected Outcome |
|---|---|---|---|
| 0-3 months | Home program | Parent stretching, positioning, tummy time | Most resolve |
| 3-6 months | PT-guided | Formal physiotherapy if not resolving | High success |
| 6-12 months | Intensive PT | More structured program, monitor progress | Most still resolve |
| Greater than 12 months | Re-evaluate | Consider surgery if significant residual deficit | Some need surgery |
Stretching Technique:
- Hold baby's shoulder down on affected side
- Tilt head TOWARD opposite side (stretches tight SCM)
- Rotate chin TOWARD affected side
- Hold 10-30 seconds, repeat 10-15 times
- Do at every diaper change (easily 4-6 times daily)
Positioning:
- Encourage looking toward affected side
- Toys, lights, parent position on affected side
- Tummy time supervised when awake
- Avoid prolonged time on back same position
Early, consistent stretching leads to greater than 90% success rate.
Surgical Technique
Open Unipolar SCM Release (Clavicular)
Standard procedure for CMT not responding to conservative treatment.
Surgical Steps
Step 1Positioning
- Supine with shoulder roll
- Head turned toward affected side (exposes clavicular SCM)
- General anesthesia
Step 2Incision
- Transverse incision 1-2cm above clavicle
- In skin crease for cosmesis
- Approximately 2-3cm length
Step 3Dissection
- Divide platysma
- Identify SCM sternal and clavicular heads
- Protect external jugular vein laterally
- Identify and protect spinal accessory nerve
Step 4Release
- Divide SCM at its clavicular and sternal insertions
- Can divide any tight bands felt
- Passively move head to test release
- Should achieve full correction on table
Step 5Closure
- Hemostasis
- Close platysma, subcuticular skin closure
- Dressing, may use soft collar for comfort
Technical Points:
- Small incision in skin crease gives excellent cosmesis
- Ensure full correction achieved intraoperatively
- Be aware of spinal accessory nerve crossing SCM
Post-operative physiotherapy is essential for maintaining correction.
Complications
Complications of Treatment
| Complication | Incidence | Prevention/Management |
|---|---|---|
| Recurrence | 5-10% (usually minor) | Compliance with post-op PT, stretching |
| Spinal accessory nerve injury | Rare (less than 1%) | Careful dissection, know anatomy |
| Scar/cosmetic | Minimal with skin crease incision | Transverse incision placement |
| Overcorrection | Rare | Avoid excessive release, PT guided |
| Residual plagiocephaly | Variable | May need helmet if severe, usually improves with time |
| Facial asymmetry persistence | Improves but may not fully correct | Earlier treatment = better outcome |
Facial Asymmetry
Facial asymmetry and plagiocephaly may improve but not fully resolve even with successful treatment. Earlier intervention leads to better remodeling potential. Families should be counseled that some residual asymmetry may remain.
Postoperative Care and Rehabilitation
Post-Surgery Protocol
HospitalDay 0-1
- Wound check, remove dressing
- Soft collar for comfort (optional)
- Gentle ROM encouraged
- Discharge day 1 usually
EarlyWeek 1-2
- Begin formal stretching exercises
- PT referral
- Wound care
- Maintain correction with positioning
RehabilitationWeeks 2-12
- Active physiotherapy program
- Stretching continued by parents at home
- Gentle strengthening as tolerated
- May use headband/brace overnight if needed
MaintenanceMonths 3-6
- Ongoing stretching maintenance
- Monitor for recurrence
- Assess facial/skull symmetry
- Discharge from active PT when stable
Conservative Treatment Rehabilitation:
- Continue stretching until full symmetric ROM achieved
- Gradual weaning of frequency once normalized
- Positioning strategies ongoing in infancy
- Monitor for recurrence
Outcomes
Conservative Treatment Outcomes:
- Greater than 90% success if started before 1 year
- Best outcomes with early diagnosis and treatment
- Pseudotumor resolves by 4-6 months
- ROM normalizes within months in most cases
Surgical Outcomes:
- Greater than 95% good to excellent results
- Full ROM typically achieved
- Facial asymmetry and plagiocephaly improve but may not fully resolve
- Earlier surgery (12-18 months) better than delayed (greater than 3-4 years)
Evidence Base
Natural History and Conservative Treatment
Cheng JC et al • J Bone Joint Surg Am (2001)
Key Findings:
- Prospective study of 821 patients with CMT
- Manual stretching effective in greater than 90%
- Earlier treatment associated with faster resolution
- Pseudotumor resolved in all by 12 months
Clinical Implication: Early physiotherapy with manual stretching is highly effective. Surgery rarely needed if treatment started before age 1.
Limitation: Single-center study, variable follow-up.
Surgical Outcomes
Shim JS et al • J Pediatr Orthop (2008)
Key Findings:
- Review of surgical release outcomes
- Greater than 95% satisfactory results
- Better outcomes when surgery done before age 4
- Bipolar release for more severe cases
Clinical Implication: Surgery is effective when needed. Earlier surgical intervention (by 2-4 years) leads to better outcomes.
Limitation: Retrospective case series.
Association with DDH
Walsh JJ et al • J Pediatr Orthop (1997)
Key Findings:
- 20% of CMT patients had hip dysplasia
- Both conditions associated with intrauterine crowding
- Recommends hip screening in all CMT cases
Clinical Implication: Hip examination/ultrasound is mandatory in all CMT patients due to high DDH association.
Limitation: Retrospective analysis.
Plagiocephaly and Torticollis
Rogers GF et al • Plast Reconstr Surg (2009)
Key Findings:
- Torticollis is major risk factor for positional plagiocephaly
- Early treatment of torticollis reduces plagiocephaly severity
- Helmet therapy may be needed for severe cases
Clinical Implication: Treat torticollis early to prevent or minimize plagiocephaly. Persistent plagiocephaly may benefit from helmet.
Limitation: Review article, limited primary data.
Endoscopic vs Open Release
Burstein FD et al • Plast Reconstr Surg (2004)
Key Findings:
- Endoscopic SCM release feasible and effective
- Smaller incisions, faster recovery
- Similar outcomes to open release
Clinical Implication: Endoscopic release is an option with experienced surgeons. Open release remains the standard.
Limitation: Limited comparison, surgeon experience dependent.
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
VIVA SCENARIOStandard
EXAMINER
"A 6-week-old infant is brought in with a persistent head tilt to the right. The mother noticed it shortly after birth and is concerned about the position."
VIVA Q&A
Q1:What is the most likely diagnosis and how would you confirm it?
The most likely diagnosis is congenital muscular torticollis (CMT). I would confirm by: (1) Examining head position - if the head tilts to the RIGHT, chin should rotate to the LEFT (away from tight side). (2) Palpating the SCM - may feel a 'pseudotumor' or just tight muscle on the right. (3) Testing passive ROM - should have limited rotation toward the right (toward the tight side). (4) Examining for plagiocephaly (right occiput flattening) and facial asymmetry. This classic pattern with an SCM mass in a newborn is virtually diagnostic of CMT.
Q2:What associated conditions must you screen for?
I must screen for developmental dysplasia of the hip (DDH). There is a 20% association between CMT and DDH, as both conditions share the etiology of intrauterine crowding. I would perform Barlow and Ortolani tests, check for asymmetric thigh folds and limb length, and arrange a hip ultrasound if the baby is less than 6 months old, or hip X-ray if older. I would also check for other packaging abnormalities like metatarsus adductus and examine the cervical spine for any features suggesting congenital osseous abnormality.
Q3:Describe your treatment plan.
My treatment plan is conservative physiotherapy-based stretching. I would: (1) Teach the parents a stretching program: hold baby's right shoulder down, tilt head to the LEFT (stretch the tight right SCM), and rotate chin to the RIGHT. Hold 10-30 seconds, repeat 10-15 times, at every diaper change. (2) Advise positioning strategies: place toys, lights, and themselves on the baby's right side to encourage looking toward the affected side. (3) Encourage supervised tummy time when awake. (4) Arrange follow-up in 4-6 weeks to assess progress. Greater than 90% of CMT resolves with this program started early. If no improvement by 6-12 months, I would refer for formal physiotherapy.
KEY POINTS TO SCORE
Head tilts toward tight SCM, chin rotates away
Palpable pseudotumor confirms CMT
Screen for DDH - 20% association
Stretching: tilt opposite, rotate toward tight side
COMMON TRAPS
✗Forgetting to screen for DDH
✗Getting tilt/rotation direction confused
✗Not demonstrating stretching technique to parents
LIKELY FOLLOW-UPS
"When would you consider surgery?"
"What if there is no palpable SCM mass?"
VIVA SCENARIOChallenging
EXAMINER
"A 14-month-old child with CMT has been receiving physiotherapy since 4 months of age. Despite reported compliance, there remains 25 degrees of rotation deficit and significant facial asymmetry."
VIVA Q&A
Q1:How do you assess whether surgery is indicated?
I would consider surgery indicated in this case. My assessment: (1) Duration of conservative treatment - 10 months of proper physiotherapy is substantial. (2) Residual deficit - 25° rotation deficit is significant (greater than 15-20° is generally considered threshold for surgery). (3) Age - at 14 months, child is in the appropriate window for surgical intervention (12-18 months is typical). (4) Facial asymmetry - this will continue to worsen if torticollis persists. (5) Reassess compliance - ensure physiotherapy has been done correctly and consistently. Given these factors, I would discuss surgical release with the family.
Q2:Describe the surgical procedure.
I would perform a unipolar open SCM release at the clavicular origin. Technique: (1) Position supine with shoulder roll, head turned toward affected side. (2) Make a 2-3cm transverse incision in skin crease above the clavicle. (3) Divide platysma and identify SCM sternal and clavicular heads. (4) Protect external jugular vein and be aware of spinal accessory nerve. (5) Divide SCM at its clavicular and sternal insertions using cautery. (6) Test passive ROM - should achieve full correction on table. (7) Close platysma and subcuticular skin. Post-operatively, soft collar for comfort, begin stretching within 1-2 weeks, and close physiotherapy follow-up.
Q3:What is the prognosis post-surgery?
Prognosis is generally excellent. Greater than 95% achieve good to excellent ROM outcomes with surgery at this age. The rotation deficit should correct fully with surgery and post-operative physiotherapy. Regarding facial asymmetry and plagiocephaly: these will improve with time and normalized head position, but may not fully resolve. Earlier surgery (at 14 months) gives better facial remodeling potential than delayed surgery at 4+ years. I would counsel the family that some residual asymmetry may persist but should be minimal with treatment at this age. Recurrence risk is 5-10% if post-operative stretching is not maintained.
KEY POINTS TO SCORE
Surgery considered if no improvement by 12-18 months
Rotation deficit greater than 15-20° warrants surgery
Unipolar clavicular release is standard procedure
Post-op physiotherapy essential for outcome
COMMON TRAPS
✗Operating too early (before adequate conservative trial)
✗Not counseling about residual facial asymmetry
✗Forgetting post-operative physiotherapy
LIKELY FOLLOW-UPS
"What if this was a 5-year-old child?"
"What is the risk of spinal accessory nerve injury?"
VIVA SCENARIOCritical
EXAMINER
"A 3-month-old presents with a head tilt but you cannot feel an SCM mass. The passive ROM seems restricted in multiple planes. The parents report the tilt was not present at birth but appeared at around 6 weeks of age."
VIVA Q&A
Q1:What concerns does this presentation raise?
This presentation raises red flags for non-CMT causes of torticollis: (1) No SCM mass - typical CMT has a palpable pseudotumor or at least tight SCM muscle. (2) Restriction in multiple planes - CMT typically affects rotation more than other planes. (3) Onset at 6 weeks - CMT is present at birth or very shortly after. This pattern could suggest: (A) Osseous abnormality (Klippel-Feil, hemivertebra). (B) Atlantoaxial rotatory subluxation. (C) Posterior fossa or spinal cord tumor. (D) Ocular torticollis. I would not assume this is CMT and would proceed with further investigation.
Q2:What investigations would you order?
I would order: (1) Cervical spine X-ray (AP, lateral, open-mouth if possible) - to look for bony abnormalities such as Klippel-Feil (fused vertebrae), hemivertebra, atlantoaxial anomaly. (2) MRI cervical spine - if X-ray is abnormal or if there are any neurological signs, to assess cord, soft tissue, and rule out tumor. (3) CT cervical spine - if atlantoaxial rotatory fixation is suspected (shows rotatory malalignment). (4) Ophthalmology referral - if infant seems to have intermittent head position or turns head when tracking, to rule out ocular cause. (5) Hip ultrasound - still screen for DDH if any intrauterine etiology suspected. I would hold off on an aggressive stretching program until the diagnosis is clarified.
Q3:X-ray shows fused C2-C3 with a low posterior hairline. What is the diagnosis and management?
The diagnosis is Klippel-Feil syndrome - congenital fusion of cervical vertebrae with the classic triad of low posterior hairline, short neck, and limited cervical ROM. Management: (1) Further imaging - MRI to assess the spinal cord and look for associated anomalies (diastematomyelia, Arnold-Chiari, syrinx). (2) Screen for associated conditions - 30% have hearing impairment (audiology), 25-35% have renal anomalies (renal ultrasound), congenital heart disease (echo if indicated), Sprengel deformity (ipsilateral high scapula). (3) Conservative management - stretching will NOT help bony anomalies. Manage symptoms and monitor. (4) Activity restrictions - avoid high-risk contact sports due to potential cervical instability. (5) Surgical intervention - rarely needed, only for instability or cord compression. This requires multidisciplinary management.
KEY POINTS TO SCORE
Atypical torticollis needs imaging
No SCM mass, onset after birth, multi-plane restriction = red flags
Klippel-Feil has fusion, short neck, low hairline
Klippel-Feil: screen hearing, kidneys, heart, Sprengel
COMMON TRAPS
✗Treating all torticollis as CMT without considering differentials
✗Aggressive stretching in bony abnormality
✗Missing associated renal or cardiac anomalies in Klippel-Feil
LIKELY FOLLOW-UPS
"What is Sandifer syndrome?"
"How would you manage atlantoaxial rotatory subluxation?"
MCQ Practice Points
Direction of Tilt
Q: In CMT affecting the right SCM, which direction does the head tilt? A: The head tilts to the RIGHT (toward the tight muscle). The chin rotates to the LEFT (away from the tight side).
Associated Condition
Q: What musculoskeletal condition should you screen for in all CMT patients? A: Developmental dysplasia of the hip (DDH). There is a 20% association.
Stretching Direction
Q: How do you stretch a tight right SCM? A: Tilt the head to the LEFT (opposite to tight side) and rotate the chin to the RIGHT (toward the tight side).
Surgical Timing
Q: When should surgery be considered for CMT? A: After 12-18 months if no improvement with proper physiotherapy, or if significant rotation deficit (greater than 15-20°) persists.
Medicolegal Considerations
Documentation Points:
- Document head position, SCM mass, ROM measurements
- Record hip examination findings
- Document stretching instructions given to parents
- Note compliance with stretching at follow-up
- Record imaging results if obtained
Consent for Surgery:
- Scarring (usually minimal in skin crease)
- Recurrence risk (5-10%)
- Spinal accessory nerve injury (rare)
- Need for post-operative physiotherapy
- Residual facial asymmetry possible
DDH Screening
Failure to screen for DDH in CMT is a medicolegal risk. Given the 20% association, hip examination and appropriate imaging should be documented in all CMT patients.
Australian Context
Epidemiology:
- Similar incidence to international data
- Managed by pediatric orthopaedic surgeons and physiotherapists
Access to Care:
- Physiotherapy widely available, public and private
- Surgical services at pediatric centers in major cities
Referral Pathway:
- Often first seen by general practitioner or pediatrician
- Referral to physiotherapy and orthopaedics
- Helmet therapy through craniofacial units if plagiocephaly severe
High-Yield Exam Summary
Clinical Pattern
- •Head tilts TOWARD tight SCM
- •Chin rotates AWAY from tight side
- •Limited rotation TO affected side
- •Pseudotumor in first weeks (resolves by 4-6 months)
Associated Conditions
- •DDH in 20% - always screen hips
- •Plagiocephaly - develops with persistent tilt
- •Facial asymmetry - ipsilateral face smaller
- •Metatarsus adductus (packaging)
Conservative Treatment
- •Tilt head OPPOSITE to tight side
- •Rotate chin TOWARD tight side
- •Do at every diaper change
- •Positioning: toys on affected side
Surgical Indications
- •No improvement by 12-18 months
- •Rotation deficit greater than 15-20 degrees
- •Significant residual tilt/asymmetry
- •Unipolar clavicular release standard
Differentials
- •Klippel-Feil (fused vertebrae)
- •AARF (atlantoaxial rotatory fixation)
- •Ocular torticollis
- •Sandifer syndrome (GERD)