Wry neck/Torticollis.
DEFINITION
✓ Wry neck is defined as rotational deformity of cervical spine , that causes turning and tilting deformity of head and neck.
✓ (Tortus – twisted , Collum – neck.)
✓ Sternocleidomastoid undergoes contracture.
• Causes
✓ Congenital – Infantile torticollis.
✓ Infective – Tb of cervical spine , acute respiratory tract infection.
✓ Traumatic – Sprain, dislocation and fracture of cervical spine.
✓ Myositis of Sternocleidomastoid.
✓ Spasmodic : Painful , persistent or intermittent Sternocleidomastoid contracture.
✓ Unilateral muscle paralysis : polio
✓ Neuritis of spinal accessory nerves.
✓ Occular disturbance.
✓ Birth trauma : Breech delivery, improper application of forceps.
• Pathoanatomy
✓ A lump may be felt in Sternocleidomastoid.
✓ Often localized near the clavicular attachment of Sternocleidomastoid.
✓ Attains maximum size within 1-2 months and usually disappears within 1 year.
✓ If it fails to disappear , then the muscle becomes permanently fibrotic , and contracted and causes torticollis.
• Clinical features
✓ Head of the patient is tilted towards the affected side, while the chin points on other side.
✓ Sternocleidomastoid is prominently seen on other side.
✓ In later stages, patient may develop facial asymmetry and muscular disturbances in the eye.
• Types
(1) Temporary torticollis
(2) Fixed torticollis
(3) Muscular torticollis.
(4)Klippel feil syndrome.
(5) Cervical dystonia.
• Management
(1) Conservative
– Initially conservative treatment is done
– It consists of NSAID’s , muscle relaxants etc.
– Physiotherapy treatment like ultrasound, massage , heat
– In acute pain, the patient is encouraged to wear a cervical collar.
– Gradual neck stretching exercises , passive stretching , and splinting.
– In severe contracture of Sternocleidomastoid, release of muscle is required from it’s lower attachment.
– Active measures : head movement
Prone lying with head turned toward affected side.
– Massage can help to relax the muscle.
– Maintainace of correction is necessary.
– Same maneuver can be repeated.
– PNF : pattern of neck extension can be used
– Home treatment .
(2) Surgical treatment
– Subcutaneous tenotomy is done
– The clavicular and sternal heads of Sternocleidomastoid are divided close to origin along with release of tight fascia.
– Head is then immobilized in a callot’s cast in over corrected position for 2-4 weeks .
– Mobilization is began as soon as the cast is removed.
– For older children / often failed operation, Bipolar release of muscle from both sides, ferkei’s modified bipolar release or z-plasty.
– In infants : surgery is delayed till fibroma is well formed .
• PT management following surgery.
– Since the contracture is removed surgically , passive sustained stretching is not necessary .
– Following measures should be done.
(1) Control of pain : pain relieving modality like hot packs and IRR.
(2) Active movements : free active movements.
(3) Self correction.
(4) Collar : cervical collar.
(5) Working posture .
