Contributing Authors:
Linus Kutup, Eric Hoffmeister, Benjamin Kersch, Niclas Samirae, Tobias Verdegem, Alexander Wolff, Lara Afaneh, Joana Strzlkowski, Nadine Fernandez, Katharina Weitzel
1. Torticollis.
Basics you need to know:
Orthopaedics vs traumatology:
– Orthopaedics: medical specialty for diagnostics and treatment of abnormal extremity function (many of which are congenital, but not all!!!)
–Traumatology: diagnostics and treatment of traumatic injuries of bone, joints and musculoskeletal structures (all are acquired)
– In the first lecture (Introduction), he explains some basic treatment principles. I don’t know how important these are… Go check them out if you want.
Torticollis
Torticollis, is a dystonic condition (abnormal muscle tension) defined by an abnormal, asymmetrical neck position (and thus abnormal head position)
– Can have a variety of causes
– The term torticollis is derived from the Latin words tortus for twisted and collum for neck.
Pathogenesis:
– The underlying anatomical distortion causing torticollis is an abnomral sternocleidomastoid muscle -> This is the muscle of the neck that originates at the sternum and clavicle and inserts on the mastoid process of the temporal bone on the same side.
– There are two sternocleidomastoid muscles in the human body and when they both contract, the neck is flexed.
– The main blood supply for these muscles come from the occipital artery, superior thyroid artery, transverse scapular artery, and transverse cervical artery.
– The main innervation to these muscles is from cranial nerve XI (the accessory nerve) but the second, third and fourth cervical nerves are also involved. Pathologies in these blood and nerve supplies can lead to torticollis.
Torticollis is a fixed or dynamic tilt (Neigung)/rotation, with flexion or extension of the head and/or neck. The type of torticollis can be described depending on the positions of the head and neck:
- laterocollis : the head is tipped toward the shoulder
- rotational torticollis : the head rotates along the longitudinal axis
- anterocollis : forward flexion of the head and neck
- retrocollis : hyperextension of head and neck backward
A combination of these movements may often be observed. Torticollis can be a disorder in itself as well as a symptom in other conditions.
Other symptoms include:
- Neck pain
- Occasional formation of a mass
- Thickened or tight sternocleidomastoid muscle
- Tenderness on the cervical spine
- Tremor in head
- Unequal shoulder heights
- Decreased neck movement
There are 2 types of torticollis:
1) Congenital
2) Acquired
1) Congenital Torticollis (Congenital Muscular torticollis CMT)
– The congenital muscular torticollis is present at birth.
– The cause of congenital muscular torticollis is thoguth be fibromatosis (hardening) of the muscle. Birth trauma or intrauterine malposition is considered to be the cause of damage to the sternocleidomastoid muscle in the neck. Other alterations to the muscle tissue arise from repetitive microtrauma within the womb or a sudden change in the calcium concentration in the body which causes a prolonged period of muscle contraction ???? Any of these mechanisms can result in a shortening or excessive contraction of the sternocleidomastoid muscle, which curtails its range of motion in both rotation and lateral bending.
– often also other musculoskeletal are present (Plagiocephaly, Talipes varus, etc)
– is more common on right side
– involves the muscle diffusely or isolated near the clavicular attachment of the muscle
-the mass (fibromatosis) attains maximum size within 1 – 2 months and usually disappears within a year
– But: When CMT is seen in early infancy, it is impossible to tell whether the mass causing it will disappear spontaneously
– The head typically is tilted in lateral bending toward the affected muscle and rotated toward the opposite side. In other words, in the direction towards the shortened muscle with the chin tilted in the opposite direction.
– Congenital Torticollis is presented at 1–4 weeks of age and a hard mass usually develops.
– Further development:
– Torticollis slowly becomes worse during growth
-the opposite shoulder elevates
-the frontooccipital diameter of the skull become less then normal
-Facial asymmetry
– Diagnosis: CMT is normally diagnosed using:
– clinically through evaluating the infant’s passive cervical range of motion (Physical examination reveals decreased rotation and bending to the side opposite from the affected muscle)
– ultrasonography (to visualize the muscle tissue)
– colour histogram (determines cross secional area and thickness of muscle)
– Treatment options:
•During infancy – conservative treatment – stretching exercises of the sternocleidomastoid muscle by manipulating the child’s head manually( up to 1 year); local injection of Hylase (an enzyme that can degrade Hyaluronsäure and thus can degrade the fibromatosis)
•Nonoperative therapy after the age of 1 year is rarely successful
• Surgery performed before the age of 6 to 8 years may allow remodelling of any facial asymmetry and plagiocephaly
•Surgery – delayed until evolution of the fibromatosis is complete:
•If the muscle is contracted after the age of 1 year it should be released
• Unipolar release of the sternocleidomastoid muscle distally – for mild deformity
• Bipolar release of the sternocleidomastoid; After surgery – first 6 to 12 weeks & head-halter traction or cervical collar
– When late discovered – deformity is fixed and there is no remodeling potential
-> In the lecture he only talks about congenital torticollis, so be sure you know the above!
2) Aquired torticolis:
There are several types of aquired torticolis:
– A self-limiting spontaneously occurring form of torticollis with one or more painful neck muscles is by far the most common (‘stiff neck’) and will pass spontaneously in 1–4 weeks. Usually the sternocleidomastoid muscle or the trapezius muscle is involved. Sometimes draughts, colds, or unusual postures are implicated; however in many cases no clear cause is found. These episodes are commonly seen by physicians.
– Tumors of the skull base (posterior fossa tumors) can compress the nerve supply to the neck and cause torticollis, and these problems must be treated surgically.
– Infections in the posterior pharynx can irritate the nerves supplying the neck muscles and cause torticollis, and these infections may be treated with antibiotics if they are not too severe, but could require surgical debridement in intractable cases.
– Ear infections and surgical removal of the adenoids can cause an entity known as Grisel’s syndrome, a subluxation of the upper cervical joints, mostly the atlantoaxial joint, due to inflammatory laxity of the ligaments caused by an infection
– Spasmodic torticollis: Torticollis with recurrent, but transient contraction of the muscles of the neck and especially of the sternocleidomastoid, is called spasmodic torticollis. Synonyms are “intermittent torticollis”, “cervical dystonia” or “idiopathic cervical dystonia”, depending on cause.
– Trochlear torticollis: Torticollis may be unrelated to the sternocleidomastoid muscle, instead caused by damage to the trochlear nerve (fourth cranial nerve), which supplies the superior oblique muscle of the eye. The superior oblique muscle is involved in depression, abduction, and intorsion of the eye. When the trochlear nerve is damaged, the eye is extorted because the superior oblique is not functioning. The affected person will have vision problems unless they turn their head away from the side that is affected, causing intorsion of the eye and balancing out the extorsion of the eye. This can be diagnosed by the Bielschowsky test, also called the head-tilt test, where the head is turned to the affected side. A positive test occurs when the affected eye elevates, seeming to float up.
Diagnosis: depends on the underlying cause. Also Physical examination, ultrasound, colour histogram, etc. Cervical dystonia appearing in adulthood has been believed to be idiopathic in nature, as specific imaging techniques most often find no specific cause.
Treatment: Treat the underlying cause and physiotherapy!
Differential diagnosis for torticollis involves:
Cranial nerve IV palsy, Spasmus nutans, Sandifer syndrome, Myasthenia gravis.
2. Scoliosis
– is a condition, in which the vertebral column is abnormally bent laterally -> S- or C- shape of vertebral column results (C- shape when there is one abnormal curve, S- shape results when there are 2 abnormal curves)
-> usually, the vertebral coloumn does not contain shifts in the lateral plane, only in the antero-posterior plane (kyphosis and lordosis)
– Scoliosis is defined as a three-dimensional deviation in the axis of a person’s spine. In the diagnostic sense, it is defined as a spinal curvature of more than 10° to the right or left as the examiner faces the person, i.e. in the coronal plane.
Get your facts and terms right:
In humans, the vertebral column consists of:
– 24 ‘free’ vertebrae (C1-C7, Th1- Th12, L1-L5)
– 23 menisci between the 24 free vertebrae
– 8-10 fused vertebrae that form os sacrum
and os coccyx.
Lordosis: anterior bulging of vertberal column
Kyphosis: posterior bulging of vertebral column:
- C1- C7 -> Lordosis
- Th1-Th12 -> Kyphosis
- L1-L5 -> Lordosis
- Os sacrum & Os coccycx -> Kyphosis
There are 3 types of scoliosis:
a) congenital (15%)
b) Idiopathic (65%)
c) 10% are secondary to a neuromuscular disease.
In the lecture, he only talks about congenital and idiopathic scolisosis, so let’s concentrate on these 2 types!
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