Congenital Muscular Torticollis
Congenital Muscular Torticollis
Congenital Muscular Torticollis
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Congenital
ETIOLOGY BY
AND
Muscular
AND M.D.,
LAMBERT,
Torticollis
PATHOLOGY ROBERT
M.D.,
RALPH
CLAUDE
T.
LIDGE,
N.
C.
BECHTOL, ILLINOIS
M.D.,
CHICAGO,
of
the as
important the
is
literature part
distinct
on an
the
subject
tortithe
first
a
of
experimental primary
Congenital
torticollis
entity, the
pathological
of
which are limited to the sternocleidomastoideus from the Latin wordstortus, meaning twisted, may be head. the result Synonyms of irregular
dictionary as
muscle 15 The term and collum, meaning of the muscles and with stiff-neck, combined
contraction
twisting
has an caput
unabridged of the
the ofneck
used
include wry-neck,
crooked-neck, and twisted-neck. There are many types of torticollis, congenital types include those resulting while
matic,
pum,
the
commoner
or
acquired
paralytic
types here.
HISTORICAL
hysterical,
factors. Only
those the
infectious, of torticollis,
neoplastic, congenital
in
origin,
will
be
considered
BACKGROUND
Dutch
surgeon, be
for
torticollis
in
is believed muscular
be
pathological
had
died that
muscle an present
at
as
six
weeks
of age of
In 1875, he presented and upon whom an the sterno-mastoid was and symptom displaced the
deformity
an induration
or sterno-mastoid of fibrous tissue between the fibers and had its usual thickness. case report by a fibrous tissue between
said
of such were
the
extent
fibers.
had
growth destroyed
the bundles continued to The drawing changes of the defeel man to give a
section Anderson
muscle
stated
eighteenth
Samuel Sharp, writing in 1740, did not by surgery and that the first of this condition was
the great
surgical
French
surgeon
DEVELOPMENT
OF
THE
STERNOCLEIDOMASTOIDEUS
in a monumental paper of the sternocleidomastoideus that the information long innervation is based been puzzled
well The
of a muscle is a good indication entirely upon the work of these by the fact that in mammals
Anatomists
musculature
comprising
VOL. 39-A.
trapezius
5. OCTOBER
and
1957
sternocleidomastoideus
is innervated
both
by
the
spinal
1165
part
1166
of
R.
T.
LIDGE,
R.
C.
BECHTOL,
AND
C.
N.
LAMBERT
the
accessory
nerve
and of
by
branches
of
the
anterior
rami
of
cervical
nerves.
the source of innervation almost universally believed tion, it has been conjectured
is an accurate indication spinal part of the accessory the trapezius-sternocleidomastoideus musculature these muscles in origin but According to in of and the the most a
complex
of visceral origin. The double innervation of this the basis of this anatomical feature, it is felt that visceral somatic origin or (2) are primarily visceral later shifted to follow a somatic (spinal) pathway. origin of the trapezius-sternocleidomastoideus the region of the branchial arches. In the dogfish (Squalus), a trapezius the vagus lature (the tissue arising not only in upper portion lateral trapezius musculature is simply nerve which supplies sternocleidomastoideus musculature typical the largest genus
in mammals is unique. On either (1) are of compound contain components which Edgeworth, the primordial of vertebrates to branchial the rami of is
variety
nerve the
segments of is undifferentiated
The consists
trapezius muscuof a single back. It inserts cartilage of the with the small indicate that which sternoand cannot musthe fish, spevagus the are
from the skin and superficial fascia over the muscles of the the shoulder musculature and in the girdle but also in the of the last branchial arch. It is thus perfectly in sequence muscles is a of the other gill posterior arches. division This of seems the to interarcualia specialized,
interarcuate musculature
branchiogenic. cleidomastoideus, more powerful be moved des can visceral especially cialization musculature branches The
being tissue
Thus, it appears that the trapezius musculature, which includes the is probably of visceral origin. In sharks, this musculature is larger and serves to move the girdle. In bony fish the membranous girdle
because of its firm attachments, as a result of which the attached move only part of the gill apparatus. Because of this anatomical muscles are much weaker in bony fish than they are in the dogfish. the Teleostei, this muscle mass is not even present as a result during evolutionary is innervated, which supply the trapezius mass
from from the
change. In all fish, the trapezius-sternocleidomastoideus as is known, solely by the posterior twig part of the gill musculature. in In most amphibians, Caudata, the the sternocleidomastoideus trapezius mass mass.
is also the
undivided
differentiated arising
is an that most
of the
in closely
superficial fascia of the back. The musculature of the common that it is very narrow and tends to arise exclusively from the resembles sole source (1913) has and second involved undivided innervated a sternocleidomastoideus of innervation however, nerves are sensory mass branch which of of than this a trapezius. According muscle in amphibians the small is extremely so far accessory In some the of
toad head to
so
branches the
culature
that Siren in lacertina also sources. It fibers. the In summary, the nerve. represents vagus
spinal
branches have
and which
amphibians
an is
musculature may The accessory dorsal side of the sertion length insertion is not trapezius
1900, development,
by spinal nerves. reptiles arises from the posterior portion scapula above In species of both the
is located on the anterior border of the of the clavicle, and on the interclavicle. was probably located along the length found mass
demonstrated from
the clavicle, along the of reptiles now extinct, cleithrum (a structure reptiles the the girdle. function Furbinger, all stages the stage the lowest
in
extant was to
and and,
the at
these elevate
which animals
the in
the
trapezius-sternocleidomastoideus
THE JOURNAL OF BONE AND
musculaJOINT SURGERY
CONGENITAL
MUSCULAR
TORTICOLLIS
1167 present the in accessory unit, indicates. is regularly vertebrates field rather The of below musculathan from reptile is by the spinal and Howell follow Furtherin may upon be all be the mdithe the
is divided. in the has developed (dorsal and the lowest nerves afferent that
of the
Since evolutionary
of scale,
this it
muscle seems
mass conclusive
is not that
branchiomeric in mammals accessory Apparently, experimental lower vertebrates they follow field
scale On fibers,
innervated
some
vagus, have, in reptiles, motor fibers also follow field of is a distinct this portion of origin from and occipital example, portion, life, and
musculature is present in all mammals. Furthermore, portion which represents the sternocleidomastoideus, although may be partially covered by the trapezius. There the sternum bone. These the the and clavicle and various sections portion, the portion. all In separate of the sterno-occipital but a few of insertions muscle may portion, the higher
named-for of animal
sternomastoid cleido-occipital
cleidomastoid
muscles
nerve
innervation is obtained by both the spinal accessory nerve and the nerves. In mammals a larger proportion of the motor fibers follows the spinalcourse, and the source of innervation of the trapezius and sternocleidomastoideus is more frequently double. The shifting of the motor fibers to follow the spinalcourse is imilar s to but more extensive than that found in reptiles. the evidence musculature forms, in the nucleus this main, of the is mass by the vagus it seems visceral. and to when spinal nerve indicate that This muscle it shifted, by the its vagus the mass origin of apparently nerve, but the trapezius-sternooriginally develshifted higher with forms the
In summary, cleidomastoideus
oped it. it part in the In the is supplied,
branchial-arch lower
region
supply in
is supplied
related
to
the
supply
of
the
of
the
gastro-intestinal
AND
EMBRYOLOGY
TRAPEZIUS
STERNOCLEIDOMASTOIDEUS
IN
THE
HUMAN
Lewis, on
writing
in
theManual
of Human
Embryology,
gives
the from a
following the
of the trapezius and and sternocleidomastoideus the At mass of the seven occipital a very extends
the lateral portion of to the shoulder girdle. mass, and as the rudiment is about anterior
common muscle mass and the accessory nerve extends nerve is carried first with it. appears to the two
trapezius millimeters
caudal location
this rudiment have been made, it is the caudal member of the closely packed cells and is indisexcept which region for its runs for in which caudalward greater some the toward condistance accesthe about some
from
densation
within
sory
and
it.
nerve
The
leaves
surrounding mass for the presence endf the o muscle vagus. From this
the
arm the
VOL.
bud level
39-A,
of the of the
NO. 5,
OCTOBER
R.
T.
LIDGE,
R.
C.
BECHTOL,
AND
C.
N.
LAMBERT
into
the
two
from caudal
which divisions
the are
and separated.
first mass
shoulder parallel
to the vagus nerve. It with them by a layer dorsal In caudally. entire of the
spinous extend
toward the deep cervical arm are the as spine far as and now of the
and is connected it from the more have adjoining dorsally migrated their portion toward the does not milli-
sixteen-millimeter
sternocleidomastoideus
trapezius is attached has extended caudally and the occipital the ligamentum cartilage. trapezius be found also the shows
nuchae. The anterior Not until after the obtain in the marked process and its adult final as form.
meters
in
does
splitting process
trapezius present
sometimes
a secondary
development occipital
in a fourteen-millimeter region to the clavicle. and trapezius for It has cleidoand any
mastoid
already mastoid.
does
indicate
EMBRYOLOGY
NERVE
TRAPEZIUS
SUPPLY
IN
TO
THE
THE
HUMAN
STERNOCLEIDOMASTOIDEUS
Streeter,
also
writing
in
the Manual
of
Human
Embryology,
the
following the adapted forms bundle group man it vagus and to supply the more which is of muscle functions
facts. The accessory vagus complex nerves. In man, is composed the motor are of several branchial fibers of this complex including specially the higher a distinct to the and in
the group of muscles derived caudal rootlets of the vagus known as the spinal accessory cells
to
from the branchial arches. In predominantly motor and form nerve. This bundle is distributed the more caudal branchial arches,
which
innervate
are
derived
from
of the arm girdle-the the nerve is carried of this musculature of the the accessory roots of nerve the
sternocleidomastoideus down across the neck. in the higher vertebrate ; additional spinal cord. rootlets These origin nucleus cord,
IN
and trapezius. Coincidental with the forms, there is inof origin may are extend obtained as far
rootlets of
the spinal accessory and ambiguus of the medulla the two being continuous.
THE HUMAN
STERNOCLEIDOMASTOIDEUS
TRAPEZIUS
In tinuous
attachment position downward,
stated which
that the trapezius and sternocleidomastoideus extends from the inion to the tip of the and therefore produces a ridge, the superior one by the attached
TRE
conprocess. line.
forward,
Below,
one
mastoid process which constitutes and medial pressure exerted head of the sternocleidomastoideus is
end of this line is the result pull of the sternocleidomastoideus. to the superior border of
OF BONE AND JOINT SURGERY
JOURNAL
CONGENFAL
MUSCULAR
TORTICOLL1S
1169
medial
articulation large
of
the
clavicle, by
while fibrous
the tissue
other to
head the
in below.
front
of
the
is join&l
and Altenberg have written obliquemucle which eftends from the mastoid of the egion extrnal It is usually in dissections superficial Human the clavicle. The and of cervicl t temporal fascia. It
that the sternocleidomastoid the anteriorsuperior portion bone has two more of the skull. of origin heads
made up of five or we1e (1) superficial (4) is stated front origins deep that of head
distinct muscle bellies. Those sternomastoid, (2) superficial sternoand or the (5) sternal a double portion deep of
occipital, (3) cleidomastoid. In Morris sternocleidomastoideus notch and that third cervical mastoid
bone. course
the
below the clavicular border of the medial area covered by external the outer line of surface of the occipital a nearly parallel
of
the
()
are
to
into insertion.
tendons
origin
comparatively
follow
:
Middleton,
three located major at the
BLOOD
SUPPLY
in
portions.
1930, The
artery
the
muscle by
is
into It of is short appears and join portion branch the the the the is the
mastoid
sternocleidomastoid
and
to
follows
travel
the
of
beneath. head
its
of the artery,
parent
its of
through thyroid
sternocleidomastoid and
the
superior
trunk
distance
and downward the sternal head it, reappearing downward (there to follow by supply branch of deep the
the above upper border of parallel to the upper of the muscle, it does in along no the junction the the artery of
head
clavicular sternal
at
once but instead passes beneath head. The artery then courses head to from in veins which the the with branches sternal pterygoid the common are head extended appears formed vein.
interval between posterior border to of the the supply superior clavicular and
are
branches
The
vein
terminates lingual
plexus facial
sternofrom the
The
branch
20
upward
from this head is uncertain. and middle portions of the branch of the superior thyroid arterial supply of the posterior insertion the sternocleidomastoid portion of the ascend and descend is extensive auricular ; this artery muscle in each branch and
to Chandler main
( 1) : the
the
cular
upper
branches
of
the
muscle
anastomoses attached
VOL. 39-A,
many
OCTOBER
maj
which
R.
T.
LIDGE,
R.
C.
BECHTOL,
AND
C.
N.
LAMBERT
branch
of
the
superior
thyroid
artery
supplies
the
middle
of the lower third of the sternocleidomastoideus muscle and sends two main branches, aswell as many small branches, down the chief muscle division ; (4) a branch of the transverse scapular artery supplies the lower portion of the muscle by means of many secondary branches ; and (5) an arterial branch which arises from the ascending branch of the transverse cervical artery supplies the lower lateral portion of the muscle. The
are even
vessels
more
which
profuse
provide
than
the
venous
drainage
of
the
sternocleidomastoideus
areas venous
of
of
venous channels,
drainage both
but within is
the are arterial also there the muscle carried by the anterior
vessels. Not only is there overlapping of are numerous communications between the main substance and on the surface. The venous all the jugular, major the veins of transverse the neck-the scapular, the
the
jugular,
jugular,
the
auricular, the posterior facial, and the anterior facial veins. There profuse communications not only between the main venous channels but their branches both on the surface and within the muscle tissue itself.
NERVE SUPPLY
receives leaves
supply by the
jugular mastoid
obliquely outward at a distance of supplying arise also the chiefly receives The spinal bellies of the spinal
process. The The The branches motor branches sternocleidomastoideus sternocleidomastoideus from the visceral motor and are both visceral and somatic. fibers of the spinal accessory sensory fibers a deep portion from course of the in the from of the vagus which second, third, and the nerve.
branches a part
accessory
origin. FUNCTION
is really trapezius
This
usually
complex
sternocleidomastoideus
muscles,
According is to
to
Morris
Human neck
the
function and
of to
the rotate
bend
the
head
and
shoulder
side. When the trapezius also acts, the head is fixed, the two muscles may further in the simplest terms, the sternocleidomastoideus side and the chin to the opposite side.
neck is flexed and the chin is raised. increase the degree of hyperextension. ctually, A rotates the occipital bone to the
ETIOLOGY In remote, regard a discussion cause to the ofthis of the etiology condition must
as
or With to be
immediate
cause,
it
whether
( 1)
neck
stages of accelerated growth, cause which has stimulated least is known. If it is postulated replacement
inquire as
or (3) a combination the most interest that the presence is the tumor. immediate fibrous
in
of origin
the of
muscle the
torticollis,
tempting
to
the to
CONGENITAL
MUSCULAR
TORTICOLLIS
Determination
be
argued that On
tend wry-neck
of the because
factors with
is apt torticollis
to
can be considered a predisposing the problem, however, we find that in the breech presentation. Recent interpretation. the cause It of congenital muscular of interest attributed at the
factor in congenital it would be possible studies of clinical have in 1670 condition the the was giving antenatal theory revived. rise of to birth Strovan to evolved Roonab-
A
in
number past
in
the
two
one
hysen, normal
and ofthe
on
pressure
theof
head
in
existence
injury, meyer
of and believed
the
sternomastoid
following
develops
deformity.
of large
felt is in reality a hematoma; of this hematoma is responsible standpoint, Stromeyer thought which replacing may it
the
by the
involve and ultimately destroy with fibrous tissue ; contraction experimentally by the tearing of tumors of the sternocleidomascontributed to the to disproving Stromeyers of true adhesions a position falls
this
muscles toideus
muscle In 1883,
leave seen
causes Witzel
no in
hematomata in no way
muscular
torticollis,
the
hematoma Petersen,
theory between
theory. in 1884,
which
was
hematoma
reported Petersen
his
combat formation
hematomata
form of in of of
by the development the face of the embryo with the development face adheres to the this side the situation, of the opposite the changes
of sections
the the
head
for
interferes
oneside
of the In on the on
opposite
ofthe on
direction.
muscle
muscle
together, muscular of
a
causing
that
in 1885,
Volkmann, This
process,
author
for
believed
microscopic
muscle
a
an
sternocleidomastoideus
with He and
of
the
of
He regarded development
he regarded as favoring the development of pelvic deformity, primiparity, and the presence same year, in 1890, Golding-Bird originated cause of which
writing is laid
wry-neck included breech preof a small amount of amniotic the neurogenic theory. He felt lesion during of type that intra-uterine the the three is arrested. two types and the considered
the
Anderson,
the
is the of believed
occurrence
of a cerebral
following
congenital
the sternocleidomastoideus that there are really intra-uterine parturition. arrest the of the side of life, He
type, which
by of the
arises accident
during during
of the secondarily
OCTOBER
1172
position of the
R.
T.
L1DGE,
R.
C.
BECHTOL,
AND
C.
N.
LAMBERT
head of
of the muscle
the
foetus in per
utero.
The
of out
torticollis Anderson
he
felt added
might little
be to
due
to
injury
se during
parturition.
the conception of the sternocleidomastoideus, probably not syphilitic Mikulicz, actually involved sternocleidomastoideus duces
passage
causes of torticollis, which formerly had in origin. in 1895, suggested general He reasoned while muscle, and thus
relaxed
writing two
factors, muscle.
ischaemia that
(actually compression
forced
rupturing infection muscle,
the fetal head is still engaged in the maternal being one of the muscles involved in the is more vulnerable to rupture-a rigid muscle muscle. Mikulicz also accepted the theory that 1897, thought origin and traumatic today theory, done that if it and infection occurs infectious in of the a muscle theories. expressed theory, theories. the it patholis imposthe muscle
if
the
infection is a factor
Kader, is ; he the
of
inj ured,
thus
the
of the theories on 1896 : (1) intra-uterine theory, time, however, using and (5) this
neurogenic of In to
theory,
combinations
experimental of a muscle addition, are favor of the presence of muscle possible a year
contracture
is infected
pyogenic organisms. In their points of attachment as in and evidence the relation as a in the area in
muscles ultimately nearer together. This malposition. in congenital that the muscle that an muscle the same
consequence
experiments
occurred only the traumatized blood stream Kader had and facts of or the
was a reported
wry-neck.
In 1899, Bradford but added no new which hematomata results did those
in torticollis
the main etiological described experiments were produced and to mean made at Three probably in to mechanics either of characteristics had ruptured trauma. were that the
known in the
not
whom
were negative ( negative develop or that the seen the in congenital muscular sternocleidomastoideus
follow-up birth
did not develop as that the so-called for the first The reason of however. that the In they blood time, for supply
infants following extra-uterine V#{246}lcker, was prolonged partial of the cells the obstruction were not by in no that infarct. occurred describe the of four club-foot,
SURGERY
1903, Gallavardin had observed atrophy The the following belief that the excised also
Savy reactivated the anterior horn (1904), Kempf myositis was is that a case that with side of in he
neurogenic theory in the cervical cord that ; he hemorrhagic torticollis first to there stated was
microscopic
of
a healed
in 1905, pregnancy.
described is believed
torticollis. as well
OF BONE
A child as bilateral
AND JOINT
and
JOURNAL
CONGENITAL
MUSCULAR
TORTICOLLIS
fingers,
theory
and
a deformity
of torticollis.
of etiology
the of
head. congenital
transmission
concerning
the
torticoffis
developed-the theory of arterial occlusion, as conceived These men based their theory chiefly on the work infants. They reported that their anatomical studies blood
pendent cate
by Nov#{233}-Josserand and Viannay. which they had done with stillborn had demonstrated three systems that each system does not arteries. the venous is an indeconare and which surrounding reasoned that communiFrom the systems
of
to
the of
sternocleidomastoideus. or
They
ofthe
unit which
supplies its own portion the other systems supply then can to the They heads proceeded be occluded
with
figuration
arterial
muscle,
also
sternal such serand of the
independent.
and as occurs clavicular during
to show that in the foetus the arteries of if the head is in a position of extreme rotation head is in of supply this position, where they interference torticollis by Morse stated the have that was in the pass tensed beneath with arterial 1915. the the
the
mastoideus
may
sternocleidoit. Nov#{233}-Josblood occlusion. presented was supply The the not muscles
work showed that occur during labor. the was cause of described and
first
case caused
case
in 191 1, stated that of bilateral torticollis delivered injury. extended wrote a result of the platysma being by He caesarian thought position
He
infant
section
condition shortened
by the
Bevan,
was
a birth partially
in 1918,
that
during
cleidomastoideus
muscle
and the
which
its muscle.
sheath. The
forms
As
changes
occur the
contracture
deep
marked is caused
of the 1920,
muscle is also extensively involved. In addition muscle. This is not due to fibrous degeneration held on one side, which causes marked reduction no alteration theory. to in or the in its histological at or ischemia of the muscles
there is a but rather in the size structure. presuperior affected. in torticollis. by abnormal evidence deformity. for although cases wrythe In
as a rule it causes the intra-uterine thought that which pressure trauma results upon into
ceding
may,
hematoma
the same year, wrote that Jones and Lovett supported position or hematomata are not by increased due must followed to by that club-foot,
heredity may the theory intra-uterine the also the a to be origin, same be cause, recognized development
play an important part that torticollis is caused pressure. is as of often a They an possible used associated cause, in muscle theory anomaly is the other as
They in
neck
cases
wry-neck,
ruptured. muscular
blastoma
previously shortened the first to suggest the being the result of an of this condition
may easily be that congenital in the muscle an anatomicalthis process theory. torticollis uterus. In this expense He felt degeneration. active
that
the
development
pathological
of muscle-tissue process
formation,
consists in connective-tissue or tendon formation at the tissue originating from the perimysium. and that it is not a sequel to ischaemic muscle believe birth. year, case that gave his to support of the the development reasons the foetus for theory and to of torticollis is
He
lasting
thus
many
the
years
first
to
an
following
in an
He
is due
voL.
39-A.
position
1957
NO.
5.
OCTOBER
1 174
R.
T.
LIDGE,
R.
C.
BECHTOL,
AND
C.
N.
LAMBERT
case
Bauman
the the
based
infant
stated
was that
in
the
breech
position had
and
was
delivered
by
In
1925,
by with
was
development congenital
upon a some
condition the
is not cases.
This observation torticoffis in had received delivery the flatly origin that of Petersen, the developColonna, of or the
this
no injury condition
series
trauma was
outside
uterus
and
some strenuous
; in
the in
not followed
Rugh,
is
writing
traumatic
of year, following
he
a
had
hematoma.
never
a case in and
in 1927, others
which
torticollis reported
had the
development
factor. a number
quoted cases,
not belief
followed abnormal
cause.
year, Hellstadius stressed the of the case of a child delivered by Petersen, who maintained condition and the intra-uterine by the flexion pressure exerted with rotation and of in basis of the
conditions
heredity theory. Rossi, in 1928, by caesarian section. He referred that there is a connection between life of walls. neck. the The This foetus, pressure position, describing the forces the in turn, of
made a complete to the theory adthe pathogenesis mechanism foetus causes as an into a faulty an abnormal and posi-
the
uterine of the on
the distance between torticollis. Petersen, of his clinical is related observations, to foetus
the sternocleidomastoideus, experiments on animals the faulty intra-uterine to various of thromecchymosis to two of his since, closed veins with the
the
tion
other
adhesions, unable
Middleton, bosed
tumor
which also produce in 1930, stated that in the sternocleidomastoideus. not have the characteristics
demonstrate that
presence
veins does
the sternocleidomastoideus for there is never any cartilaginous. of one Excision 1931, wrote presented that be
or
fluctuation and from the onset more, the process is diffuse instead
before
is firm, hard, and feels and there is an interval with hemorrhage. Bargellini, in in 1933, sternocleidomastoid it would seem that supply being the same expressed and the Abels, cause. theory. the origin by by scar of in the
the
supporting
which
consistent
definitely
for to may
due to theory.
experimental
injection
condition,
when the
be
shut
off
during
the middle and inferior is in a certain position, labor without the arterial there is Abels, year, which the foetus the rupture the observers The produced in 1934, malposition held is due heredity
that,
mentally
least, ligation.
muscle
a result
of intra-uterine
the that
Kastendieck,
stress of
supported
in
1938,
stated
in
1940,
stated
fibers
some birth.
the of
muscle
replacement of a part of the may be followed by the .Jan#{233}k,he next t year, affirmed in Oslers Principles sternocleidomastoideus
and
is
Practice shortened,
in congenital is atrophied
AND JOINT
to
wrya con-
SURGERY
CONGENITAL
MUSCULAR
TORTICOLLIS
siderable cleidomastoideus
produce
degree.
an
This due
be
sterno- the of
which may torticollis number of conmal-
induration.
occur stated
results, tributory
not
from factors
a which
single may
type
disturbance, together.
separately of
opinion
intra-uterine
position and the local ischaemia contribute to the development maldeveloped, fibrous, shortened, may also Johnson, be a factor. the next year,
and pressure which may be caused by muscular torticollis by rendering the and ischaemic. They felt that trauma that the muscle may become
wrote
contracted utero in
may undergo fibrosis and shortening as a result He added that in many cases a hematoma can week after birth. Chandler, in 1948, stated that
and tearing during in the muscle during that contracture same year, was on the head than into tumor tumor two formation. and 1950, caesarian
to the
sternocleidomastoideus may exist prior to birth. Stevens, in the congenital muscular torticollis in identical twins. The condition both infants and there was greater involvement of the clavicular head. He considered the condition to be a congenital anomaly. In 1950, Hulbert reviewed 100 cases. He classified the patients
those
with with
postural muscular
torticollis torticollis
in in
no
associated
formation
associated
muscular
torticollis
by
prior
section.
expected
The date
operation of delivery.
was
performed
before
onset
of
PATHOLOGY
The
in
of the
as in done.
seen
microscopically, a he
was
written a sixthe
the week-old
condition
of
case of described
He
stated character
to
that,
st#{233}rnocleidomastoideus muscle his knowledge, his case was lesion had been ascertained. bundles in tumor of muscle fibers, some parts the showed dense,
or sternocleidomastoideus the first on record It was found that was and destroying double its connective
developed
extending
between
such
degree that
usual
Study
of
of
fibrous
In the middle portion alone was present and tissue normal and quantity Deeper of fibrous in
of the muscle, where most it was no striated muscular could fibers was in were of the tissue only moderately appearance and less fibers distinctly and elastic of abundant size, while striated tissues, than but
end of the muscle, the muscular of the fibers of this tissue were twisted, and by of varying a considerable growth. amount breadth
surrounded
substance in which
muscle fibers lay isolated in the midst of the waxy bands. The tissue was neither completely localized nor uniformly diffuse. One of the most interesting secondary changes in congenital muscular asymmetry ofthe skull and face-was carefully described by Witzel in 1883. that that the
and
VOL.
and
atrophic
of the
and
mouth
that
is less
measurements
than
also full.
1957
is less of this
arched, condition
the
nose has
satisfactory
1176
R.
T.
LIDGE,
R.
C.
BECHTOL,
AND
C.
N.
LAMBERT
Witzel thought it is probably due to imperfect blood if the torticollis is treated early. In 1891, in a discussion of a paper by Whitman, Hadra open operation which he stated he first described had in York shown cicatricial
occurred
The
asymmetry for
Record
in
1884.
He
said
that
in that which
muscle had entirely He found it hard the condition reported but caused Spencer
in
disappeared to believe
In toideus that
been
1891, muscle
origin. swelling
the muscle.
in which by reported
fifteen
torticollis of the
nearly 300
subsequently
developed.
torticollis In 1892,
observed
a hematoma
sternocleidomastoideus
R.
autopsy
or
tion
had
; in
died two
shortly cases
after forceps to
birth. had
Ten been
in the breech or footling two no instruments been had cases muscle. and
used. into
inch
revealed hemorrhage As a result of the was one-third of an tissue, view infiltrated showed with blood large sublatter
blood,
effusion
between
fibers
appeared
also, others
ends. The sarcolemma had given way. The being indistinct, areas the fine the distribution in wavy, transverse of the
In many fibers there were were usually more uniform. blood in these infants was children. of the infant
areas and in concluded to that seen and cut Chirurinto the it been
British Royal Medical five weeks old he had resembling performed of the muscle blood. by sheath
had that
In this Volkmann had masses In concludblood or even tissue totally had clot
the
anterior
masses
posterior
inch thick.
had
that
they
contained that
some
muscle
Microscopic study of these and ordinary scar tissue. trace that that normal of pigment had been or altered
he had found no infants with torticollis. specimens of muscles and appeared said
partially
formed in place of the muscle fibers. Hildebrand, in 1897, reported that study of microscopic sections had indicated that marked decrease in the muscle fibers in the region of the tumor had occurred in an eight-week-old child. Many fibers still remained functional, however, and no blood pigment had been demonstrated. The diagnosis was interstitial myositis. In
oped had with with been
1903,
after
VSlcker
prolonged
described
partial microscopically
a peculiar
obstruction
muscle the
which These
had changes
devel-
observed
congenital
torticollis.
Postpartum showed
In size
Heusinger
which
reported
was nine
case
of two
OF BONE
a sternocleidomastoideus
long. Pathological
of a hazelnut
which
had
THE
developed
JOURNAL
days
AND
birth.
SURGERY
Micro-
CONGENITAL
MUSCULAR
TORTICOLLIS
1177 no trace of blood pigment. life the head, and lateral Henthat a
scopic
study
revealed
with
during position
intra-uterine of
that
result
of
ofthe cervical spine the affected side. in the lower thoracic region. by several authors: V#{246}lckerhad had noted that the diseased
is always present, the convexity of the curve being directed Occasionally, there is also a secondary compensatory curve In 1915, Morse summarized the pathological findings reported demonstrated degenerative changes in the muscle, Koester muscle had been almost entirely replaced by fibrous tissue, the changes Kader same
contracted
Volkmann changes
enous study Zenker ing of
had as
spread excised
interpreted myositis,
infection. portions of
as had year,
had
the hematog-
fibrous
In
and the
of
that Simmons
as
the waxy degeneration myositis culminating gave the following rupture of muscle ; (2) Heller by injections
considering of the
possible pyogenic dence toideus anterior,
Stromeyer by
and
be
implausible and
animals
is never
organisms;
followed (3)
or
contracture
showed it of actual
most by
of
injury; and
the (4)
torticollis.
with torticollis seen after birth show no eviinstances hematoma of the sternocleidomassame article he pointed out that the scalenus involved this in condition contracture represents conditions a type of
and splenius capitis are frequently affecting the sternocleidomastoideus. Three years later, in 1918, Bevan stated that
fibrous degeneration
in
which In muscle
muscle cells are Albee stated that that in long-standing shortened. that in torticollis
replaced by connective-tissue cells, this condition is usually limited severe cases, the platysma, the sternocleidomastoideus tissue may the occur muscular findings in contains in would 1925, patches tissue. seem wrote
to the the
In
abnormal throughout
tissue.This
scarlike
fibrous
is also to
in severe cases it may of the other soft parts of fibrous myositis and
There that
indicate
Clark,
as a result of the pathological studies made and others, the character of the muscle change is a substitution of fibrous-connective tissue for
replacement fibers is almost complete, resulting
by Bouvier, Krogius, Volkmann, had been determined. stated He that there the muscles and that sometimes of of four the insertion. muscle, tissue.
more
Mikulicz, the
the in
band.
The
muscle
In muscle
however, rhage there
sternocleidomastoideus in one of these cases, fourth case the hemorin the outer aspect muscle mass or side. of the The tissue fibers
site
injury
of the of the
In the although In
extensive
was
tumor
still distributed
as the
to be normal muscle mass scar, of becoming at either end severe degeneration, and more extensive may solve that dense the other the problem
all
was
approached
or,
in
one the
case,
in
the
neck added
months in the
showed a closer
pressure. Von early period, possible the muscle apparently the fibers mass and
after birth,
lesion. midst of He
by
at
connective
operation.
Connective muscle
tissue some
homogenous fibers,
appearance indicating
the
presence
of
vacuoles
degeneration.
1178
R.
T.
LIDGE,
R.
C.
BECHTOL,
AND
C.
N.
LAMBERT
In
seen in
1930,
later
in
a survey
of clinical rational
ninety
cases,
wrote
that
the
condition seen to to a
infancy
common two of weeks
and
cause.
sternocleidomastoideus
tumor
one
the
frequently
after birth ; it first appears as a spindle-shaped sternocleidomastoideus muscle, occasionally involving involving both sternal and clavicular heads.
swelling occupying the position only the sternal head but The uppermost portion of the affected. is present six months torticollis one begins side as The for two after while to the enlarged or three birth. the muscle months It tumor is not is is
to
the
mastoid
process when
is touched.
seldom, The of
if
ever,
to
absorbed, disappearing show a mild degree In some head to original about the tumor collections somewhat in result
fibrous
its
fullest
is
diminishing
cases being be
a true drawn
torticollis over to
develop tumor
while the is abresembles tissue no nuclei reveals is no degensmaller and show it the
sorbed. Grossly,
a soft
in
the are
tumor
Microscopic
appears
study
fibroma.
shows that
which
vacuolation
remnants
and are
of in
or
the
undergoing
Many with
there
or
degeneration.
mastoideus that
erating
a child stage
young
eight has
tissue;
fully
are
in
characteristics.
swathes adult,
fibrous than
none
scattered varying
normal
of the
Although usually
infant does
infant, of
does
does
abnormal lags
is because the neck time. When growth has been normal partly muscle.
commence,
by
muscle will in
the
muscle
becomes
producing
deformity. Middleton described a number of pathological changes which skeleton in association with congenital torticollis. One such change may develop in the clavicle when there is fibrosis in the clavicular Exostosis is never seen at the sternal attachment because in this region fibers
vicular
may appear in the is that an exostosis head of the muscle. the fibrosed muscle insertion. bone. which In the clathe Apparently are inflicted
from the
the
bone
the
normal
fibrous
of
the
upon
subperiosteal
layers
muscle. face and skull. There is on the side of the shortthe level of the eye side than eminence other side, the the the is
well
ened
slope
especially in the skeleton of the bone in the skull, and the eyebrow downward. The portion of the face below On the the on
appears to corresponding
flattened and
be
shorter portion
there
and to be wider from side to the affected side the frontal occipital region, while on the
marked
in
the vault
is rather flat. In short, and pushed forward on severity of to diminish early, all was
AND JOINT
opposite curve
after
surgical
The deformity of the skull varies according to the as growth continues ; thus the facial asymmetry tends correction the of deformity. If treatment is undertaken may disappear. reported several cases. In
THE
the
asymmetry In
1 93 1 Holloway ,
one
case
JOURNAL
the
OF
patient
BONE
operated
SURGERY
CONGENITAL
MUSCULAR
TORT1COLL1S
1179 literature. by fibrous patient was found in weeks definitely degenin this in 1842. old,
twelve
days
after birth,
which is the earliest time of operation recorded in the muscle fibers of the tumor were found to have been replaced of sections showed that there were no blood cells. Another five weeks afterbirth; in this patient thrombus formation was changes. marked quoted composed
Hough
addition showed In
proved erative country
another as
wrote that
when tumor
young
also
cellular of Boston
John
torticollis of Boston
and Altenberg, in 1944, a fusiform swelling of the swollen muscle was from
centimeters
their series gross pathological study including both sternal and clavicular centimeters in length and from one at times, cartilaginous. child, after disappearance fibrous Instead replaced of tendinous it showed by dense and all there further more so contains
and five
to
one-half
On
of
the
tissue the
width in and felt firm, white and glistening. found no muscle many calcification and fibroblasts. and the tissue hyaline resembles
findings
muscle
to
replaced
of which in
muscle
(some
remaining
varying absence
degeneration, changes
In
fibrous
that
muscle
as
the
cells
patient
vanish rows
older fibrous
begins dense
to
that
in
remains
parallel Reye, congenital
inelastic thus
autopsy
tissue
one,
arranged
of age
in 1951,
with
sections.
torticollis.
He
was
the
first
to
relate
of with
degeneration.
studies revealed They also revealed the and in cells that fibrous the
concerning
the
tissue this
cells
replaced tissue
textbook been seen
muscle
diseases
line
of demarcation
muscle, dams A
described
representing
these
early
of of
patients sarcolemmic
of
attempts
regeneration
and associates stated that giant congenital muscular torticollis. They nuclei and interpreted their presence muscle fibers. In 1955, Kiesewetter and with cases they of atrophy cent of the duration. had cases reviewed, being present but Evidence was not of the muscle bundles in the surviving conspicuous, degeneration of dogs. completely various changes
as
associates
were muscle replaced
reported by that
in 85 tissue, lesions
fibers. of
Dense striated
collagen muscle
found 20 in per
suggesting
atrophy
were
was
not
and
kinds
Among
Some has
his
work
a
regarding previously.
of
changes Brooks
disturbances in
occurring
result
in muscle following 1922, studied the circulation. He did his in leading from a muscle the
fact
that
when
the
vein
occluded
resulted.
acute in the
but These
inflammation,
the
artery changes
and
was left intact, pathological changes in included hemorrhage, oedema, degeneration fibrosis ofthe muscle. The surrounding tissues so that that
and
1957
process, found
gangrene
OCTOBER
eventually permanent
necrosis but
muscle of cause
result
39-A,
substitution
1 180
muscles with of arterial fibrous or in 1926,
R.
T.
LIDGE,
R.
C.
BECHTOL,AND:C.
N.
LAMBERT
ence
ing
animals
the
venous
.Jepson,
obstruction. by venous the same occlusion. conclusions Middleton as Brooks. did similar
essentially
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