Krivosheya in a newborn: set, muscle, congenital, neurogenic

The torticollis in the newborn is the wrong position of the child's head, which is accompanied by a change in the position of the head and the curvature of the muscles of the neck. This pathology occurs in boys and girls equally often and can have a different degree of severity. But taking into account the consequences of pathology, timely diagnosis and treatment are very important for the prevention of complications.

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Epidemiology

Statistics of torticollis indicate a wide prevalence of this problem among congenital pathologies of the musculoskeletal system. Krivosheya takes third place after other pathologies of the muscular system. More than 75% of cases are congenital, which indicates the possibility of early diagnosis. More than 89% of cases of torticollis can be successfully cured without the appearance of consequences by the first year of the child's life.

[2], [3], [4], [5], [6]

Causes of the torticollis in newborn

First of all, it must be said that torticollis can be congenital or acquired. When it comes to newborn babies, the torticollis is more often congenital in them. Congenital torticollis is more often muscular, which is due to the involvement of neck muscles in the process.

One of the most common causes of torticollis in a newborn is considered to be trauma at birth or surgical intervention, which leads to a lesion of the sternocleidomastoid muscle. This can be a simple birth injury or vacuum extraction, which causes trauma to this muscle with the formation of a hematoma. In the future, a scar from the connective tissue can be formed on the site of the hematoma, which disrupts the normal function of this muscle. To date, this is considered the most common cause of such a pathology. But the causes of torticollis can be completely different when the muscle function is disrupted in utero. In the origin of such torticollis, the main role is played by the congenital underdevelopment of the muscular tissue of the nodding muscle due to numerous external and internal factors:

1. Toxicosis of pregnant women is a risk factor for the development of various pathologies, including the laying of the muscular system;
2. Nephropathy can cause a metabolic disorder through the baby's placenta with the toxic effect of these metabolic products on the tissues and organs of the baby;
3. infectious diseases of the mother (sore throat, flu, rubella, rheumatism) - bacteria and viruses can cause direct damage to the muscles or organs of the child, which leads to such a pathology;
4. beriberi reduce the activity of muscle cells, their normal division, which can lead to the replacement of muscle fibers with a connective tissue;
5. radiation, vibration, hypothermia - can cause any intrauterine lesions;
6. heredity (often combined with congenital hip dislocation, clubfoot and other congenital developmental anomalies). The risk of developing torticollis in children whose parents had a similar problem in childhood is much higher than that of uncompromised ones.

Risk factors

Risk factors for the formation of torticollis may be as follows:

1. pathology of pregnancy in the early stages, which affects the laying of organs and tissues of the child;
2. weakness of labor activity with the need for active generic tactics and the use of forceps or other invasive methods;
3. birth trauma in a newborn;
4. the presence of other bone anomalies in the newborn - dysplasia, clubfoot.

[7], [8], [9], [10], [11]

Pathogenesis

The pathogenesis of the formation of changes in torticollis is sufficiently explained. With congenital torticollis, the muscles of the entire half of the neck develop underdevelopment, but the largest changes are localized in the sternocleidomastoid muscle.

Histological studies showed the presence of connective tissue regeneration of muscle fibers, narrowing the lumen of the arteries, reducing the amount of glycogen and glycosaminoglycans. All this indicates the defeat of the muscle, which occurred even during its formation, when the child was in utero. That is, the cause of such torticollis could be any of external or internal factors. Injury of an underdeveloped and dense muscle during labor contributes to the onset of hematoma and traumatic edema in the muscle. Such a hematoma can not independently resolve itself and in its place a scar from the connective tissue is most often formed. Such a process occurs after birth, and most likely that the cause of such changes is precisely birth trauma. The incorrect position of the nodal muscle begins on the base of the skull in the mastoid process.

This muscle departs with two legs from the clavicle (clavicular part) and one from the sternum (sternal part). Due to the shortening of the nodal muscle, the disturbances in its anatomical structure, its shortening takes place and this pulls all the muscles of the facial skull of the child. In the third week after delivery, at the level of the middle third of the nodding muscle, a densely-elastic formation of various sizes occurs without signs of inflammation of the tissues above the compaction. The position of the head may be correct or somewhat forced due to the shortening of the nodding muscle.
This form of torticollis with the presence of limited compaction at the level of the middle third of the nodal muscle happens quite often. Sometimes congenital torticollis passes without local compaction of the nodding muscle. Such compaction may be undiagnosed or slightly expressed and not palpable through the skin. In the presence of local compression of the nodal muscle, the maximum magnitude and density it reaches at the 6th week after delivery. Then the compaction gradually decreases, completely dissipates and degenerates into a connective tissue. This causes the whole clinical picture of torticollis.

[12], [13], [14],

Symptoms of the torticollis in newborn

Symptoms of torticollis in a newborn can appear immediately after birth, if the pathology is innate. Also, the first symptoms can appear within three weeks after the birth of the child. Sometimes a doctor can not always see the symptoms of torticollis in a newborn, then the first person who can notice the clinic of this pathology can be a mother. The most visible symptom is the inclination of the child's head to the sore side. And, accordingly, right-sided or left-sided torticollis of newborns will lead to tilting the head in one or the other direction. Given that the newborn's neck is short enough and this feature is not always visible, then you can see that the child, when lying always turns the head to the side. In this case, the eyes and lobes of his ears are not on the same level. This may be the first signs of torticollis in the baby. Over time, one can see the asymmetry of the face of the baby and the muscles on one side can be strained. The newborn, who has large enough cheeks, is easy to notice.

Often when the baby is bathing, the mother may notice a symptom of the thickening of the affected muscle. This can be when the mother is doing massage to the baby, she may notice that one muscle is strained or it is slightly shorter than the other. This may be one of the symptoms that require further diagnosis.

Congenital torticollis in newborns is also represented by other diseases: Klippel-Feil syndrome, Sprengel's disease, and cervical ribs. All these types of torticollis are congenital in nature, manifested in the first month of life and are characterized by the curvature of the neck.

The Klippel-Feil syndrome is a congenital hereditary disease that has an autosomal dominant type of inheritance. The classic manifestations of this disease are:

1. a short neck in the child, which is quite easy to see precisely because of the severity of this symptom - after all, the chin can sometimes touch even the shoulder line;
2. the hair growth line behind is very low;
3. with the rotation of the head there is a pronounced restriction of turns to the side.

Shortening of the neck is usually detected at birth, which directly indicates the diagnosis of torticollis. But sometimes this symptom can not be noticed, and when the child grows, you can see how the whole of his skeleton is changing. At the same time, the thorax is shortened and the lower aperture widens. The shoulders are located at different levels and the scapula are very small. Children can not turn their heads, so they respond to any stimuli only by turning their eyes. Further with age, the following symptom, which the mother may notice - the child does not hold his head, when he already has to do it.

Sprengel's disease is a congenital high standing of the scapula. The pathology arises sporadically, due to the delay in the development of the scapula and the lowering of the 3-4th week of embryonic development. It is characterized by the following main features:

1. A marked asymmetry of the contours of the neck (on the side of the high standing of the scapula, the contour of the neck is flattened).
2. Restriction of movements in the cervical spine and in the shoulder joint on the side of the lesion.
3. High position of the blade (6-12 cm higher than in the opposite scapula).
4. Reduction of the size of the scapula.
5. Rotation of the scapula around the sagittal axis.
6. Atrophy of the muscles of the shoulder, shoulder on the side of the lesion.
7. Reduction of the mobility of the scapula, especially with bone fusion.

All these symptoms arise precisely because of the small size of the scapula, so the torticollis is already considered a secondary symptom.

Acquired torticollis in newborns develops after birth. The cause of it may be a bacterial infection or a disease of other organs. And accordingly, different types of torticollis are distinguished:

1. Myogenic (due to muscle damage). This can occur with inflammation of the nodding muscle, the tumor of this muscle.
2. Bone - develops with congenital fractures or dislocations of the vertebrae, as well as in rickets, spondylitis.
3. Neurogenic (with pathologies of the nervous system). In children with congenital infantile paralysis with violation of innervation of the muscles and their paralysis or paresis.
4. Desmo - dermatogenic (with pathology of the skin and ligamentous apparatus). This kind of torticollis can develop with large skin scars, which can pull on the muscles, as well as with eye disease, as a compensatory mechanism.

The most common form of acquired torticollis, which can be in newborns is the so-called Grisell's disease. It is characterized by the appearance of curvature of the neck against the background of inflammatory processes between the I-II cervical vertebrae.

The cause of such torticollis are the inflammatory processes of the nasopharynx, the ears. In newborns, a long undiagnosed otitis can quickly lead to a zygomatic abscess, which leads to contracture of the muscles near the cervical spine. First, the child's body temperature rises, which indicates an acute inflammatory disease of the nasopharynx or ear. The nerve muscle on the side of the torticollis is not tense, not shortened. Then the child tilts his head in one direction, which can be noticed after some time after the symptoms of hyperthermia.

Setting or positional torticollis in newborns is considered one of the simplest variants of the disease. It develops throughout the first month of life, when the child is lying in the wrong bed. This can lead to the fact that the muscles on one side can be strained, while on the other hand they are relaxed. This happens if the child sleeps incorrectly or all the time turns to sound or light and lies in this position. When the baby starts to hold the head, then the muscles are more developed on one side and the neck is curved in this direction.

Complications and consequences

What is dangerous for torticollis in newborns? If it is positional torticollis, then no complications in treatment are observed. But in the case of congenital torticollis, the consequences can be very serious:

1. secondary changes in bones and muscles with prolonged absence of treatment;
2. compensatory scoliosis;
3. weakening of ventilation of the lungs with pronounced changes in the skeleton and violation of the anatomy of the respiratory tract;
4. difficulty breathing and swallowing;
5. neurological symptoms (paresis, paralysis, sensitivity disorders).

But considering the most unpleasant complication - a cosmetic defect that is harder to fix, the more time has passed since the detection, then the diagnosis and timely correction are very important.

[15], [16], [17], [18]

Diagnostics of the torticollis in newborn

Diagnosis of congenital torticollis should be carried out in the maternity hospital by a neonatologist. If muscular torticollis begins to appear in the third week of a child's life, then it is very important to notice this during this period.

For the diagnosis it must be taken into account that in the case of pathological births with an incorrect fetal position, especially with breech presentation, clavicle fractures, maternity brachioplexites, even in the absence of signs of torticollis in the early stages, this diagnosis can not be ruled out in the future. A characteristic diagnostic feature is that at the 3rd week after delivery at the level of the middle third of the nodding muscle, a densely-elastic formation of various sizes occurs without signs of inflammation of the soft tissues over the compaction. In the presence of local compression of the nodal muscle, the maximum magnitude and density it reaches at the 6th week after childbirth. Then the compaction gradually decreases, completely dissipates and degenerates into a connective tissue.
A large group of symptoms are signs that are visible by a simple examination.

The child determines a somewhat unusual position of the head: the head is tilted to the sore side, and it is difficult to turn it into a healthy side. The face is also rejected and mimic muscles can be stretched. On examination, the asymmetrical location of the shoulder-lines is noted - on the injured side of the forehearth is higher than on the healthy side. Often there is a change in the contours of the neck - on the side of the torticollis the contour of the neck is pointed, on the healthy side - flat.

A different degree of face asymmetry is also determined. Due to the growth of the skull, there is a decrease in the vertical and an increase in the horizontal size of the face. The pull of the nipple muscle deforms the mastoid process; curved nasal septum and auditory passage, deformed upper and lower jaws, sinuses of the nose. Also due to torticollis, there is compensatory curvature of almost all parts of the spine. So, at first the cervical section is curved in the opposite direction from the torticollis. At first, the curvatures have a compensatory character, but with time scoliosis develops.
When palpation of the nodding muscle, it is sharply shortened, tense, but without signs of inflammation (swelling, local and general temperature increase, tenderness, changes in blood). Mandatory comparative palpation of both nipple muscles (on the side of the torticollis and on the healthy side) is mandatory.

For more accurate diagnosis, a metric measurement is made.

When measuring the length of the nipple muscle with a centimeter tape on the side of the torticollis, its shortening can be determined in different sizes. The length of the nodding muscle is measured from the base of the mastoid process to the site of attachment of one of the portions of the nodding muscle. The difference between the metric data of healthy and diseased nodding muscles on the side of torticollis is the magnitude of the shortening of this muscle. The measurement of the angle of inclination of the head in the frontal plane also indicates the size of the torticollis. There are three degrees of torticollis:

1. Art. Shortening of the nodding muscle - up to 2 cm, angle of the head - up to 5-8;
2. Art. Shortening of the nodal muscle - up to 3 cm, angle of the head - up to 12;
3. Art. Shortening of the nodding muscle - more than 3 cm, angle of the head - more than 12.

[19], [20], [21], [22]

Differential diagnosis

Differential diagnosis of different types of torticollis should be performed with other hereditary diseases that have similar symptoms.

Shereshevsky-Turner syndrome is one of the chromosomal pathologies, which are accompanied by symptoms of torticollis. But apart from this, it is characterized by the following main features:

1. presence of skin folds on the neck on the sides;
2. low or dwarf proportional growth;
3. different forms of deformation of the chest;
4. deafness, cataract;
5. exophthalmos, pigmented degeneration of the retina;
6. narrowing of the aorta, defect of the interventricular septum.

Often, differential diagnosis of torticollis and various congenital diseases requires consultation of the geneticist.

[23], [24], [25],

Treatment of the torticollis in newborn

The approach to treating torticollis depends on the duration of the disease and on the degree of manifestation of the changes. Treatment of muscular torticollis in a newborn can be conservative and operative. Conservative treatment is the use of exercises, physiotherapy and massage.

Massage with a crooked newborn can be considered one of the first stages of rehabilitation and a very effective method of treatment. How to massage a newborn with a crooked? The technique of massage can be the following:

The kid lies on the table face up, and at the same time his mother fixes his shoulders.

• The first exercise. Stroking a sick nodding muscle (with it, the head should be bent backwards with slight movements).
• The second exercise. The fingers massage the affected muscle in the transverse direction.
• The third exercise. The muscle on the side of the lesion is massaged, as if expanding its fibers, gradually the fingers are displaced along the entire neck.
• The fourth exercise. Massage of the face and the premaxillary area, which prevents the secondary changes in the facial muscles of the face.
• Fifth exercise. One hand is located on the shoulder joint, the second - in the area of the lower jaw. Slow massing movements try to tilt the head in the opposite direction.
• The sixth exercise. The head of the kid is grasped by the hand and a smooth turn of the face in the direction of the torticollis, in the direction of the affected nodding muscle. The duration of the massage and the number of movements are gradually increased from 5 to 30 daily.

Exercises for crooked in newborns should supplement the massage and can already be performed by the mother herself after several lessons.

Great importance in the further consolidation of the results is played by a bandage from the torticollis, which corrects and retains the results obtained with the massage. Orthopedic pillow and orthopedic collar for newborns with crank can be used to hyper-correct the position of the neck. Children up to 6 months head can be fixed with a cotton-gauze "lamb", bonnet. The collar of Shantz for the newborn with curvature is also widely used. In this case, the height of the collar on a healthy side is 1-2 cm less.

Surgical treatment can be carried out if conservative methods are ineffective in children up to two years. There are also other indications for surgical intervention:

1. Forced head position.
2. Negative results of active and passive samples.
3. Compensatory changes in the skull, spine.
4. Sharp shortening and thickening of the nodding muscle.

Operation is spent at children after two years. The technique of surgical intervention consists in dissection of the affected muscle. Then, after sewing the wound, apply a cotton-gauze bandage in the position of hypercorrection of the head. This allows the muscle to form a connective tissue scar already with the correct position of the neck and head. After the removal of the stitches (7-8 days), the thoraco-cranial gypsum bandage is applied in the hypercorrection position, that is, the head should be tilted to the side opposite to the operated region, returned to the operative wound. Fixation with plaster bandage lasts 5-6 weeks. Then the plaster bandage is removed and the collar of the Shanz type is worn, which is worn for 6 months.

Prevention

Prophylaxis of an innocent torticollis is as follows:

1. Prevention of pathology of pregnancy (toxicosis, nephropathy, anemia of pregnant women, beriberi, infectious diseases).
2. Prevention of birth trauma.
3. Special care for children at risk (large fetus, breech presentation, transverse fetal position, heavy births, maternity fracture of the clavicle, maternity brachioplexitis).
4. Early diagnosis of pathology.
5. Stage inspection of children (maternity hospital, polyclinic, kindergarten, school).
6. Gradual, stage-by-stage treatment of the patient from the moment of diagnosis to the period of completion of growth.

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Forecast

The prognosis for the full recovery of the child is often favorable, with timely treatment tactics. If the problem can not be eliminated by conservative methods, then the
Cosmetic effect of surgical treatment is also often favorable. Secondary degenerative changes in the spine sometimes cause severe neurological disorders. Therefore, timely diagnosis and comprehensive treatment is important.

Krivosheya in a newborn with the appearance of her symptoms in this period is more often muscular. It is amenable to correction and the child can fully live after the courses of massage and exercise. It is important only to start treatment in time and differentiate different types of torticollis for proper treatment. In this case, the prognosis for recovery is favorable.

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