Torticollis

Case of the week: Torticollis



Torticollis is an abnormal posturing of the head secondary to contraction of the neck muscles. This may occur secondary to osseous, ligamentous, or soft tissue injuries, but can also be a condition which occurs along side disease, particularly that of the central nervous system.




Classifications of torticollis:

• Congenital Muscular Torticollis (CMT) which is detected at or shortly after birth, and is primarily caused by unilateral shortening and fibrosis of the sternocleidomastoid muscle. 
• Acquired Torticollis is a noncongenital muscular torticollis resulting from scarring or disease of the cervical vertebrae, adenitis, tonsilitis, rheumatism, enlarged cervical glands, retropharyngeal abscess, or cerebellar tumors. This may present as either spasmodic (clonic) or permanent (tonic).
• Spasmodic Torticollis (Cervical Dystonia) is characterized by involuntary movements of the head due to spasms of the neck and shoulder musculature.
• Tonic Torticollis is characterized by a constant posturing of the head and neck due to contraction of the neck and shoulder musculature

Torticollis can further be described by type depending on the position of the head and neck:

• Rotational Torticollis: This most common type is characterized by rotation or torsion of the head along the longitudinal axis. Muscles commonly involved are ipsilateral splenius capitus, trapezius, and levator scapula, and contralateral sternocleidomastoid.
• Laterocollis: This second most common type is characterized by an ear to shoulder positioning, sometimes accompanied with elevation of the shoulder. Muscles commonly involved are splenius capitus, scalene, trapezius, levator scapula, and sometimes sternocleidomastoid.
• Anterocollis: Characterized by forward flexion of the head and neck, the sternocleidomastoid and scalene muscles are most commonly invovled. There may also be accompanied difficulty with swallowing, speaking, and vision.
• Reterocollis: Characterized by extension of the head and neck due to tightening or spasms of the neck extensors, this may also affect communication, vision, and swallowing.

Apart from the obvious abnormal positioning of the head, other symptoms may include enlargement, stiffness, and painful spasms of the neck and shoulder muscles, limited range of motion of the head and neck, and headaches. Symptoms can range from mild to severe and generally progress slowly over the course of 1-5 years, after which it plateaus.

Treatment depends on the etiology. Congenital cases treated early on with physical therapy to stretch the tight muscles and repositioning of infants have been proven to have a good prognosis. Acquired cases can also be treated with physiotherapy, however the success rates are varied. Specifically with spasmodic torticollis, oral medications (pain relievers and muscle relaxants) in combination with physical therapy and botox injections have promising results, however theses treatments must be continued and repeated at regular intervals to maintain effectiveness. Physical therapy alone may be effective for mild cases through the use of manual therapy to move the neck through a normal range of motion and stretch spasming agonist muscles. When other conservative treatments fail, selective denervation surgery can be used to remove muscle motor nerves that actuate affected muscles. This procedure is irreversible, however fortunately success rates are very high. This must be followed by physical therapy to help the patient acclimatize to the modified neuro-muscular situation.

Due to the deforming nature of torticollis, there are psychosocial aspects to consider as well. Patients may become concerned with personal appearance, which may lead to social isolation and difficulty maintaining employment. With regards to employment, some modifications to a work station may be helpful. A good support system and a positive attitude go a long ways, but referral to a psychologist or similar health care professional may be warranted, and should not be overlooked by focusing solely on the physical aspects.

References:
1)   http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2484944/pdf/jcca00047-0020.pdf
2)   http://www.oandp.org/jpo/library/2004_04S_018.asp
3)   http://www.torticollis.org/spasmodic-torticollis.html
4)   http://researchmedicalcenter.com/your-health/?/11495/Torticollis
5)   http://www.dystonia-foundation.org/pages/more_info___cervical_dystonia_spasmodic_torticollis/46.php

6)   http://www.umanitoba.ca/cranial_nerves/spasmodic_torticollis/

7)   http://www.nlm.nih.gov/medlineplus/ency/article/000749.htm
8)   http://brainfoundation.org.au/medical-info/90-cervical-dystonia
9)   http://en.wikipedia.org/wiki/Torticollis
10) http://emedicine.medscape.com/article/1152543-overview

Trochlear Dysplasia

Chronic knee pain, feeling of instability, feeling like the knee gives out... The go to guys to check would be meniscus, LCL, MCL, ACL, and PCL. But when everything clears, what next? A young, athletic person with no perceivable injury should not have these symptoms. With x-ray and MRI diagnostics, further anatomical structures can be analyzed beyond standard testing. One possible explanation for these symptoms may be trochlear dysplasia.

Femoral trochlear dysplasia is characterized by an abnormal shape of the trochlea at the distal end of the femur. The femoral trochlea loses its normal concave anatomy to become flat and sometimes convex with highly asymmetrical facets. Normally, the trochlear groove is concave and has a higher ridge on the lateral side. This helps to allow the patella to slide easily through the groove at the distal end of the femur, guided by it's bony constraints. Once the patella is engaged in this groove it is extremely difficult to dislocate (1)

Normal Knee Anatomy

When the groove becomes flattened, shallow, or convex, the patella becomes unstable, relying on the medial patellofemoral ligament and the quadriceps to hold the patella in place (1). In Trochlear Dysplasia the trochlea does not adequately contain the patella until the knee is in deep flexion. This leaves the patella vulnerable to dislocation early in the knee flexion arc, which is the position in which the foot strikes the ground when running (4). This gives patients a sensation of instability and buckling of the legs in daily and sports activities. Trochlear dysplasia also causes knee pain during flexion activities such as walking up or down stairs or running (2).

Because the severity of trochlear dysplasia can vary from minor to severe, treatment options are varied. They can include a reconstruction of the medial patellofemoral ligament, a tibial tubercle osteotomy, a trochleoplasty, where the distal aspect of the femur is cut and reshaped to create more of a normal groove, a distal femoral osteotomy, and other associated treatments. A thorough workup is necessary to determine the best course of action for each patient (1). 

More conservative treatment methods for may include physiotherapy with a focus on quadriceps strengthening, proprioceptive training, and stabilizing the knee. A hinged knee brace with patellar alignment guides may also be useful for milder cases, providing additional support and stability.

References:
1) http://drrobertlaprademd.com/trochlea-dysplasia
2) http://www.orpha.net/consor/cgi-bin/OC_Exp.php?lng=EN&Expert=1863
3) http://www.bjj.boneandjoint.org.uk/content/88-B/10/1331.long
4) http://www.kneesurgeon.com.au/patella-trochlear-dysplasia.html

Rectus Femoris Rupture

A most interesting case came across my desk the other day. A retired, yet active gentleman with a complete rupture of the rectus femoris. Now this isn't something one typically finds on an average day, so I directed my attention towards the research and what I might say to this fellow when he came in later.

I'm sure one of my first questions will simply be of curiosity as to how it all came about.

According to Wheeless' Textbook of Orthopedics I should expect to find "large hemarthrosis, freely mobile patella and an impressive loss of extensor function with intact knee flexion, inability to walk, palpable defect..." So, to say the least I expected he would be limping. To my surprise, he walked in just fine and described the problem as completely asymptomatic, save for the large bulge of retracted muscle that appeared with slight activation. MRI confirmed a complete rupture and a significant 17 cm retraction.

With a tear at the musculoskeletal junction it served to review literature on muscle and tendon rupture. The Journal of the American Academy of Orthopaedic Surgeons feature an article entitled, "Quadriceps Tendon Rupture" in which they note that an incomplete or partial tendon rupture could be treated conservatively, however a complete rupture required surgical repair. If neglected this injury could results in substantial disability.

BMJ case reports discussed delayed surgical treatment with good success rates, although full recovery would take 8-12 months. Perhaps this was not what he would want to hear, but at least I could offer a solution, be it a time consuming one.

On examination, I surmised, that there would surely be weakness, and decreased ROM, but again I was amazed and astonished that a month after the injury there was no appreciable difference in strength or ROM from one leg to the other.

With the patient asymptomatic and his remaining quadriceps muscles fully compensating for the lack of rectus femoris usability it was deemed unnecessary for him to undergo surgery at this time. Although, should he have chosen to have it repaired, we would gladly have facilitated such a process. With such a good prognosis he fairly ran out of the clinic back into his active lifestyle. I hope I don't see him again with future complications. With such a prominent muscle out of the game, I likely would have tended towards repair myself.

Resources:
http://olc.metrohealth.org/SubSpecialties/Trauma/Media/JAAOS/11.3.pdf
http://www.wheelessonline.com/ortho/rupture_of_the_quadriceps
http://casereports.bmj.com/content/2012/bcr.06.2011.4359.full