The Torticollis Clinic at St. Louis Children's Hospital provides treatment for mild to severe cases of congenital (present at birth) muscular torticollis. This condition results when an infant's neck muscle is shortened, causing the neck to twist. Although some extremely mild cases may resolve on their own, most need some type of treatment.
In this segment, Dr Matthew Dobbs, a Washington University pediatric orthopedic surgeon at St. Louis Children's Hospital, discusses Torticollis (Wry Neck or Loxia) and when to refer to a specialist.
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Torticollis (Wry Neck or Loxia)
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Learn more about Matthew Dobbs, MD
Matthew Dobbs, MD
Matthew Dobbs, MD, is a Washington University pediatric orthopedic surgeon at St. Louis Children’s Hospital.Learn more about Matthew Dobbs, MD
Transcription:
Torticollis (Wry Neck or Loxia)
Melanie Cole (Host): Wry neck or torticollis is a painfully twisted and tilted neck in children. This condition can be congenital or acquired. It can also be the result of a damage to the neck muscles or blood supply. It may sometimes go away without treatment; however, getting treatment quickly can keep it from becoming worse. My guest today is Dr. Matthew Dobbs. He's a Washington University pediatric orthopedic surgeon at St. Louis Children’s Hospital. Welcome to the show, Dr. Dobbs. What is torticollis or wry neck and what causes it?
Dr. Matthew Dobbs, MD (Guest): Thank you for having me. Torticollis is in simple terms is when a child has their head tilted to one side, and the vast majority of cases are caused by a tightening of one muscle in the neck and this is – usually children are born with this – the most common variant, and so again they present with their head tilted in one direction, and they have their head turned in the opposite direction.
Melanie: And is there a reason if it's congenital – is it something that you could spot on an ultrasound before the baby is born?
Dr. Dobbs: Yeah, that’s a great question, and the answer is usually not. Occasionally you can pick this up on ultrasound, but often it's not until the child is born, and we don’t know – it's not clear on the cause of torticollis. It is sometimes associated with other orthopedic problems such as hip dysplasia in babies, but often it occurs without any other problem and is what we call idiopathic or isolated, so we don’t know its etiology. There are some times where it can be caused by trauma. So, it could be a difficult delivery that then results in swelling of the neck and resulting torticollis, but that’s not the most common presentation.
Melanie: So when – what is the most common presentation and when would it become apparent to the pediatrician?
Dr. Dobbs: It usually could be diagnosed in the first couple of weeks of life, and sometimes immediately after birth, it's apparent, but most often it's diagnosed in the first two weeks.
Melanie: So then what would you like pediatricians to know? What is your clinic’s approach to treatment and when should they be referring?
Dr. Dobbs: So what I would like to infer upon a pediatrician is early referral of torticollis. So, I think, you know, in our general medical training it has been taught that many torticollis patients – this deformity resolves without any treatment and for that reason, children are often not referred until later and so with the thought that it's going to resolve over time, and we often then get kids into the clinic at a year of age or shortly thereafter, and the treatment options at that stage are more difficult. So, you know, my clinic’s approach to the treatment of torticollis is aggressive physical therapy. So, we get the kids enrolled with a specialized physical therapist that has experience with torticollis, and we have a really an intensive protocol of that over a several month period where the child visits with a physical therapist, and the parents are taught by the therapist exercises to do on their own, and with that particular protocol if we catch the children early, you know, soon after birth or in the first few months of life, most torticollis we can get to resolve with this regimen.
Melanie: And what if physical therapy alone is not enough? Then what's next?
Dr. Dobbs: The next step after physical therapy alone is the addition of Botox injections, and we do that directly into the tight neck muscle and that allows – it's not a cure-all, and it's not a replacement for physical therapy, but it's adjunct to physical therapy. So, we do the Botox injections. It allows the muscle to temporarily relax so over a several week period so that the therapist can then gain more motion and more stretch and this has been an extremely effective protocol in our hand, and we have avoided the need for tendon lengthening surgery in almost all of our patients.
Melanie: So that was going to be my next question – is there a time when surgical intervention to maybe correct the shortened muscle might be necessary?
Dr. Dobbs: Yeah, so if we have residual torticollis that’s persisting after the age of three years, that’s when surgery does become an option. It doesn’t mean that every child with residual torticollis has to have that done, but it does become an option at that stage, and our goal again is to minimize the number of children reaching that age with residual torticollis, and the most effective way is to aggressively intervene early with therapy and/or therapy and Botox. Again, starting ideally around the three to four month age in terms of referral.
Melanie: Dr. Dobbs, what do you tell parents about their expectations for the course of this condition and what they should be on the watch for while their child is going through – whether it's physical therapy or Botox? What would you like parents to know and other physicians how to deal with the parents about their expectations for the course?
Dr. Dobbs: Absolutely. So, you know, our early conversations with the family is centered around that this is not going to go away overnight – that this is a team approach and then the parents are key team members and the treatment because they're going to be doing a lot of the stretching and positioning with their baby on a daily basis. So, I give parents an outlook on this that if they're coming to see me at three or four months of age – our goal is to have the torticollis completely resolved by the time their child is walking, and that’s really the timeframe. It’s not overnight; it's not one week. It is a several month process to get this to fully resolve.
Melanie: Are there some red flags that you would like maybe even physical therapists to know if these are identified when the physician should come back into play?
Dr. Dobbs: Yes. There are some red flags, and the big one is if the child is going through the early treatment and is not responding or is a particularly rigid case of torticollis, then other causes should be looked at and the biggest, you know, secondary cause of torticollis that I see in my practice is usually related to vision. So, if the children have a muscle imbalance in their eye, that can cause the children to hold their head tilted to actually see straight and that, you know, can be a red flag to then, you know, need to refer to an ophthalmologist for further evaluation. So, that’s really the biggest other diagnosis and red flag in this type of torticollis that we see in the young child.
Melanie: So, in summary, Dr. Dobbs, tell other pediatricians what you'd like them to know about recognizing torticollis and when to refer and anything that you think is really important that you want them to understand.
Dr. Dobbs: Yes. So, I think, you know, my message to the pediatricians is that torticollis is not always benign, and it doesn’t always go away without intervention. So, I encourage physicians to truly look for that on all of their well-child visits, you know, starting in the newborn period, and when it is recognized and diagnosed to teach them, you know, stretching exercises, but if that’s not resolved by three or four months of age, then that child should be then referred to physical therapy and ideally to an orthopedic surgeon that specializes in torticollis that can oversee the management.
Melanie: What can a pediatrician expect from your team after referral in so far as communication with the referring physician and your team approach?
Dr. Dobbs: Yes. So, we do – we give handouts and our medical notes right back to the referring pediatrician to let them know our plan, our approach, and the importance of therapy, and we want to make sure that we get their buy into this approach because they have a very strong relationship with the family. So, we very much believe in communication throughout the entire process, and we do let them know that the timeframe of this, you know, is several months in the making in terms of full resolution.
Melanie: Thank you so much, Dr. Dobbs for being with us today. A physician can refer a patient by calling Children's Direct Physician Access Line at 1-800-678-HELP. That's 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children's Hospital. For more information on resources available at St. Louis Children's Hospital, you can go to stlouishildrens.org. That’s stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.
Torticollis (Wry Neck or Loxia)
Melanie Cole (Host): Wry neck or torticollis is a painfully twisted and tilted neck in children. This condition can be congenital or acquired. It can also be the result of a damage to the neck muscles or blood supply. It may sometimes go away without treatment; however, getting treatment quickly can keep it from becoming worse. My guest today is Dr. Matthew Dobbs. He's a Washington University pediatric orthopedic surgeon at St. Louis Children’s Hospital. Welcome to the show, Dr. Dobbs. What is torticollis or wry neck and what causes it?
Dr. Matthew Dobbs, MD (Guest): Thank you for having me. Torticollis is in simple terms is when a child has their head tilted to one side, and the vast majority of cases are caused by a tightening of one muscle in the neck and this is – usually children are born with this – the most common variant, and so again they present with their head tilted in one direction, and they have their head turned in the opposite direction.
Melanie: And is there a reason if it's congenital – is it something that you could spot on an ultrasound before the baby is born?
Dr. Dobbs: Yeah, that’s a great question, and the answer is usually not. Occasionally you can pick this up on ultrasound, but often it's not until the child is born, and we don’t know – it's not clear on the cause of torticollis. It is sometimes associated with other orthopedic problems such as hip dysplasia in babies, but often it occurs without any other problem and is what we call idiopathic or isolated, so we don’t know its etiology. There are some times where it can be caused by trauma. So, it could be a difficult delivery that then results in swelling of the neck and resulting torticollis, but that’s not the most common presentation.
Melanie: So when – what is the most common presentation and when would it become apparent to the pediatrician?
Dr. Dobbs: It usually could be diagnosed in the first couple of weeks of life, and sometimes immediately after birth, it's apparent, but most often it's diagnosed in the first two weeks.
Melanie: So then what would you like pediatricians to know? What is your clinic’s approach to treatment and when should they be referring?
Dr. Dobbs: So what I would like to infer upon a pediatrician is early referral of torticollis. So, I think, you know, in our general medical training it has been taught that many torticollis patients – this deformity resolves without any treatment and for that reason, children are often not referred until later and so with the thought that it's going to resolve over time, and we often then get kids into the clinic at a year of age or shortly thereafter, and the treatment options at that stage are more difficult. So, you know, my clinic’s approach to the treatment of torticollis is aggressive physical therapy. So, we get the kids enrolled with a specialized physical therapist that has experience with torticollis, and we have a really an intensive protocol of that over a several month period where the child visits with a physical therapist, and the parents are taught by the therapist exercises to do on their own, and with that particular protocol if we catch the children early, you know, soon after birth or in the first few months of life, most torticollis we can get to resolve with this regimen.
Melanie: And what if physical therapy alone is not enough? Then what's next?
Dr. Dobbs: The next step after physical therapy alone is the addition of Botox injections, and we do that directly into the tight neck muscle and that allows – it's not a cure-all, and it's not a replacement for physical therapy, but it's adjunct to physical therapy. So, we do the Botox injections. It allows the muscle to temporarily relax so over a several week period so that the therapist can then gain more motion and more stretch and this has been an extremely effective protocol in our hand, and we have avoided the need for tendon lengthening surgery in almost all of our patients.
Melanie: So that was going to be my next question – is there a time when surgical intervention to maybe correct the shortened muscle might be necessary?
Dr. Dobbs: Yeah, so if we have residual torticollis that’s persisting after the age of three years, that’s when surgery does become an option. It doesn’t mean that every child with residual torticollis has to have that done, but it does become an option at that stage, and our goal again is to minimize the number of children reaching that age with residual torticollis, and the most effective way is to aggressively intervene early with therapy and/or therapy and Botox. Again, starting ideally around the three to four month age in terms of referral.
Melanie: Dr. Dobbs, what do you tell parents about their expectations for the course of this condition and what they should be on the watch for while their child is going through – whether it's physical therapy or Botox? What would you like parents to know and other physicians how to deal with the parents about their expectations for the course?
Dr. Dobbs: Absolutely. So, you know, our early conversations with the family is centered around that this is not going to go away overnight – that this is a team approach and then the parents are key team members and the treatment because they're going to be doing a lot of the stretching and positioning with their baby on a daily basis. So, I give parents an outlook on this that if they're coming to see me at three or four months of age – our goal is to have the torticollis completely resolved by the time their child is walking, and that’s really the timeframe. It’s not overnight; it's not one week. It is a several month process to get this to fully resolve.
Melanie: Are there some red flags that you would like maybe even physical therapists to know if these are identified when the physician should come back into play?
Dr. Dobbs: Yes. There are some red flags, and the big one is if the child is going through the early treatment and is not responding or is a particularly rigid case of torticollis, then other causes should be looked at and the biggest, you know, secondary cause of torticollis that I see in my practice is usually related to vision. So, if the children have a muscle imbalance in their eye, that can cause the children to hold their head tilted to actually see straight and that, you know, can be a red flag to then, you know, need to refer to an ophthalmologist for further evaluation. So, that’s really the biggest other diagnosis and red flag in this type of torticollis that we see in the young child.
Melanie: So, in summary, Dr. Dobbs, tell other pediatricians what you'd like them to know about recognizing torticollis and when to refer and anything that you think is really important that you want them to understand.
Dr. Dobbs: Yes. So, I think, you know, my message to the pediatricians is that torticollis is not always benign, and it doesn’t always go away without intervention. So, I encourage physicians to truly look for that on all of their well-child visits, you know, starting in the newborn period, and when it is recognized and diagnosed to teach them, you know, stretching exercises, but if that’s not resolved by three or four months of age, then that child should be then referred to physical therapy and ideally to an orthopedic surgeon that specializes in torticollis that can oversee the management.
Melanie: What can a pediatrician expect from your team after referral in so far as communication with the referring physician and your team approach?
Dr. Dobbs: Yes. So, we do – we give handouts and our medical notes right back to the referring pediatrician to let them know our plan, our approach, and the importance of therapy, and we want to make sure that we get their buy into this approach because they have a very strong relationship with the family. So, we very much believe in communication throughout the entire process, and we do let them know that the timeframe of this, you know, is several months in the making in terms of full resolution.
Melanie: Thank you so much, Dr. Dobbs for being with us today. A physician can refer a patient by calling Children's Direct Physician Access Line at 1-800-678-HELP. That's 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children's Hospital. For more information on resources available at St. Louis Children's Hospital, you can go to stlouishildrens.org. That’s stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.