STERNOMASTOID

DONALD From Torticollis due to and

TUMOUR
MACDONALD, Hospitalfor of of

AND

MUSCULAR
SYDNEY, AUSTRALIA Bristol,

TORTICOLLIS

the Royal

Sick

Children,

Engla,zd

contracture the results

the

sternomastoid treatment
gratifying.

muscle or even
The

is a well terminology.
greatest

recognised The
interest lies

entity, deformity
in the

but

there

seems
cosmetic of

little

agreement

as to etiology,
treatment

is largely causation

pathogenesis histological
relationship

this condition, with reference in particular to sternomastoid tumour. remains uncertain but appears unique, there being no known clinical parallel in any other disease process. The objects of this paper are to clarify
of sternomastoid tumour to torticollis, to present some observations on the

The or the
two

conditions

and

to discuss

the

results

of treatment.

ETIOLOGY

AND

PATHOGENESIS

Despite
Lidge, tumour Bechtol or

several
and muscular

comprehensive
Lambert (1957),

reviews,
there

notably
agreement

by Chandler
about the

and

Altenberg

(1944)

and one age. of

is little

etiology

of sternomastoid

to the other By contrast,

tumours

torticollis. Chandler and as so certain that they recommended Hulbert (1950) and Coventry and completely without active

Altenberg regarded the progression from excision of all tumours at the earliest Harris (1959) contended that the majority
Gray

resolve

treatment.

that
by

most
parents or

children
and and Harris only

presenting (1959)
detected

with stated
on

torticollis that
routine

give their

no history cases tumour

examination.

(1935) and Bianco of a sternomastoid of a tumour preceded and

(1958) claimed tumour, but was missed

Coventry

in half
paediatric

the presence is frequently 1933, Chandler

It is now
forceps

well

established birth

that (Witzel

a sternomastoid 1883, 1959). that fibrous

with

by a breech, Altenberg 1944, is a

that

primiparous

Fitzsimmons It is tempting rupture of the

Hulbert trauma. tumorous

neonatal

1950, Coventry and Harris Stromeyer (1838) postulated haematoma, by breech muscle (1933) tumour injury. and that
or stillbirth necropsies

to assume that the common factor muscle during parturition produced subsequent torticollis.
Spencer (1893)

replacement
sternomastoid

caused

Of fifteen
found

haematomata,

twelve were post-mortem Fitzsimmons sternomastoid due to birth

or forceps delivery. Sanerkin and Edwards (1966) demonstrated extensive fibre damage, haemorrhage and ischaemic change after a breech delivery. reviewed fifty-four cases of Erbs palsy and found an associated in eleven. Experimentally, This he construed
(1930)

as further
produced

evidence
histologically

that

the

tumour
tumours

was

Middleton

similar

by ligation of veins draining during parturition was the sternomastoid tumour,

the sartorius muscle in dogs, and inferred cause in babies. However, the striking as early as 1875 by Taylor, is profuse

that venous histological fibrous

occlusion feature of of as at

described

replacement

muscle (Figs. I and 2) without a trace of haemosiderin, three weeks after birth (Chandler 1948). Reye (1951) ages (1955), in eight much
desmoid

even in specimens excised as early examined four necropsy specimens that the very of
been

between

four

and

twenty

weeks, surgical were

birth

and

concluded found with

have

appearances
Nelson,

suggested
Palladino and

almost
Koop

an overgrowth

of tendon

at the expense

of muscle.

Kiesewetter,

in a study only. more closely instances

1924, Rossi

of thirty-two lesions resembled

Finally,

specimens, consistent
cannot

small palmar

amounts or

of haemosiderin and plantar the tumour or fascia,

These

not

massive

haematomata,
a factor in the

fibrosarcoma,
injury

fibromatosis following 1944,

tumours.

published
Stern 432

of sternomastoid 1928, Chandler and

tumour

Caesarian Kiesewetter
THE

section

now numerous (Schloessmann 1911,

Alternberg

et a!. 1955).
OF BONE
AND JOINT SURGERY

JOURNAL

STERNOMASTOID

TUMOUR

AND and

MUSCULAR Harris deliveries. or

TORTICOLLIS (1959), The abnormal Altenberg that intra-uterine subsequent uterine (1944)

433
torticollis

It is conceivable, predisposes tumour abnormal cause of could to a high then be muscle. torticollis.

as suggested incidence a form Sippel of Van of

by Coventry breech muscle and (1670)

or forceps

sternomastoid

dysplasia,
first Chandler

indeed
and

a response

to trauma

of already
pressure as a a

Roonhysen (1920)

postulated

demonstrated

correlation between the breech and Chandler (1948) noted

position asymmetry

and

the side of a subsequent of the pinna and face

tumour. together

Schmidt (1890) with torticollis

FIG. 1 FIG. 2 Figure 1-Histological section from the edge of a sternomastoid tumour in a 4-week-old boy. Note the swollen fragmented muscle fibres in the lower right hand corner, and the extensive fibrous tissue replacement in the remainder of the field. No haemosiderin can be seen. (Haematoxylin and eosin, 70.) Figure 2-High power view of the same affected muscle fibres. (Haematoxylin and eosin, 350.)

immediately environmental
dismissed.

after birth and factors, genetic

Von Lackum (1929)

before the development influence as first postulated

quoted a family of three

of

a tumour. by Joachimsthal
with

Aside from purely (1905) cannot be

torticollis, and Stevens

siblings

(1948)
twins.

published

an

unusual

case

of a right-sided

torticollis

symmetrically

affecting

identical

A curious hemiatrophy
it to skull basis
explanation

accompaniment so succinctly poliomyelitis.

bones, shortening
of

of established torticollis described by Golding-Bird Middleton

it is difficult of the and exists. anatomical (1936) developmentally peculiarity that to

is the widespread facial asymmetry or (1890) though he mistakenly ascribed extensive

the observed

incipient
and facial of relative

(1930)
account

documented
for all

bony
changes

changes
purely

in the
on the

and phenomenon

sternomastoid

muscle

during

growth.
has

No

really

satisfactory
insufficient is unique in

this

The emphasis. its double

developmental Straus innervation, and

of the muscle the sternomastoid

received muscle

Howell and

emphasised

it may be primarily visceral in origin with later somatic components added. Last (1963) pointed out that the muscle really consists of four parts, and Jahss (1936) differentiated between sternal torticollis and clavicular torticollis, relating the distinction to the results of treatment. Formerly the blood supply of the muscles was believed, by Nov#{233}-Josserand and Viannay (1906), to be segmental via end arteries, occlusion evidence followed and follows of which from dogs, an identical
(1944),

resulted

in segmental (1930) However, that pattern,

infarction. assumed subsequent there and this

AND

In applying that

to humans

his experimental of the muscle by Chandler supply which

Middleton pattern. have shown or segmental

the venous drainage injection studies, notably arterial on both and venous doubt these

Altenberg

is an abundant casts

no regular

hypotheses.

TERMINOLOGY

CLASSIFICATION

since

The the
51 B,

term congenital deformity is seldom,

NO.

torticollis, if ever,

or wry neck, present at birth.

is widely Caput

used but seems inappropriate obstipum (Holloway 1931),

an

voi.

3, AUGUST

1969

434 old (1967) title used has though in much little modern cases may of the German

D. MACDONALD

literature,

emphasises has been childhood

the

obstetric

background

but

otherwise

significance. present at

The condition any age through

called or

infantile by Adams indeed in adolescence. on

the as to

Anderson muscular

(1893) referred simply torticollis (Chandler

to sternomastoid 1948) seems preferable

doubts

torticollis, and as it underlines

been raised

the

whole

the

term

basic the

pathological uniformity of

process. Apart from differences in terminology, have

all cases. that type, arising and

Anderson solely a

(1893) as a result

distinguished ofbirth
type

between trauma. due Hulbert

torticollis (1950)

of a truly described sternomastoid

congenital a transient tumour.

nature postural

and

muscular

presumed

to a previous

Finally, tumours to question

both Hulbert (1950) and Coventry and resolve completely and did not progress whether the two are not in fact separate

Harris (1959) to muscular pathological

showed that most sternomastoid torticollis. This has led some entities.

CLINICAL

MATERIAL

Between for were

1950
groups

and the
of within

1965, Bristol
patients.

152 Royal which

children Infirmary settled

weeks Twenty-six

with and babies

life

torticollis

were

seen

at the

Bristol

Hospital

Sick
three

Children, postural
presented

the Winford presented

Orthopaedic at or shortly
tumour.

Hospital. There after birth with Fifty-one

Seventy-five

transient
babies

torticollis
the

with
of

a minimum
with

ofconservative
a sternomastoid

treatment.

first

children Of congenital
followed making because therefore

presented at various the fifty-one babies deformities and

up fifty and in all examined available

ages with muscular with a sternomastoid was left out of the

personally, for study. and a further

torticollis. tumour, series.

Of

one was associated the remainder,

case notes were

with multiple thirty-one were

available, thus

nineteen

Of the seventy-five
of inadequate

children
documentation.

presenting
One

with
was

muscular
associated

torticollis,

twenty-nine

were

excluded

left out. Of the remaining personally and the case records were seven patients from the sternomastoid torticollis. The This made fifty-two twenty-six babies with

with Engelmanns disease and was forty-five, thirty-four were followed up and examined available in a further eleven. To this number were added tumour group who subsequently developed muscular study. were not considered relevant to this study

cases available for postural torticollis

and were not included. In these cases the etiology was not clear, but in many cases positioning in utero was suspected. The early onset at or soon after birth precluded an ophthalmic cause which, according to Duke-Elder (1949), is not seen until eighteen months of age when it is commonly associated with a non-concomitant squint.

PATIENTS

PRESENTING

WITH

A STERNOMASTOID

TUMOUR

weeks history

In fifty babies a sternomastoid of age, the mean being three is summarised in Table I.

tumour (Fig. 3) was weeks. Thirty were in Over half the children

boys

palpable between one and fifteen and twenty in girls. The birth breech or forceps birth, and of

had

the remainder over half again were firstborn. twin (unaffected) and in two others a second The tumour occurred on the right side had been by the breech, the preponderance had associated deformities,
which

One case occurred in a child with an identical degree relative was known to have had torticollis. in three-quarters of all cases, and when the birth was even higher (Table II). Many of the babies

mainly subsided

minor with

in nature the

(Table tumour.

III).

Nearly

one-quarter was

showed recorded in

transient

torticollis

Plagiocephaly

approximately

one-fifth of all cases.

THE JOURNAL OF BONE AND JOINT SURGERY

STERNOMASTOID

TUMOUR

AND

MUSCULAR

TORTICOLLIS

435

Most A
few were measures

of the
given were

babies
stretching

received
exercises,

no

treatment
supervised

except
by

for

simple

instructions
department.

to the

mother.
No other

a physiotherapy

taken. of the
patients were

Two-thirds

followed

up

for

between
was

two one

and year

sixteen or less.

years

average

of six years,

but

the

length

of follow-up

in one-third

The

with an clinical

FIG.

Figure 3-Photograph I month with a right

of a boy aged sternomastoid

tumour. He had had a breech birth. Figure 4-Photographs of the same child as shown in Figure 3, when 8
years of age. Some tightness and thickening of the clavicular head and very slight facial asymmetry can be seen.
FIG. 4

state muscular degrees

at follow-up torticollis. of

is summarised The or

in Table remainder tightness had could

IV.

Seven no be

out

of fifty but

patients

subsequently

developed
minor one-quarter

complaint demonstrated

on in

careful

examination

asymmetry

approximately

(Fig.

4).
PATIENTS PRESENTING WITH MUSCULAR TORTICOLLIS

Fifty-two and twenty-three even a fairly However, approximately In ten to an cases

children girls. spread retrospective one-third there through

presented Their ages the assessment commenced was a history first

with are decade, of of

muscular shown the proven after age first

torticollis 6. The sporadic onset of life. probable which of year or

(Fig. children

5).

Twenty-nine presented were contracture seen

were at all ages in adolescence. revealed

boys with that

in Figure

cases of the

in the

sternomastoid

tumour

at by of breech One

birth.

Moreover,
pattern forceps had twins. degree
VOL.

the
those delivery identical Four relatives. had

birth
and, twin

histories
with of who the was affected

of

the

whole

group
tumour.

(Table
Over were singly and

V) showed
half had were affected four had one-half

a remarkably
been born firstborn. members similarly affected

similar
or child second

of babies

sternomastoid remainder, not affected. first degree

approximately Two relatives

binovular

similarly

51 B,

NO.

3,

AUGUST

1969

436
TABLE
FIFTY BABIES WITH BIRTH

D. MACDONALD
I
TUMOUR:

TABLE
FIFTY BABIES WITH SIDE Number

II
TUMOUR:

STERNOMASTOID HIsroRlEs

STERNOMASTOID OF LESION

Birth

history
. . .

Breech
Forceps

Number
.

of babies

17 12 12
5 Right Left Total

Primigravida Multigravida Unknown

.

normal normal
.

Whole Breech

series births

37
15

13
2

50 17

TABLE
FIFTY BABIES WITH

III
TUMOUR: FIFTY BABIES AVERAGE WITH

TABLE
FOLLOW-UP

IV
TUMOUR:
WAS

STERNOMASTOID

STERNOMASTOID

ASSOCIATED

DEFORMITIES

SIX

YEARS

Associated

deformities
. .

Number

of

Outcome

cases 12
I

following sternomastoid tumour

. . . . . .

Number

Transient Plagiocephaly

torticollis
. .

Normal Minimal

22
5

tightness asymmetry
.

or band

Cephalohaematoma
Pyloric Congenital stenosis dislocation
.

2 I I

Minimal Torticollis Too recent

or plagiocephaly
. . .

7 7 9

of hip

or unknown

TABLE
FIFTY-TWO CHILDREN TORTICOLLIS: BIRTH

V
WITH MUSCULAR

TABLE
FIFTY-TWO CHILDREN
TORTICOLLIS: HISrORIES

VI
WITH MUSCULAR

SIDE OF LESION

Birth

history
. . .

Number

Number

of babies

Breech Forceps
Primigravida Multigravida
Unknown

22 9 14 4 3 Breech births
.

Right

Left

Total

normal normal
. .

Whole

series

31 14

21 8

52 22

TABLE
FIFTY-TWO CHILDREN FACIAL TORTICOLLIS:

VII
WITH IDIOPATHIC FIFTY-TWO T0RTICOLLIS: ASYMMETRY

TABLE
SITE

VIII
WITH OF CONTRACTURE

CHILDREN

Facial

asymmetry
. . . .

Number 36 7 9 Mainly Mainly Both

Site of contracture
sternal clavicular heads
.

Number
. .

Present

head head

8 19 25

Absent
Unrecorded

or very slight
.

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

STERNOMASTOII)

TUMOUR

AND

MUSCULAR

TORTICOLLIS

437

The
this site cases: cipally
bony associated

contracture
with the most

was
was of head

more
the

frequent

on the
two but was involved, was

right
was noted often by

side,
(Table no

and
VI). means

in children
Facial invariable

born
(Table

by the
(Fig. VII).

preponderance of contracture clavicular VIII).

approximately contractures the was case muscle this usually within In one

to one

asymmetry

breech 5) was
The

in most prinwith a

the

(Table
anomaly

associated

within

the

clavicular
DISCUSSION

attachment.

There
early after forceps

is a strong
delivery, presenting On the events.

similarity
tumour in

between
children the hand, firstborn, with

the
born and one

association
by the the after baby developed in breech, associasimilar seven mus-

of

sternomastoid

and

in later other

tion obstetric with cular though revealed

of children a sternomastoid torticollis. careful intermediate restriction by

following

torticollis only

tumour

subsequently

In

the
residua,

remainder
in some The such

the

tumour
later in the

resolved,
in is further of both life muscle

#{149}

examination of movement. the striking

children as a band relationship preponderance

Torticollis child was

in first

FIG.5

aged at

6.

The

or slight underlined
lesions

seen

2 months

right-sided

breech
Coventry both lesions by the and

births,
Harris may finding be

an

observation (1959).
to antenatal

previously It suggests
in one

months. rather of five babies than with to birth trauma.

recorded the This cause

by of is supported

that
position out sternomastoid

related

of plagiocephaly

tumour,

an

incidence (1968).

twice Familial

that

found factors,

in the although

normal not

population preponderant,

under may

one play

year a part.

of age

by

Wynne-Davies

In nine

25

IJAGE
lAGE

AT

COMMENCEMENT

NUMBER2#{176} OF

AT

PRESENTATION

15
10

CASES

iIfllhil I.
AGE IN YEARS

I.
was

J.

FIG.

Diagram to show the age of onset children, and the age when they of a combined 100
tumour

6 of muscular torticollis presented for medical

relative

in fifty-two treatment. affected. One patient

cases and likely It may

or

a Alten

first
also

or berg

second

degree

with
were

sternomastoid

suffered

from (1944).

congenital

pyloric

stenosis.

Three

such

cases

recorded

by Chandler

The
in the variable
sternomastoid

relationship
it seems sequelae.
tumour:

between

the
that it may resolve

two

conditions
at or completely:

is therefore
before it may latent, is more birth

complex.
and has clinically subsequently

Whatever
three undergoing become

the change
inconstant manifest and as a

muscle

it is present remain torticollis. contracture case this was

clinically

a variable head clavicular as

degree In described
VOL.

of cicatrisation established by Jahss

NO.

to torticollis (1936).

produce the In one

common with a bony

in

the anomaly

clavicular in the

associated

51 B,

3,

AUGUST

1969

438

D. MACDONALD

head, though torticollis

like not

that

previously

recorded present by Hough

TREATMENT

by it was (1934).
OF

Middleton not The possible

(1930). relationship

Facial is not

asymmetry its severity necessarily

was with a direct

generally, that of the one.

invariably, as suggested

but

to correlate

MUSCULAR

TORTICOLLIS

According the first recorded

to

Hulbert
instance

(1950)
was that

subcutaneous
by Isaac Minnus

tenotomy
in 1685.

was ( I 929),
(1749)

practised
The method

in Roman
has the first used been

times,
advocated

but

subsequently
(1950). open William operation,

by

Howell
Cheselden a technique

Elmslie
was

( I 943)

and
by

Hulbert
an

to describe Meyerding

subsequently

(1921)
involving

and

Hough
medial

(1934).
transplantation

Jahss

(1936)
of

described
the clavicular

a variation
belly.

Hellstadius (1927) and double approach using

i

Soeur (1940) reported a lower subcutaneous Chandler and

stage

the results of a tenotomy and an

(1944) advised sternomastoid

upper block tumours maintain

open division. excision at or cicatrised correction

Altenberg
of frank was

the

earliest muscle. after

The
operation

use Hough

of a plaster
advocated

collar and Soeur thirtydivision

to
by

Meyerding
(1940).

(1921),

Howell

(1929),

(1934) torticollis, by open

7).

Of the six examined

#{149}- #{149}

fifty-two children with muscular at follow-up had been treated

attachment of the muscle (Fig.

of

the

lower

Two-thirds

of

FIG7 Photograph of the same child as shown in Figure 5 after open division of both heads of the sternomastoid muscle. At 14 years of age there was a good scar but slight residual facial asymmetry was present.

these operations remaining third nique. The age shown in

. .

by at

were performed by one surgeon and the a number of surgeons using the same techoperation and the length of follow-up are all cases a low In most in many and was transverse incision was heads deep layers, than

Figure
.

8. instances both the underlying the applied skin for in two and longer

Operative

technique-In

used dividing of the muscle performed was closed. five duration cases After were was

skin and platysma. were divided, and by suturing operation stretching much less. the platysma a dressing exercises

fascia
though four

(Table

IX).

Closure
skin In

was only only the

occasionally begun. and months,

immediate

physiotherapy

continued

in many

AGE IN YEARS

J iiJ i 11
1

H
Diagram All However, (Table X). patients at were follow-up pleased stringent with the

________________

INDIVIDUAL

CASES

FIG. 8 of the age of operation in thirty-six cases of muscular torticollis, and the time of follow-up in years in each case.
RESULTS

correction were

and used

none to

presented reveal minor

for

further cosmetic

treatment. blemishes

criteria

THE

JOURNAL

OF BONE

AND

JOINT

SURGERY

STERNOMASTOID

TUMOUR

AND

MUSCULAR

TORTICOLLIS

439 of rotation and of the muscle of the clavicular

frequently they

Musculo-fascial lateral flexion

to the head.
contained

bands-These were generally only of the neck (Fig. 9). They stretched
and bands were invariably attached consisted
muscle.

demonstrable at extremes from the occipital attachment to the normal

and skin only,

clavicle The

well of tight

lateral fascia

insertion
but more

sometimes
contractile

actively

They

appeared

to result

from

anomalous

reattachment

TABLE
THIRTY-Six CHILDREN EXTENT OF OPEN

IX
WITH T0RTIC0Lus: THIRTY-SIX SECTION FOLLOW-UP

TABLE
CHILDREN AFTER

X
WITH T0RTIC0LLIS: OPERATION

Extent

of open

operation

Number
2

Residual

blemishes

Number 4 12
.

Residual

torticollis-slight_
facial asymmetry bands of movement of sternal scar column
. .

________________________________
Clavicular head
.

Sternal

head

only

Residual

only
.

Musculo-fascial 19 14 Restriction Absence Disfiguring

23 I2 14 2 I

Both heads
Both heads Total

and deep
. .

fascia
.

36

Reverse

torticollis

of the
of
some

severed
cases,
terminal

clavicular
they were
restriction

head
seldom
of

as suggested
an
movement.

by Jahss
cosmetic

(1936).
defect,

Although
though in

present
general

in two-thirds
they caused

all

important

Restriction It seldom
was due

of movement-This affected more than

to a musculo-fascial

occurred only the last 15 degrees

band.

at

the extremes of rotation of range. Usually, though

or not

lateral flexion. invariably, it

of the

Absence of sternomastoid

the sternomastoid muscle in the

neck

column-Absence of the normal vertical contour resulted in a quite noticeable cosmetic defect (Fig.
1 1 and 12) the sternomastoid column was in end further

10) in

just over one-third of cases. Reverse torticollis-In one case (Figs. absent and a reversal of the torticollis Disfiguring
particularly

completely

had

occurred,
a cosmetic showed

presumably
defect broadening sufficient to

due

to muscular
extent medial

imbalance.
all (Fig. cases, 10), surgical

scar-The
in

neck
girls. The did this

scar
scars

constituted frequently

some of the to warrant

the

but

in two

cases

only

constitute

a disfigurement

measures. Residual
that
facial

facial

asymmetry-Facial
of the thirty-six half,
was generally

asymmetry

of

varying

degree

was

recorded

before

operation

in twenty-five

cases. and the

At

follow-up by eyebrow. were year likely restoration other of patient

residual cases and residua yet the of

asymmetry are parent of the still retained of shown alike

was (Fig.

detected 13. 7). but (Fig. after tenotomy

in twelve, Residual most of the Three seen in these one 13). when surgery of It was

is in approximately
asymmetry

details

of these

in Figure that torticollis asymmetry bands in all

unnoticed

readily twelve of the seven,

detected cases patients nine and child with

from residual were ten may

the position asymmetry treated years prevent later. in the

of the there first It seems

It is noteworthy life that

persistence

the
bands

young

complete indicated.

symmetry.

Further

is therefore

probably

DISCUSSION

In the and
VOL.

treatment

of

this

largely satisfactory

cosmetic results.

problem The

many major

methods deformity

are

open

to the

surgeon
to correct

almost
51 B,
NO.

all claim 3,
AUGUST

equally 1969

is not

difficult

440 and
surgery.

D. MACDONALD attention must

most

be focused
common

on
criticism

the to

relatively
of

minor open

cosmetic is the scar. On

defects
resultant

that other

precede
scar.

or In this the

follow series method

The
two

the

operation

only

patients

were

considered

have

a disfiguring

the

hand,

Two examples

of musculo-fascial

bands

FIG. after

9 open

division

of both

heads

of the muscle.

Absence division

of the sternomastoid of the muscle. Note

FIG. 10 column on the left side of the neck after open also broadening of the medial end of the scar.

was on lateral bands.

safe

and

posed the

no principal

threat

to deformity severed

the

neurovascular without clavicular the head use

structures of subsequent to a high and

THE

in the

neck. splintage,

It could
but this
AND

be relied
anomalous

to correct

reattachment

of the

led

incidence to prevent
OF BONE

of musculo-fascial complication
JOINT SURGERY

These

were

previously

noted

by

Hough

(1934),

JOURNAL

STERNOMASTOID

TUMOUR

AND

MUSCULAR

TORTICOLIIS
A

441

FIG.

Figure lI-Five-year-old aged 8 years. Reverse

11 FIG. 12 girl shown before operation with right-sided torticollis. Figure 12-The torticollis has developed following open division of both heads and Note complete restoration of facial symmetry despite this.

same child deep fascia.

Jahss

(1936) they that of

described belly.
caused

a variation series these

terminal some

of the bands related

technique were seldom

of

involving a serious movement.

medial cosmetic There

transplantation blemish, was some

25

of the though in evidence.

clavicular
general

In this their slight

restriction

however, persistence

persistence degrees of

was facial

to the
20

asymmetry.

Hough (1934) of asymmetry

and Soeur (1940) stated could be expected the age resolution these noticeable of fourteen did not early cases

that correction if surgery was

AGE IN YEARS

performed under series, however, even after one most treatment of all but present. The

years. always of bands

In this occur, life. In

BANDS#{149}

in the residual

years

were loss
TiGHTNESS

cosmetic

defect

was

of the normal contour noted by Hough (1934). muscle

resulted,

of the neck, also previously In one case division of the that

muscular

#{149}11
#{149}

RESIDUAL

t2T1OOLL
INDIVIDUAL CASES

had

been

so complete
from

reverse

torticollis
It
FIG.

presumably

imbalance.

was worth noting metry disappeared period of three

that years

in this completely (Fig.

case 12).

the facial asymover a follow-up

13

Diagram of the causes of twelve cases of residual asymmetry, with the age of operation and time of follow-up in years.

SUMMARY

AND

CONCLUSIONS presenting

I.

A parallel

study

has

been

made

of fifty

patients

with
incidence

a sternomastoid
of breech,
forceps

tumour and

and fifty-two patients presenting 2. In the birth histories of both

primiparous VOL.

with these

muscular torticollis. groups there was a high of each was strikingly

births.
NO.

The

distribution
1969

similar.

51 B,

3. AUGUST

442

D.

MACDONALD

3. Only
residua

Sternomastoid of the in seven one

tumours breech proceeded

were births. to

right-sided There muscular at any of previous head, and had the age, was

in three-quarters twice torticollis, but one-third the but

of all cases expected incidence in some commenced tumour. associated degree The with similarly at birth,

and

in an even remainder year

higher minor of life.

proportion could Muscular one

of plagiocephaly.

of the

4. Only

be detected. torticollis presented gave

the

in the first contracture some degree affected

it has three

in five
for

a history
clavicular

predilection

sternomastoid was generally or second in the

showed a of facial

asymmetry. 5. Nine 6. and

manifest

of a combined that sequelae.

102 cases whatever

a first condition

relative.
inconstant

It is concluded variable
as a tumour;

muscle

The torticollis or it may remain to produce torticollis.

torticollis established

may resolve completely ; it may become clinically latent, subsequently undergoing

by open division is described and the

clinically a variable
follow-up

degree
7. The

of cicatrisation
treatment of

in thirty-six 8. This number

to

cases operation of minor

recorded. can be relied on to cure the principal deformity, cosmetic defects. Of these the most striking are
of

but is accompanied tight bands apparently sternomastoid even column in the

by a due of early was

anomalous

reattachment

the

clavicular on to cure

head, facial

and

loss

of the

the 9.
years

neck. The
of

method

could

not

be relied

asymmetry

completely,

allied

life. However, there to persistence of other

was some evidence to suggest residua of the torticollis, for

that persistence example fascial

of asymmetry bands.
under

My thanks care most

are due to the surgeons of the Bristol area, and in particular to Mr A. L. Eyre-Brook of the cases were, and to Mr A. H. C. Ratliff for much criticism and encouragement. REFERENCES

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1969