---

1. Malformations of the Musculoskeletal System in Children — Muscular Torticollis

Overview

---

Etiology & Pathogenesis

• Primary cause: fibrosis and shortening of the SCM, likely from intrauterine compartment syndrome, birth trauma, or venous occlusion → ischemia → fibrosis
• Risk factors: breech presentation, forceps/vacuum delivery, prolonged labor, primiparous mothers, large birth weight
• Histology: replacement of normal SCM muscle fibers with fibrotic tissue (type I collagen deposition)

---

Classification

---

Clinical Presentation

• Head tilt toward the affected side (ipsilateral to contracted SCM)
• Chin rotation away from the affected side (contralateral)
• Palpable SCM mass or tightness in the neck (may be visible at birth or appear at 2–4 weeks)
• Facial asymmetry (plagiocephaly): asymmetric flattening of the skull/face due to positioning — develops if untreated
• Limited passive range of motion of the neck
• Normal neurological examination

---

Differential Diagnosis

• Osseous torticollis: Klippel-Feil syndrome, atlantoaxial instability, C1–C2 rotatory subluxation
• Ocular torticollis: compensatory tilt for superior oblique palsy
• Spasmodic (dystonic) torticollis: neurological, episodic
• Sandifer syndrome: GERD-associated posturing
• Cervical spine tumors or infections
• Posterior fossa tumors

Key distinguishing point: always perform cervical spine X-ray (AP/lateral/odontoid views) to rule out osseous etiology before diagnosing CMT.

---

Diagnosis

1. Clinical examination: head tilt + chin rotation + SCM tightness/mass
2. Ultrasound of the SCM (preferred): confirms fibrosis, evaluates mass extent, guides prognosis
3. Cervical spine X-rays: AP, lateral, open-mouth odontoid view — rule out vertebral anomaly
4. MRI/CT: reserved for atypical cases, neurological symptoms, or failure to improve

---

Treatment

Conservative (First-Line — >90% resolve)

• Physiotherapy (passive stretching): initiated as early as possible; SCM stretching exercises 3–5×/day
  • Lateral bend toward contralateral shoulder
  • Chin rotation toward ipsilateral shoulder
• Active repositioning and stimulation
• Best response: when started <3 months; success >95% if treatment begun early
• Duration: usually 6–12 months of supervised physiotherapy

Surgical (for refractory cases)

• Indication: failure of conservative treatment after 12–18 months, residual torticollis >15° after age 18 months
• Procedure: SCM release (unipolar or bipolar)
  • Bipolar release preferred for severe cases: distal (sternal + clavicular heads) + proximal (mastoid) release
• Postoperative: cervical collar + continued physiotherapy
• Optimal surgical age: 1–4 years (best facial remodeling potential)
• Outcomes worse if surgery delayed beyond 8–10 years

---

Complications of Untreated CMT

• Permanent facial asymmetry and plagiocephaly
• Scoliosis
• Visual disturbances (diplopia due to head repositioning)
• Basilar skull asymmetry

---

---

2. Hernias of the Anterior Abdominal Wall & Inguinal Hernias

Anterior Abdominal Wall Hernias

A. Umbilical Hernia

B. Epigastric Hernia

• Protrusion of preperitoneal fat through a defect in the linea alba, between umbilicus and xiphisternum
• Usually small and may not be easily reducible
• Rarely contain bowel
• Treatment: elective surgical repair (high recurrence if not repaired)

C. Spigelian Hernia (Lateral Ventral Hernia)

• Rare; occurs through the spigelian fascia (aponeurosis of transversus abdominis) at the lateral edge of the rectus sheath
• Located at or below the arcuate line
• Often interparietal (between muscle layers) → difficult to detect clinically; ultrasound/CT helpful
• High risk of incarceration → elective repair recommended

D. Paraumbilical Hernia

• Adult variant; occurs adjacent to (not through) the umbilical ring
• Common in obese middle-aged women
• Treatment: surgical repair (does not resolve spontaneously; risk of incarceration)

---

Inguinal Hernias

Anatomy

• Anterior wall: external oblique aponeurosis + internal oblique (lateral)
• Posterior wall: transversalis fascia + conjoint tendon (medial)
• Roof: internal oblique + transversus abdominis
• Floor: inguinal ligament + lacunar ligament

---

Classification: Indirect vs. Direct

Hesselbach's Triangle boundaries: inferior epigastric vessels (lateral), rectus abdominis (medial), inguinal ligament (inferior)

---

Congenital Inguinal Hernia in Children

• Mechanism: persistence of the processus vaginalis (normally obliterates after testicular descent)
• Epidemiology: 1–3% of all children; M:F = 6–10:1; right-sided predominance; premature infants at higher risk
• All childhood inguinal hernias are indirect
• High risk of incarceration in infants (<6 months) — surgical urgency
• Contralateral exploration in girls and infants <2 years is debated (laparoscopy allows assessment)

---

Clinical Presentation

• Asymptomatic bulge in the groin/scrotum/labia, enlarging on standing/straining/coughing, reducing on lying down
• Incarceration: irreducible, tender swelling → nausea, vomiting, obstruction
• Strangulation: compromised blood supply → fever, erythema, peritonism → surgical emergency

Diagnosis (Bailey & Love, p. 1088)

"Often the hernia will reduce on lying and reappear on standing."

• Reducibility test: patient supine → hernia reduces; pressure on deep ring → cough test
  • Controlled (hernia doesn't appear): indirect hernia
  • Not controlled (hernia bulges medially): direct hernia
• Ultrasound: confirms diagnosis, especially in obese patients or when unclear
• CT scan: for complex, recurrent, or atypical cases

---

Treatment

Children

• Elective surgical repair as soon as feasible after diagnosis (high incarceration risk)
• Herniotomy (sac ligation only, no mesh): processus vaginalis is ligated and excised at the deep ring — floor repair unnecessary in children
• Laparoscopic approach: increasingly preferred; allows contralateral inspection

Adults

Emergency (Incarceration/Strangulation)

1. Attempted manual reduction (taxis) if no signs of strangulation
2. If irreducible or strangulated → emergency surgery
3. Bowel viability assessed intraoperatively; resection if necrotic

---

Complications of Inguinal Hernia Repair

• Early: wound infection, hematoma, urinary retention, injury to vas deferens or testicular vessels
• Late: recurrence (1–3% with mesh), chronic groin pain (ilioinguinal/iliohypogastric nerve injury), testicular atrophy, hydrocele

---

Summary Comparison: Abdominal Wall Hernias