Muscular Torticollis in Children

Definition

Etiology and Pathogenesis

• Intrauterine moulding — abnormal fetal positioning in the uterus leads to compartment syndrome-like ischemia of the SCM, followed by fibrosis (Bailey & Love, p. 651)
• Birth trauma — difficult deliveries (breech presentation, forceps use) may cause SCM injury with subsequent hematoma and fibrous replacement
• Venous occlusion theory — venous obstruction during labor causes edema and muscle necrosis
• Intrauterine crowding — associated with other positional deformities (hip dysplasia, metatarsus adductus)

Classification

Clinical Presentation

• Palpable firm, non-tender mass within the SCM (fibrous pseudotumor), typically appearing at 2–4 weeks of age
• Head tilts to the ipsilateral side (toward the shortened muscle)
• Chin rotates to the contralateral side
• Restricted passive cervical rotation

• Plagiocephaly — flattening of the skull ipsilateral to the tilt
• Facial asymmetry (hemihypoplasia) — the face on the affected side appears flattened and smaller; develops progressively after 3–6 months
• Compensatory "C-curve" of the trunk and spine
• Oblique pelvic tilt (global postural adaptation)

Left-sided CMT: characteristic lateral head tilt, compensatory trunk C-curve, and pelvic obliquity

Diagnosis

• Asymmetric head position, restricted cervical range of motion
• Palpable SCM mass or tightness
• Measure passive rotation and lateral flexion deficit

• Shows thickening and increased echogenicity of the SCM
• Confirms fibrous mass, rules out vascular anomalies
• Non-invasive, no radiation — ideal for infants

• Excludes bony causes (atlanto-axial instability, Klippel-Feil syndrome, hemivertebrae)

Differential Diagnosis

Management

Conservative (First-line, initiated early)

• Passive and active SCM stretching
• Lateral cervical flexion and rotation exercises
• Should begin within the first weeks of life
• Success rate: ~90–95% if started before 3 months of age

• Visual and auditory stimuli placed on the contralateral side to encourage active correction
• "Tummy time" to promote symmetric muscle use

• Used as an adjunct in refractory cases before surgery
• Temporarily reduces SCM tension, augments physiotherapy

Surgical (Second-line)

• Conservative treatment fails after 6–12 months
• Significant residual deficit after 12–18 months of age
• Progressive facial asymmetry (Bailey & Love, p. 651)

• Distal release (sternal and/or clavicular head) — most common
• Bipolar release (origin + insertion) — for severe contractures
• Post-operative physiotherapy and neck orthosis essential

Complications of Untreated Torticollis

• Permanent facial asymmetry / hemihypoplasia
• Plagiocephaly
• Cervical scoliosis and compensatory thoracic scoliosis
• Visual disturbances (from chronic head tilt)
• Psychological impact (cosmetic deformity)

Prognosis

Bailey and Love's Short Practice of Surgery, 28th Ed., p. 651

Hernias of the Anterior Abdominal Wall and Inguinal Hernias

General Definition

• Sac — peritoneal outpouching
• Contents — bowel, omentum, bladder, ovary, etc.
• Coverings — layers of abdominal wall draped over the sac

PART I — Hernias of the Anterior Abdominal Wall (Ventral Hernias)

• Primary ventral hernias — occur spontaneously at anatomically weak points
• Incisional hernias — occur at previous surgical wounds (Bailey & Love, 28th Ed., p. 1093)

1. Umbilical Hernia

In Infants

• Due to failure of the umbilical ring to close after birth
• Very common; majority close spontaneously by 3–4 years of age
• Surgical repair indicated if persists beyond age 4–5 or if ring diameter > 1.5 cm

In Adults

• Strictly termed paraumbilical hernia — hernia passes through a defect just above or below the umbilical ring (not through it)
• More common in obese, multiparous women
• Contents: omentum, transverse colon, small bowel
• Risk of strangulation is relatively high — elective repair recommended even if asymptomatic
• Repair: Mayo "vest-over-pants" repair or mesh repair for larger defects

2. Epigastric Hernia

• Occurs through defects in the linea alba between xiphoid process and umbilicus
• Usually small; contains extraperitoneal fat (pre-peritoneal fat plug), rarely a true sac
• More common in young adult males
• Often multiple; frequently symptomatic (pain disproportionate to size)
• Treatment: surgical closure; mesh for larger defects

3. Incisional Hernia

• Develops through a previous surgical incision in the abdominal wall
• Risk factors:
  • Wound infection, dehiscence
  • Obesity, malnutrition, steroid use
  • Poor surgical technique (excessive tension, inadequate closure)
  • Midline incisions carry highest risk

• Location (midline vs. lateral)
• Width of defect (W1 <4 cm, W2 4–10 cm, W3 >10 cm)
• Recurrent vs. primary

• Small defects: primary suture repair
• Defects ≥ 4 cm: mesh repair (open or laparoscopic) — lower recurrence rate
• Component separation technique for massive defects

4. Spigelian Hernia

• Occurs through the spigelian fascia (aponeurosis of the transversus abdominis) at the lateral border of the rectus sheath, typically just below the arcuate line
• Interparietal — sac lies between muscle layers (difficult to detect clinically)
• Often missed on examination; diagnosed by ultrasound or CT
• High risk of strangulation
• Treatment: surgical repair (laparoscopic preferred)

5. Lumbar Hernia

• Through the superior lumbar triangle (Grynfeltt) or inferior lumbar triangle (Petit)
• Rare; often contains retroperitoneal fat
• Treatment: mesh repair

6. Obturator Hernia

• Through the obturator canal in the obturator foramen
• Predominantly elderly, thin women
• Classic sign: Howship-Romberg sign — pain along inner thigh (obturator nerve compression)
• Frequently presents as small bowel obstruction; diagnosed on CT
• High morbidity due to delayed diagnosis

PART II — Inguinal Hernias

Anatomy of the Inguinal Canal

• In males: spermatic cord (vas deferens, testicular artery, pampiniform plexus, cremasteric muscle, processus vaginalis remnant) + ilioinguinal nerve
• In females: round ligament of the uterus + ilioinguinal nerve

Classification of Inguinal Hernias

• Medially: lateral border of rectus abdominis
• Laterally: inferior epigastric vessels
• Inferiorly: inguinal ligament

Epidemiology

• Most common hernia overall (~75% of all hernias)
• Lifetime risk: 27% in males, 3% in females
• Right side > left side (due to later descent of right testis)
• Indirect > direct (ratio ~2:1)
• Bilateral in ~20% of cases

Clinical Presentation

• Groin lump, typically appearing on standing/straining and reducing on lying down
• Dragging, aching discomfort
• In scrotal hernias: visible and palpable scrotal swelling

• Visible/palpable impulse on coughing
• Invagination test: finger in superficial ring — indirect hernia impacts fingertip, direct hernia impacts pulp
• Reducibility assessment
• Irreducibility = hernia cannot be reduced (may still be viable)
• Obstruction = bowel obstruction without vascular compromise
• Strangulation = vascular compromise → surgical emergency

Imaging

• Uncertain or occult hernias: ultrasound (first line)
• Complex cases, recurrence, or pre-operative planning: CT scan
• Identification of bilateral occult hernias: MRI (sports hernia evaluation)

Intraoperative anatomy: S1 and S2 = two direct hernia sacs on either side of the inferior epigastric artery (IEA); indirect sac visible laterally. Note anomalous superficial course of IEA along the posterior canal wall.

Differential Diagnosis of Groin Swelling

Management

Conservative

• Watchful waiting is acceptable for asymptomatic or minimally symptomatic direct inguinal hernias (low strangulation risk)
• Truss: rarely used; not curative; may mask symptoms

Surgical Repair

Open Repair

Laparoscopic / Minimally Invasive Repair

Complications

Special Situations

• Strangulated hernia: Emergency repair after resuscitation; bowel resection if non-viable; mesh use controversial in contaminated field
• Inguinal hernia in children: Always indirect (patent processus vaginalis); treated by herniotomy (sac ligation only); high incidence of contralateral patent processus — many surgeons explore both sides
• Inguinal hernia in women: Rare; always exclude femoral hernia; round ligament may be in sac; repair principles same

Bailey and Love's Short Practice of Surgery, 28th Ed., pp. 1086, 1093