Initial pre-referral workup

Clinical history

Age at onset and duration of symptoms are important for diagnosis and treatment. 

Neonatal torticollis – peri-natal history is also important for diagnsis and trearment.

In cases with new onset torticollis in a child – enquire about history of trauma or recent history of upper respiratory tract infection (Grisel’s syndrome).

Physical examination

Look for associated plagiocephaly in the neonate/infant with torticollis.

Look for asymmetric tightness or a mass in the sternocleidomastoid opposite to the direction the chin is pointing.

Investigations

• AP/Lat/open mouth odontoid x-rays of the cervical spine
• ultrasound of the neck may identify asymmetry in the sternocleidomastoid muscles in muscular torticollis

GP management

Torticollis in the newborn should be referred to a general paediatrician as a first step.  Muscular torticollis in the neonate/infant (younger than one year) can often be managed by specialist physiotherapy.

New onset torticollis in the child following trauma or following a recent upper respiratory tract infection should be referred to the local paediatric emergency department due to the risk of acute C1-2 rotatory subluxation.

For cases with muscular torticollis in child over the age of one, refer to paediatric orthopaedic surgeon as physiotherapy often not successful.

Indications for specialist referral

Emergency

New onset torticollis in the child following trauma or following a recent upper respiratory tract infection should be referred to the local paediatric emergency department

Routine

• torticollis in setting of abnormal X-rays
• age over one year, with muscular torticollis

General Paediatrician review

• torticollis in setting of normal x-rays should be reviewed by a general paediatrician prior to orthopaedics referral to rule out central cause.