Plagiocephaly and gait problems

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Does anyone have any experience of children who have had plagiocephaly (assymetrical flattening of the head) and any secondary gait effects?

I have recently received a referral for an 18 month old child with "gait issues" that previously wore a protective helmet for plagiocephaly. I have tried to research this but found very little literature on the subject. The local paeds physio tells me there maybe some anecdotal evidence for hip deformity and leg length discrepancy, but I have been unable to find any.

I have yet to see the patient but any ideas/thought gratefully received.

Ella

 

Re: Plagiocephaly

Have seen a few patients with plagiocephaly. So far as i remember the issues were more the standard stability stuff, Talo crural frontal plane instability controlled in boots. Don't remember any particular tendancy to LLD but thats not to say it wasn't there.

Basically treat what is there. There's not a great deal you can do with the head!

Regards
Robert

 

Re: Plagiocephaly

My understanding is that most (?almost all) cases of plagiocephaly resolve by 2 yrs of age (I know your case is only 18 mnths) and it is largely a cosmetic issue ... if there is a gait problem, may need to rule out other problems.

 

Thank you Robert and Craig for your replies. You've confirmed my initial thoughts really, which is good! Thanks again

Ella Hurrell (nee Currie)

 

What are the gait deviations? Does it involve in-toeing on one side?

Plagiocephaly & torticollis are associated with a higher incidence of hip dysplasia. Normally, the pediatrician or physical therapist checks this out.

If the torticollis was caused by a visual alignment issue, there will be postural and gait deviations if the strabismus was not corrected.

 

Hi Dawn:
I'm fairly certain that patients with torticollis are more likely to develop positional plagiocephapy only because they are forced to sleep in a similar position nightly due to the decreased ROM in the neck.

Is that what you meant?

Also; I don't think these patients wear PROTECTIVE HEAD GEAR - customized forms are made and changed every few weeks to RESHAPE the cranium.
I would be very surprised is there were any CNS and or motor sequelae from plagiocephaly.

Steve

 

I thought I would share some of the information I have about this problem.

The incidence of torticollis is 1/ 300 infants. Plagiocephaly develops from this 80-90% of the time. The flatness on the posterior aspect of the occiput is contralateral to the tight SCM.

There are many congenital & developmental disorders with signs or symptoms of torticollis. They are broken into 3 categories
1) Osseous types (Klippel Feil, C1-C2 rotary subluxation, fractured clavicle, etc)
2) Non-osseous types (CMT, Sandifer Syndrome)
3) Neurogenic types (CNS tumors, Arnold Chiarri malformation, ocular torticollis, etc)

Plagiocephaly does not have motor consequences, but torticollis does. I have found that shortness of the SCM goes along with tightness in other muscles in that area (most commonly leveator scapulae & upper trapezius, sometimes scalenes). Because of the abnormal position, strength, and flexibility, there are motor sequelae throughout the body. In sitting, they lean toward that side of the tightness, placing more weight-bearing on the same side hip than the opposite. When in prone, the scapular muscles are not able to stabilize on that side, and usually weightbearing is on the ipsilateral side of the torticollis, causing postural deviations and poor motor strength on the opposite side.

My point with that was that torticollis does cause problems throughout the body if it is not resolved and the muscle strength & postural deviations are not corrected.

What I wanted to bring up to the experts on this form was the incidence of ocular torticollis because that causes postural deviations even in the foot. The paralysis of the Trochlear cranial nerve is the cause of 90% of the ocular torticollis cases (and actually the only nerve I've ever seen be involved). The superior oblique muscle is affected,so the child tilts the head to the normal side in an effort to correct the double vision. There are no research articles regarding this, but I've seen that the child then rotates the head toward the affected eye, rotates the trunk to the affected eye, and internally rotates the hip on the normal side. There are then some things going on with the normal side foot that I refer out to you guys because I get perplexed on what to do. I will get referrals for gait deviations in older children & teenagers and find they had a history of torticollis and a continued lateral head tilt.

Has anyone else seen this gait deviation? What are you doing to treat it? Thanks for your input!

 

Dawn,

I've yet to see the patient - it was a referral I received and I wanted to be as informed as possible before I see them. I will report back with the gait details when I have seen the patient.

Thanks for your info so far.

Ella

 

Hi Dawn:
Unless I'm msitaken (and it does happen, ask my ex) torticollis is a condition of the sternocleidomastoid muscle which causes the typical short - thick neck, tilt, decreased ROM, etc....

I'm a bit confused as to why we entered a discussion of Torticollis from the plagiocephaly question. If the patient in question has plagiocephaly AND torticollis wouldn't the Torticollis be fairly hard to miss? Are there occult torticollis cases?

Thanks

Steve

 

Steve-

Well, according to my husband, I like to go off on tangents but I usually have a train of thought leading me that direction.

We started talking about torticollis since it is one of the main causes of plagiocephaly. I refer patients to podiatrists that have had torticollis when they were younger with the resultant plagiocephaly (those that are moderate to severe I recommend to get treated with the DOC band- cranial molding, but not all want to put their child through that) only because of the postural deviations I see in the lower extremities. So when the post was made asking about gait deviations with plagiocephaly, my mind jumped to a baby with torticollis who developed plagiocephaly, didn't get proper treatment as an infant, and ended up having postural & gait deviations as an older child. That was my tangent

There are those children that continue to have some limitations in the SCM, usually with the lateral tilt that might not be obvious. With the limitations under 10 degrees, most doctors & parents don't opt for botox injections or surgery to lengthen the muscle because "it's not a big deal" to them.

There are occult cases of torticollis- usually caused by dysfunction in the vestibular system, possible brain tumors, and strabismus issues (I use the term ocular torticollis for vision issues so I don't get confused, but I'm not sure that is the correct medical term). In my experience, I've seen the vestibular dysfunction torticollis (which changes from left to right torticollis sometimes), but most are eye alignment issues. The ocular torticollis may come on only when the child is tired or has been doing a lot of reading/etc.

Are we on the same tangent now? :wacko:

 

Hi Dawn

"Are we on the same tangent now?"

Sure, it's a little slippery though!!!!!

Steve

 

I have just seen the patient mentioned in the original post. He does not have intoeing on one side, but he does have a very wide base of gait. While I would not normally be concerned about this in a child of this age, he does not walk in a particularly 'normal' way for this age. He tends to twist his upper body to lead with one shoulder corresponding to the same leg he is stepping on - ie, one shoulder leads anteriorly, then swaps to the other with the next step. His health visitor described this as 'walking like a chimp or monkey' if that helps you to imagine what I am trying to describe

Hip ROMs are ok, and non-weightbearing joint assessments are all within normal ranges. He looks normal for his age in static stance. He has a rugby player-type physique and a larger than average size head. My instinct says there is something else going on here, more than just normal instability for his age. I can't really put my finger on it, so I have arranged for a paeds physio to see him soon for a second opinion - will keep you posted.

 

Hi Ella:
Perhaps weak hip flexors of Neuromuscular origin. Other possibility is instability.
I wouldn't hesitate to get a neuro consult.
Steve

 

I would definitely refer to a pediatric neurologist. I'm sure your instincts are right....and it sure sounds like there is something neurologically going on.

 

This may or may not be of interest, but it turned up on the radar scope this morning under "orthotic":

Long-term treatment effectiveness of molding helmet therapy in the correction of posterior deformational plagiocephaly: a five-year follow-up.
Cleft Palate Craniofac J. 2008 May;45(3):240-5.

 

I agree with the refferal to a paed neurologist. Larger than normal head size combined with instability could be sinister. However at the same time, go hand in hand when you think anatomically. Larger head on a developing body, add to that a helmet that changes proprioceptive input and possibly auditory feedback and you will have a few gait oddities. But to be safe than sorry though.

 

Thanks for recent posts - as is sometimes the way with interesting cases, they didn't turn up to the paeds neuro appointment! I have informed the GP and tried to make contact with the family. I'll let you know if they resurface again!n Shame though - I would have liked to have more to report.