A 9-month-old male child had a fall on his head from a height of 4 feet
when he was being carried in arms by the elder sibling. The child
developed tilt of his head to left and resisted any attempts to passively
correct the tilt. The child did not have any other injury and there was no
neurological deficit. Radiographs of the cervical spine showed fracture of
lamina at C2 level. The child was given a Minerva jacket plaster for 3
weeks. When the plaster was removed at the end of 3 weeks, the child could
freely move his head and neck without any tilt and had no tenderness in
the cervical spine. The follow-up radiographs showed healing of fracture.
Congenital torticollis is the commonest cause of
torticollis in children. It is caused by injury to sternocleidomastoid
during a difficult labor when it undergoes ischemic necrosis and
contracture. The occiput is deviated towards the ipsilateral shoulder and
chin is deviated towards the contralateral side. The other common causes
include cervical lymphadenitis causing reflex spasm of sternocleidomastoid
and dystonic side effects of some drugs like phenothiazines,
metoclopramide, haloperidol, carbamazepine and phenytoin. Congenital
cervical spine and craniovertebral region abnormalities are the true
congenital reasons of torticollis. Post-burn contractures and neoplastic
lesions of posterior cranial fossa and spinal cord can be the other
causes. Benign paroxysmal torticollis is a self-limiting condition in
infants characterized by episodes of head tilting.
Injuries to cervical spine in children are very
uncommon and account for 1% of paediatric fractures
and 2% of all spinal injuries [1]. These children have high mortality
rates because of associated lethal head injuries [1,2].
Cervical spine injury in the 0-2 year age group occur mainly at C1
– C2 level [3]. There are many anatomical reasons
for this difference. Younger children have relatively large head size,
increased ligament laxity, poor musculature, anterior wedging of cervical
vertebral bodies, horizontally oriented facet joints and a higher fulcrum
at C1
– C2 [2]. We could not find a similar case in the English literature
where the patient had an isolated fracture of C2 lamina without
neurological deficit in infancy. We also could not find any report of
pediatric cervical spine injury where torticollis was the presentation.
This report highlights the fact that the survivors of upper cervical spine
injury can present with very subtle signs and symptoms, including
torticollis. It is important to screen the cervical spine before excluding
any injury to this part. Most of these fractures when detected early can
be managed non-operatively and usually have a favorable outcome.
References
1. Patel JC, Topas JJ III, Mollitt DL, Pieper P.
Pediatric cervical spine injuries: Defining the disease. J Pediatr Surg.
2001;36: 373-6.
2. Kokoska ER, Keller MS, Rallo MC, Weber TR.
Characteristics of pediatric cervical spine injuries. J Pediatr Surg.
2001;36: 100-5.
3. Sullivan JA. Fractures of spine in children. In:
Green NE, Swiontkowski MF, editors. Skeletal Trauma in Children.
Pennsylvania: Saunders; 2003. p. 344-70.