Today, I review, link to, and excerpt from Pediatric Torticollis from Emergency Medicine Cases‘ Quick Hits 66.*
*Helman, A. Schonfeld, D. Swaminathan, A. Petrosoniak, A. Morgenstern, J. Tagg, A. Myers, V. Tintinalli, J. EM Quick Hits 66 – Pediatric Torticollis, Stable Stable Wide Complex Tachydysrhythmias, Post-intubation Neurocritical Care, Hyponatremia Correction Rates, Paronychia Management, Women in EM Leader Series with Judith Tintinalli https://emergencymedicinecases.com/em-quick-hits-july-2025/. Accessed August 9, 2025.
All that follows is from the above resource.
Deborah Schonfeld on pediatric torticollis (02:33 – 28:21)
Pediatric torticollis: Not just muscular injury
Broad Categories in the differential diagnosis of pediatric torticollis
Muscular (SCM/trapezius): Most common; typically resolves within a week.
Atlantoaxial Subluxation: C1/2 instability due to ligamentous or osseous abnormalities.
Infectious:
- Viral URTI/Pharyngitis → Referred pain, muscle spasm
- Retropharyngeal Abscess (typically ages 2–4): Limited neck extension, fever, dysphagia, drooling, stridor
- Osteomyelitis/Discitis: Cervical spine tenderness
- Lemierre Syndrome: IJ thrombophlebitis post-oropharyngeal infection → SCM or jugular tenderness/swelling
CNS Lesion (typically painless):
- Up to 20% of posterior fossa tumors present with torticollis
- 50% of pediatric malignant brain tumors are located in the posterior fossa
- Clinical red flags: headache, vomiting, gait changes, ataxia, focal neuro deficits
Atlantoaxial Subluxation
Risk Factors for Atlantoaxial Subluxation
- Ligamentous injury (more common than fracture in children)
- Congenital hypermobility: Trisomy 21/Down syndrome, Marfan’s Syndrome, Juvenile Idiopathic Arthritis
- Grisel Syndrome: Post head/neck surgery with local inflammation → ligament laxity
Physical exam pearl to distinguish atlatoaxial subluxation from muscular torticollis
- Muscular torticollis: Head tilts toward spastic SCM
- Subluxation: Tilts away from affected side
Imaging for suspected atlantoaxial subluxation
XR: Odontoid and lateral views; assess Atlantodental Interval (≤5 mm if <8 years) – use as screening in low pretest probability patients; be aware than sensitivity is poor
CT: Gold standard when high suspicion or red flags present
Bottom Line
- Most cases of torticollis self-limiting, due to SCM muscle spasm
- Torticollis >1 week or with neurological findings → Image to rule out subluxation, infection, or CNS lesion
Source: Radiopaedia under the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported licence
Reference
- McInerny, Thomas K, and American Academy of Pediatrics. American Academy of Pediatrics Textbook of Pediatric Care. Washington, D.C: American Academy of Pediatrics, 2009. Print.
