An Intro to…
Abnormal Head Shapes
An introduction to abnormal head
shapes…
Craniosynostosis
• Early suture closure
associated with a
small head
circumference and
rigid sutures
Primary Craniosynostosis
• 1 or more sutures fuse prematurely
• Growth is restricted perpendicular to the
suture
– If multiple sutures fuse while the brain is still
increasing in size, intracranial pressure can
increase
Secondary Craniosynostosis
• More frequent than primary craniosynostosis
• Results from early fusion of sutures due to
primary failure of brain growth
– results in microcephaly
• Intracranial pressure usually is normal
– Surgery seldom is needed
Head Shapes
Scaphocephaly
• Premature fusion of the sagittal suture
• MC craniosynostosis (> 50%)
• Head is elongated in the
A-P diameter and shortened
in the biparietal diameter
• Ridging of the sagittal suture
is palpable
Brachycephaly
• Premature fusion of both coronal
sutures
• Increased biparietal diameter,
shorter A-P diameter
Trigonocephaly
• Premature fusion of the metopic suture
• Results in pointed forehead
– usually mild and requires no surgical
intervention
MILD--------------------------------------------SEVERE
Posterior Plagiocephaly
2 predominant causes of posterior plagiocephaly
1. craniosynostosis of the lambdoid suture (<2%)
2. positional molding (vast majority)
Craniosynostosis:
• trapezoid shaped
• frontal bossing is observed
contralateral to the flattening
VS.
Positional Head Deformity
If plagiocephaly is present at birth…
Differentials include:
• In-utero or intrapartum molding
– uterine constraint
• multiple birth infants
– birth injury associated with forceps or
vacuum-assisted delivery
– premature birth
• Craniosynostosis (lambdoid suture)
If plagiocephaly develops later…
“result of static supine positioning”
AAP, 2003
• Torticollis
• “Back to Sleep” campaign
– Since 1992 there has been a significant increase in
the diagnoisis of plagiocephaly
• one center reported a six-fold increase (1992-1994)
• Subluxation…
Epidemiology
• 1992: 1 per 300 healthy infants
• 1999: 1 per 60 healthy infants
Examination
1. Palpate lambdoidal suture
– Palpable ridge suggests synostosis
2. Check ear position
– Ear on flattened side more posterior suggests
synostosis
– Ear on flattened side more anterior suggests PHD
3. Assess facial symmetry
– Forehead prodruding on the side of flattening
suggests PHD
• Positional head deformity
– ear migrates forward
– forehead protrudes on the side of occipital
flattening
• Eyes may appear to
have unequal
positioning
Examination
4. Observe unilateral bald spot
– Unilateral bald spot suggests PHD
5. Inspect by arial view
– “Parallelogram shape” suggests PHD
• Positional Head Deformity (left) – parallelogram
shape
• Synostosis of lambdoid (right) – forehead does
not protrude
Skull Radiographs and CT?
• Useful in cases with atypical skull pattern
or moderate-severe skull deformity
…suspecting craniosynostosis
Differential Diagnosis is Critical!
Craniosynostosis
Positional Head Deformity
• Palpable ridge
• Ear on flat side more
posterior
• Forehead does not
protrude
• No bald spot (no sign
of external pressure)
Management of PHD
•
•
•
•
Preventive counseling for parents
Mechanical Adjustments
Exercises
Skull modling helmets
– “…option for patients with severe deformity
or skull shape that is refractory to
therapeutic physical adjustments and
position changes.”
AAP (2003)
• Surgery
Chiropractic Adjustments!
Preventive Counseling
Parents should be counseled during
the newborn period (2-4 weeks)
1. Alternate supine sleep positions (i.e. L & R occ.)
2. When awake and being observed, the infant
should spend time in the prone position
3. Minimal time in car seats (when not a
passenger in a vehicle) or other seating that
maintains supine positioning
Mechanical Adjustments
• Position the infant so that the rounded side
of the head is placed dependent against
the mattress
• Change the position of the crib in the room
– require the child to look away from the
flattened side to see the parents and others in
his or her room
Exercises
• Supervised “tummy time” on firm surfaces
when the infant is awake and being
observed
• If torticollis is present, parents should be
taught specific neck motion exercises
– head rotation and lateral bend
• Done at each diaper change
• Hold 10 seconds; 3 repetitions
• Most will improve within 2-3 months…
If parents follow these guidelines!
Referral
“If there is progression or lack of improvement of
the skull deformity after a trial of mechanical
adjustments, then referral to a pediatric
neurosurgeon, a general neurosurgeon with
expertise in pediatrics, or a craniofacial surgeon
or craniofacial anomalies team should be
considered.“
(AAP, 2003)
• correct diagnosis?
• subsequent management
– molding helmets or surgery
Skull-Molding Helmets
• Research opinions are mixed
• Best results 4-12 months of age