Year: 2026 | Month: January | Volume: 13 | Issue: 1 | Pages: 416-424
DOI: https://doi.org/10.52403/ijrr.20260139
Surgical Management of Congenital Muscular Torticollis in an Adult: A Case Report on Bipolar Release and Z-Plasty Technique
Adhi Satriyo Utomo
Department of Orthopedic and Traumatology, Faculty of Medicine, Universitas Brawijaya – Dr. Saiful Anwar General Hospital, Malang, Indonesia
Corresponding Author: Adhi Satriyo Utomo
ABSTRACT
Introduction: Congenital Muscular Torticollis (CMT) is a common musculoskeletal deformity in infants, typically diagnosed early in life. However, in some cases, it remains undiagnosed and untreated until adulthood. This report describes a case of adult-onset CMT and its management.
Case Presentation: A 27-year-old female presented with a longstanding neck deformity first noticed at age 3. Despite a slight spontaneous improvement during adolescence, the deformity persisted into adulthood. She complained of neck and back stiffness, particularly with physical activity. Clinical examination revealed a right-sided head tilt, limited range of motion, and a fibrotic mass in the sternocleidomastoid (SCM) muscle. Radiological assessment confirmed levoscoliosis cervicalis and secondary postural scoliosis in the upper thoracic region.
Discussion: Surgical intervention was considered due to the persistence of the deformity despite spontaneous improvement in adolescence. Bipolar SCM release combined with Z-plasty on the sternal head of the SCM muscle was chosen as the surgical approach. This technique aims to restore muscle length and eliminate abnormal tension. Postoperative rehabilitation focused on active and passive neck stretching exercises to maintain the range of motion and prevent scarring. The patient showed significant improvement in both functional and cosmetic outcomes, with reduced head tilt and enhanced neck mobility.
Conclusion: This case demonstrates the importance of early diagnosis and intervention in CMT. For adults with long-standing, untreated CMT, surgical correction remains a practical option, with favorable outcomes when combined with a structured rehabilitation program.
Keywords: bipolar release, congenital muscular torticollis, neck muscles, z-plasty
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