Tratamento de plagiocefalia e braquicefalia posicionais com órtese craniana: estudo de caso Plagiocephaly and brachycephaly treatment Download PDF. Create a book · Download as PDF · Download as PDF · Printable version. This page was last edited on 12 August , at Text is available under the. Download full-size image . braquicefalia (comumente encontrada em craniossinostose sindrômica).6, 7, 8 Afeta predominantemente o sexo feminino ( 60%).
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Since then, the parents had made efforts to reposition the baby to improve the shape of the skull, albeit unsuccessfully.
Upon physical examination, there was an important flattening of the child s entire occipital region, more prominent on the left, and the left ear anteriorization in relation to the right one. No limitation of the child s cervical range of movement was detected while following visual and auditory stimuli which could suggest congenital torticollis. Likewise, there was no clinical evidence to suspect of craniostenosis. The baby was then positioned on an appropriate chair, and right side and vertex incidences pictures were taken.
On the same occasion a scan was performed. The scanning process uses anatomical reference points to determine a reference plane from which anthropometric measurements are obtained, the skull is divided into four quadrants, and volume indexes are calculated.
The main anatomical landmarks are the selion and the right and left tragions upper margin of ear tragus. Interference from hair is eliminated using a stockinet made of white malleable fabric.
Such template allowed a customized orthesis to be made, which began to be used on May 2, , when initial adjustments were made and orientation was provided on how to use the device. In addition, information on warning signs of exaggerated pressure points was given. From beginning to end of treatment, there were 6 follow-up visits with two-week intervals approximately, on which adjustments were made on the orthesis, to adapt to skull growth, and direct growth toward desired sites.
After one month of treatment, photo registration and scan were repeated to monitor development, and also upon discharge on July 29, , in order to document results. These periods were named T1 initial assessment and scan , T2 reassessment for follow-up, one month after initiating use of the orthesis and T3 last assessment made, totaling 3 months and 3 weeks from initial assessment.
The values obtained before and after treatment were compared and the following variables were used: - cephalic index: percentage resulting from dividing skull width by skull length at level 3 plane 3cm above the reference plane ; - quadrant volume: measurement of the volume in cm 3 of each quadrant, from level 2 to level 8 of the cross section of the child s head, as shown in figure 1; - diagonal difference: difference, measured in mm, among 30 oblique diagonals; - cranial asymmetry index: difference between diagonals 1 and 2, at 30, divided by the largest diagonal, expressed in percentage; - anterior symmetry ratio: index obtained from the division of the smallest anterior quadrant by the largest anterior quadrant, resulting in a comparative percentage between both; - posterior symmetry ratio: posterior percentage index, analogous to the anterior symmetry ratio Figure 2 shows the initial photograph and scan.
Based on the image, the flattening of the entire occipital region is evident, larger on the left side, and with slight right frontal flattening. Figure 2.
Right side image and vertex of the infant and result of the initial scan, showing the asymmetrical flattening of the occipital region Eight and sixteen weeks after the initial scan and totaling, respectively, one and three months of treatment, the clinical exam did not show any asymmetry. Figure 3 shows the images obtained on the last assessment, after three months of treatment.
Figure 1. Representation of cross-section of quadrants Before After Figure 3.
Comparison before and after 3 months of orthesis 4 Plagiocephaly and brachycephaly treatment with cranial orthosis Table 1 shows data obtained before beginning treatment and after 3 months and 3 weeks of assessment, totaling a 3-month management period. Likewise, improvement of all indexes on the second scan stand out in the analysis.
Table 1. Table 2. Figure 4. This parameter, as demonstrated by Plank et al. Ratios or indexes are essential to assess plagiocephaly, as they determine reproducible comparisons from one subject to another, regardless of patient s age or head circumference. The increase in quadrant 4 is easily observed in figure 4, area in which the growth was desired most, to reach better posterior symmetry of the head.
The consequent increase in volume of this quadrant, in relation to the remaining ones, can be checked on table 2, and also the largest posterior symmetry index. These results occur due to the constant contraposition that the orthesis offers to protuberant anterior and posterior regions, in which growth is not desired, while simultaneously allowing free space for the flattened regions to reach the desired growth.
In this way, the orthesis conducts and shapes the natural growth of the infant s skull. Frequent adjustments to the orthesis are necessary, typically every 15 days, during the entire treatment, occasions on which the result of correction is also supervised.
Other studies have already showed major decreases in the value of the cranial asymmetry index with orthesis treatment. Mulliken et al. Graham et al. In the treatment described, the diagonal difference went from 10 to 1.
It is important to present the results that have been achieved in clinical practice, since there are no Brazilian data regarding treatment with skull ortheses. Such technique has been investigated and used in the United States for over two decades, and the scanning technology has only been available in our country recently. This scenario makes the case report important, and also stimulates domestic scientific production, very scarce in this area 12, However, severe cases may cause serious emotional and psychological problems, and concerns about the patients perception of selfimage.
To avoid this, early and appropriate instructions to keep the baby in the supine position to reduce risk of sudden death of the newborn, along with orientation to change the baby s position when awake and that it play in the prone position under supervision, are important, avoiding therefore, more pronounced cases of positional plagiocephaly.
Attention should be equally paid to early diagnosis of congenital torticollis and other conditions that favor the vicious support on one of the sides of the head. The treatment of this condition requires joint effort of parents and pediatricians, who should assess the shape of the infant s skull early, ideally before 2 months of age, and, if there is an association with congenital torticollis, physical therapy should be immediate. When parents find information on deformational plagiocephaly and act immediately, stimulating repositioning, it is possible to correct deformity with conservative and low cost treatment, in most cases.
Several studies, however, have already clearly established guidelines for the treatment approach to be changed at the right moment, without unjustified delay in using skull orthesis, whenever indicated.
Such studies recommend that babies with moderate to severe plagiocephaly be treated with customized ortheses 11,14,16,17 , and the present case report underscores the results obtained with orthotic treatment. The authors emphasized the need for domestic studies that may show the statistically supported results observed in the treatment, comparing it to other therapeutical modalities and to the international literature. Macro- y microcefalia.
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