Clinical Approach to Plagiocephaly

Fig. 5.1
Different shapes of the skull in lambdoidal synostosis (a, b, c on the left column) and in PPP (a, b, c on the right column), viewed from the top (a), from the back (b) and front (c). In lambdoidal synostosis, the head viewed from the top (a) has a trapezoidal shape (a-left), while in PPP a typical parallelogram shape (a-right)

Table 5.1
Comparison and differences in the shape of the skull in lambdoidal synostosis and in PPP

Lambdoidal synostosis

Posterior positional plagiocephaly

Vertex view

Depressed right occiput

Vertex view

Depressed right occiput

Prominent right forehead

The forehead is prominent on the left and severely flattened on the right side

Parallelogram cranial shape

Trapezoidal cranial shape

Anterior shift of the right ear

Anterior shift of the right ear

Posterior view

Depressed right occiput

Posterior view

Depressed right occiput

Compensatory increase in cranial height on the right side

Decreased cranial height on the right side

Level ears

The right ear is positioned inferiorly relative to the left

Frontal view

Forehead and cheek more prominent on the right than the left

Frontal view

Forehead prominent on the left and severely flattened on the right side

Right eye appears more open than the left

Right eye appears more open than the left

Nose is straight

The nose is slanted

Chin point rotated to the left

Chin point deviation to the left

See also Fig. 5.1

In addition to the observational data, several anamnestic information can be helpful in supporting the different diagnostic hypotheses.

5.1.1 Risk Factors for PPP

It is known that posterior positional plagiocephaly (PPP) can be prevented, but it is also known that some individual or environmental factors, prenatal, neonatal, and postnatal, may give way to its onset [710].

The identification of these risk factors can be helpful in the diagnostic process and support the care management (Table 5.2).

Table 5.2
Risk factors for positional plagiocephaly

Obstetric factors


Assisted delivery

Low birth weight

Preterm birth

Infant factor

Neck problems

Infant difficulty turning head

Decreased cervical rotation

Limited passive cervical rotation

Limited active cervical rotation

Consistently sleeps with head turned to one side

Male sex

Larger cerebrospinal fluid spaces

Infant care factors

Cumulative exposure to the supine position

>20 h per day in supine position

<1 h per day upright

Placed in prone <3 times per day

Position of head not varied when infant is put to sleep

Firmer mattress

Position of infant when fed

Only bottle fed

(From Bialocerkowski et al. 2008 [7])

With reference to Table 5.2 information about the prenatal, neonatal, and postnatal period, let make us presume the positional nature of the disorder.

Observational data and medical history will be sufficient to enable us to orient ourselves in the differential diagnosis between postural plagiocephaly and synostotic plagiocephaly.

If we are oriented towards the diagnosis of positional plagiocephaly and we have checked the absence of postural head anomalies of clinical relevance (head tilted to the contralateral side of rotation, deficit of contralateral rotation), we will not need to conduct further diagnostic exams, and we can explain to the parents the developmental dimension of the clinical features addressing the case to a pediatric physiotherapeutic treatment.

5.1.2 Developmental Risks of PPP

PPP has a prognosis of spontaneous improvement, but in the most “serious” cases, a residual deformity can still be observed at the end of preschool age [11]. The possibility that PPP may represent a clinical problem not only concerning “aesthetics” has been studied by evaluating the quality of case studies of neurobehavioral development in children.

It has been reported that children with PPP get different achievements in neurobehavioral development at 18 months and at 36 months (according to the Bayley Scales of Infant and Toddlers Development – III Edition): the cognitive and the linguistic areas seem to be those which mostly show recognizable immaturity [12, 13].

It has been reported that PPP can alter the development of the visual field [14] and determine disorders of the auditory processing [15].

It has been observed that, when beginning primary school, 39.7 % of children diagnosed as having PPP at 6 months of age required special care and educational needs in comparison to only 7.7 % in the control group [16].

5.2 Synostotic Plagiocephaly

The observational diagnosis of synostotic plagiocephaly requires confirmation by neuroimaging studies. The three-dimensional computerized tomography (3D CT) of the head will be the investigation of choice to confirm the clinical hypothesis of synostosis (Fig. 5.2).


Fig. 5.2
A 3D CT image showing a synostosis of the suture was superimposed to the baby’s head photography in which the anterior and inferior position of the left ear clinically suggests a left lambdoid suture synostosis. The image overlapping led to diagnostic confirmation

The 3D CT study will help us to verify the presence of other cranial suture synostosis (differential diagnosis between single synostosis and multiple synostoses).

Magnetic resonance imaging (MRI) of the brain is not universally recommended for routine examinations in isolated craniosynostosis as it usually does not add any information that may affect treatment decisions [17]. MRI of the brain may, however be useful, even in isolated forms, to assess the presence of brain malformations (i.e., agenesis of the corpus callosum, Chiari malformation type 1, or conditions of intracranial hypertension) [18].

Neuroimaging has otherwise a specific indication when neurobehavioral delays, dysmorphisms, or malformations of other organs and systems are detected during the clinical observation of the child. In this diagnostic context, a consultation by a geneticist pediatrician becomes very useful.

The diagnosis of a specific syndrome may provide prognostic factors of great importance in order to define a correct therapeutic approach to the cranial shape disorder. Some genetic syndromes that include the presence of cranial synostosis are listed below (Table 5.3).

Table 5.3
Syndromic forms of craniosynostosis, with involvement of different sutures (metopic, coronal, sagittal, lambdoidal)

Pfeiffer syndrome

Crouzon syndrome

Apert syndrome

Jackson-Weiss syndrome

Muenke syndrome

Saethre-Chotzen syndrome

5.2.1 Developmental Risks of Synostotic Plagiocephaly

Several longitudinal observations have investigated whether isolated craniosynostosis may involve risks of neurodevelopmental delay or worse outcomes.

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Mar 29, 2017 | Posted by in ORTHOPEDIC | Comments Off on Clinical Approach to Plagiocephaly
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