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Chiropractic Journal of Australia : CJA December 2013
126 Chiropractic Journal of Australia Volume 43 Number 4 December 2013 metopic synostosis varies between 1/700 and 3/10,000, with increasing incidence.14,20,21 The rate of lambdoid synostosis is even less common, with rates estimated at 3/100,000 births.22 The most common type of craniosynostosis is sagittal synostosis (51%), followed by metopic synostosis (25-27%), and unilateral coronal synostosis (11.4%).17,18 All other types (including lambdoid synostosis) comprise approximately 12% of the group.17 In contrast Deformational (positional/non-synostotic) Plagiocephaly is much more common, with rates reported at 1/300,23 which is probably underestimated. For example, one study showed a prevalence of 8.2%.24 Another revealed the point prevalence to vary at different ages, with a peak of 19.7% at 4 months age.25 In a cohort from the Netherlands the prevalence was 6.1% at birth and 22.1% at 7 weeks.26 Furthermore, at 24-72 hours of age, the incidence in singletons was 13%, with an increased incidence of 56% in twins.27 In one study of cases referred to the Adelaide Craniofacial unit, 2/204 patients (under 1%) had lambdoid craniosynostosis, with the rest being of the Deformational Plagiocephaly type.28 The key point for the Chiropractor is that craniosynostosis is not common, but must be considered and ruled out in any infant with head preference, torticollis or head shape issue. Clinical Examination Risk factors for craniosynostosis include male sex, twins, prematurity, breech presentation, presentations other than vertex, low birth weight, birth weight greater than 4000gm, emergency caesarian birth, maternal age over 35, and paternal age over 40.15,20 In unilateral craniosynostosis the right suture is more commonly affected.17 The key clinical fndings in recognising craniosynostosis are characteristic head shape and suture abnormalities, and these depend on the suture affected. In sagittal craniosynostosis there is an increase in the anterior to posterior dimensions of the cranial vault (Scaphocephaly). In addition, there is signifcant “ridging” of the sagittal suture, which palpates as a clearly demarcated ridge down the sagittal suture. This is greater than what would be expected with cranial molding after the birth process, or mild over-ride as expected with cranial faults. Cranial molding may be present in the frst 2/3 days in a term infant, or 2/3 weeks in a premature infant.23 Fusion of the metopic suture results in narrowing of the anterior vault, creating a pointed/triangular forehead appearance (see Figure 3). The eye brow may appear narrowed. Fusion of the coronal suture results in wider lateral (bi-temporal) vault dimensions and a shorter anterior to posterior vault (Brachycephaly). There is contralateral bossing of the forehead, ipsilateral recessed forehead, and possible asymmetry of the orbit. These types are not easily confused with Deformational Plagiocephaly. The condition that is easily confused with positional plagiocephaly is lambdoid synostosis. RECOGNISING CRANIOSYNOSTOSIS O’NEIL • STEWART (Used with permission from Renee L Cannon MA CMI) Figure 1: Sagittal Craniosynostosis: (Used with permission from Renee L Cannon MA CMI) Figure 2: Metopic Craniosynostosis Figure 3: Coronal Craniosynostosis Deformational Plagiocephaly Lambdoid Craniosynostosis Figure 4: Deformational Plagiocephaly versus Lambdoid Craniosynostosis (Used with permission from Renee L Cannon MA CMI)
CJA September 2013