DIAGNOSIS AND MANAGEMENT OF POSTERIOR PLAGIOCEPHALY

Objective. The management of infants with posterior plagiocephaly has been controversial both because of widely differing estimates in the l iterature of the relative frequencies of true lambdoidal synostosis vs positional molding and because of divergent approaches to treating th is problem in different institutions. Based on our experience, we hypo thesized that the vast majority of children with posterior plagiocepha ly did not have true synostosis and that the cosmetic impairment in su ch patients could be effectively treated with nonsurgical modalities. Methods. Between 1992 and 1995, we prospectively applied in 71 infants a consistent management philosophy for these malformations that has i ncorporated a detailed evaluation of sutural anatomy as the basis for a physiologic approach to treatment. This approach has been directed a t distinguishing true synostosis from deformational plagiocephaly and at avoiding surgery for patients with deformational abnormalities by u sing a combination of nonsurgical modalities to restore normal cranial growth dynamics. All children first underwent skull radiographs to de termine whether the lambdoidal sutures were patent. In equivocal cases , computed tomography was also performed. Patients without true synost osis were enrolled on a course of positional therapy. In patients that did not improve after 2 to 3 months, a custom-fitted orthoplastic mol ding helmet was applied to facilitate passive skull recontouring. Resu lts. Forty children had patent sutures based on skull radiographs, and 29 others, in whom the radiographs were equivocal, had open sutures b ased on computed tomography, thus establishing the diagnosis of deform ational plagiocephaly in 69. Predisposing factors for this deformity i ncluded a strong positioning preference during early infancy (n = 67), torticollis (n = 10), prematurity (n = 6), and developmental delay (n = 2). Only two patients had true lambdoidal synostosis; in each case, this was associated with synostosis of the posterior sagittal suture and was managed effectively with cranial reconstructive surgery. Thirt y-five patients with deformational plagiocephaly had a dramatic improv ement in their cranial contour with positional therapy alone; 34 patie nts failed to improve and were treated with molding helmets. All but f ive children, each of whom was more than 6 months old at initial inter vention (P < .025), developed a normal or nearly normal head shape wit h these measures. Conclusion. The vast majority of children with poste rior plagiocephaly do not have true synostosis and can be effectively managed by nonsurgical means. The impact of positional preference on t he development of this process is discussed.