Hip Spica Cast : Wheeless' Textbook of Orthopaedics

- See: Pediatric Femoral Frx Menu

- Discussion:
    - timing:
           - Immediate single-leg spica cast for pediatric femoral diaphysis fractures.
    - contraindications:
- unacceptable shortening or angulation;
- open fractures;
- thoracic or intra-abdominal trauma;
- large or obese children (inability for parents to care for child);
- position of spica:
- place affected thigh in 10 deg of abduction or in neutral position w/ opposite hip in moderate abduction to facilitate perineal hygiene;
- to decrease muscle forces & to minimize amount of shortening, place the lower extremity in the relaxed position;
- w/ hip flexion, abduction, external rotation & knee flexion;
- common mistake is to place the fractured thigh in marked abduction w/ resulting lateral bowing due to the pull of strong adductors;
- consider placing the limb in the correct position before application of spica;
- proximal 1/3 frx:
- hip flexion : 45 deg
- hip abduction: 30 deg
- ext rotation: 20 deg
- mid shaft fractures:
- hip flexion: 30 deg
- hip abduction: 20 deg
- ext rotation: 15 deg
- distal 1/3 frx:
- hip flexion: 20 deg
- hip abduction: 20 deg
- ext rotation: 15 deg

- Technique:
- technique pearls: padding:
- place a folded towel on the anterior thorax and abdomen and apply all padding and casting material over this towel;
- following cast application the towel is removed;
- this will create space between the cast and the thorax/abdomen and will avoid cast tightness and difficult w/ breathing;
- using this technique, it is not necessary to window the abdomen of the cast;
- its useful to place 2 layers of body stockingette over the patient's torso to ensure that the cast padding can be pulled up over
the edges of the cast;
- gortex soft wrap is preferable to cotton wrap (gortex can be cleaned if it gets soiled);
- soft wrap (preferably Gortex) is placed, w/ care to evenly spread the cotton across the back and buttochs (including sacrum);
- a thick belt of felt is taped across the chest, just below the nipple line;
- a second felt belt is fashioned to cover the sacrum, PSIS, and ASIS;
- reduction:
- prior to cast application, use flouro to help determine the optimal position for reduction;
- distal femoral traction pin is inserted if fracture needs to be brought out to length;
- apply the cast, but apply minimal cast material around the injured thigh;
- once the cast is hard, bring in flouro and determine if the reduction is adequate;
- if the reduction is not adequate, then circumferentially cut the cast at the level of the frx;
- then re-reduce the fracture under flouroscopic control;
- once the reduction is adequate, have an assistant quickly apply more casting material while the thigh is held in the reduced position;
- cast re-enforcement:
- apply a "broom stick" between the thighs and apply cast material over this, inorder to strengthen the cast and prevent cast
breakdown at the hip joint;

- Cast Care:
- goretex liner allows the child and the cast to be washed;
- a panty shield napkin can be applied to the perineum to prevent soiling of the cast;
- child is seen every 2 weeks for evidence of skin break down