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Hip Spica Cast


- 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




     - references:
            - Modified functional bracing in the ambulatory treatment of femoral shaft fractures in children. 
            - Functional fracture-bracing of long-bone fractures of the lower extremity in children. 
            - Long-term results in the treatment of femoral-shaft fractures in young children by immediate spica immobilization. 
            - Improved treatment of femoral shaft fractures in children. The "pontoon" 90-90 spica cast. 
            - Early spica cast management of femoral shaft fractures in young children. A technique utilizing bilateral fixed skin traction 
            - Immediate spica cast system for femoral shaft fractures in infants and children.
            - Rotational deformity and remodeling after fracture of the femur in children.   
            - Incidence of skin complications and associated charges in children treated with hip spica casts for femur fractures.
            - Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children.
            - Single-Leg Spica Cast Application for Treatment of Pediatric Femoral Fracture

Improved treatment of femoral shaft fractures in children. The "pontoon" 90-90 spica cast.

Long-term results in the treatment of femoral-shaft fractures in young children by immediate spica immobilization.

Spica Casting for Pediatric Femoral Fractures: A Prospective, Randomized Controlled Study of Single-Leg Versus Double-Leg Spica Casts.

Immediate spica cast system for femoral shaft fractures in infants and children.