Taking care of a child in a hip spica cast can be a difficult experience for both you and your infant/child. This information sheet will help you care for the spica cast, avoid common mistakes and problems, and decrease overall stress and anxiety.
A spica cast is most often needed in infants with developmental hip dysplasia (DDH) and in infants/young children (<5-6 years) with femur fractures or after hip/pelvis surgery. The length of time that your infant/child needs to be in the cast varies from about six weeks to three months depending on the condition being treated. The actual position of the body and legs in the cast will also vary slightly depending on the reason for the casting. A hip spica cast usually takes 1-2 hours to apply, and is done under anesthesia in the operating room. Your infant/child will typically spend one night in the hospital on the infant/toddler unit at MassGeneral Hospital for Children. This allows us to make sure the cast is comfortable and well tolerated. Additionally, the pediatric orthopaedic team and nurses on the floor can assess your overall level of comfort in managing the cast. If the cast will need to be on for greater than six weeks, the cast will usually need to be changed in the operating room. After a spica cast change, your child will be discharged home from the hospital on the same day (will not be admitted overnight).
Handling the cast may be a bit awkward at first, but you and your infant/child will quickly become accustomed to it. REMEMBER: BE PATIENT, YOU WILL GET THROUGH THIS!!!!
Most spica casts today are made of fiberglass. A fiberglass cast usually dries quickly after it is applied. They are usually completely dry about one hour after applied, and fiberglass casts weigh much less than plaster casts. To avoid skin problems, it is extremely important that the cast be kept as dry and clean as possible. Keeping the cast clean and dry is challenging for all caregivers. To help prevent skin breakdown, the spica cast is lined with a Goretex Pantaloon liner. This helps protect the cast and padding from becoming soiled from moisture.
To prevent skin irritation around the edges, the casts will need to be prepared. This process is called “petaling.” A soft adhesive tape, called moleskin is most commonly used to prepare the cast. Petal shaped strips are cut about 3-5 inches in length and 2-3 inches in width. The are then placed around all the edges of the cast overlapping slightly. The moleskin tape may need to be replaced if it becomes soiled or start to fall off. A colorful fiberglass covering is often added to the casts before your infant/child is taken home.
This is usually the most difficult aspect of caring for an infant/child in a spica body cast. For infants and toddlers, diaper and skin care can often be a challenge.
The general rule of thumb is to keep the infant/child as normal as possible, and the cast as dry as possible!
If urine or bowel movements are allowed to remain in contact with the skin (such as under a wet or soiled diaper or beneath the edges of the cast) diaper rash and subsequent skin breakdown are likely. For infants and toddlers, diapers will need to be changed very frequently (about every 2 hours during the day and every 3-4 hours at night). A smaller diaper or incontinence pad is usually placed under a larger diaper which then goes over the spica cast You should experiment with various pads, newborn preemie diapers, and incontinence pads until you find the right one for your infant/child. Every child's urinary and bowel routines are different. It is generally a good idea to allow the diaper area to be open to air for a few minutes each day. This will decrease the possibility of diaper dermatitis (rashes) and skin irritation.
This is a very common problem with hip spica casts. The diaper area tends to be the most common area of skin irritation/skin breakdown. This is usually caused by moisture from urine/stools that irritates the skin. You should definitely check the skin at least 2-3 times a day for any redness or areas of irritation. Positioning and frequent diaper changes are the key to avoiding the common problem of skin irritation. To assist with positioning, a Bradford frame will be given to you by a cast technician shortly after the spica cast is applied. This frame sits on the bed, and allows gravity to work on our side. Your child will lie on the frame which is higher at the head, and has an opening in the middle. The opening allows for a bedpan to be placed beneath your child to collect urine and stool. The frame should be secured to the bed with straps and side rails should be used. The Bradford frame is helpful in draining urine or stool away from the cast.
It is always MUCH easier to prevent skin irritation/skin sores, than to heal them. If skin redness or irritation is to develop, the general rule of thumb is to allow it to be OPEN TO AIR if possible. It is not a good idea to put lotions, creams, or powders down the cast as this will make the skin condition worse. A hair dryer on a COOL setting (NEVER WARM OR HOT!) at held at least 10-12 inches from the cast will help the damp portion to dry.
If itching is a problem, first try the cool hair dryer and position changes. If your child continues to complain of itching (most common at night), you can give him/her pediatric Benadryl [Diphenhydramine]. Benadryl is an antihistamine that can often help with itching. It is obtained over- the- counter (without a prescription) and the dose will vary based on your child’s weight. Please check with a pharmacist or call the office if you are unsure about what dose to give. In general, the itching will decrease as your child becomes accustomed to the cast. NEVER NEVER stick anything down the cast to scratch the skin!! This will often lead to skin irritation/infection. If you find that your child has put something down his/her cast, you should contact the office to schedule an appointment.
If you are concerned about skin redness or skin irritation, you can always contact our office at (617) 726-8523.
As always, nutrition is very important. There are a few things you can do to help prevent problems associated with being in a cast. Feeding your child fresh fruits, vegetables, and whole grain breads (increasing fiber) will often help prevent constipation. It is also important to drink plenty of water and juices to prevent dehydration. The first few weeks in a spica cast are generally not a good time to introduce new foods in a child's diet. New foods have a higher likelihood of causing loose stools or diarrhea. If this occurs, diaper changes will obviously need to be made more frequently and skin care becomes even more important. If your child complains of a tight feeling in the cast and being full, you may want to try giving smaller, more frequent meals. To prevent food from falling down into the cast while eating, a large shirt or towel should be used to cover the front of the cast.
The hip spica cast will add extra bulk, so larger clothing will often be necessary. Your infant/child will be most comfortable if kept cool. Sweating under the cast can cause itching. He/She may not need much clothing over the spica cast, especially in the summer months. For the majority of patients, a t-shirt, nightshirt, or loose dress may be the only clothes that are needed. In addition, a larger sized one-piece outfit (Onesies) may be used in infants/young toddlers. Young children may want to wear clothes that cover the cast more. Large t-shirts, pants that button up the side, loose dresses, etc can usually be worn over the spica cast. Clothes can also be adapted by cutting the seams as necessary and sewing in Velcro. Again, it is a good idea to experiment with several different types of clothes and see which one works best for you and your child.
You should give your child a sponge bath daily while he/she is in the spica cast. Be very careful NOT to get the cast wet. The skin around the spica cast should be washed with gentle soap and water. Do not put anything under the cast, including lotions, powders, or oils. Lotions can often macerate and soften the skin, making it easier for the skin to break down.
Powders have a tendency to “cake” under the cast, and again lead to further skin irritation. While cleaning the skin daily, it is a good idea to check carefully beneath the case edges for areas of skin irritation, redness, blistering, open areas, or pressure spots. It is often helpful to use a flashlight to look down cast edges for any area of skin irritation.
While in the hospital, you will learn how to turn and position your child. Frequent position changes and turning will often help prevent skin irritation and skin breakdown. The child in the hip spica cast should be positioned frequently, usually about every 2-3 hours during the day. Turn your infant/child on his/her back, sides, and stomach. Keep heels free of pressure by placing a rolled towel or small pillow under to calf of the leg. The child may sit propped up with cushions or pillows. Make sure that your child is secure and cannot roll or fall. Strollers, bean-bag chairs, and wagons can usually be adapted so that your child can play and eat in different positions throughout the day. NEVER leave a child unattended while in any adaptive equipment.
Small children can often be pulled in a wagon, while older children will often find a reclining wheelchair most comfortable. It is important to provide activities for your child throughout the day. To allow for some independence, place things within easy reach so your child can get them safely. Bringing the child for walks or into an area with the family will help avoid isolation. To provide comfort, you should be encouraged to hold infants and small children when possible. Your child can do anything that does include standing or walking and that does not wet or break the cast. Do not allow your child to play with small toys that can get lodged inside the cast.
It is often possible for your infant/child to fit into their regular car seat in a spica cast. If he/she is not about to fit into the regular car seat, there are several Spelcast car seats that are designed especially for infants/toddlers in a spica cast. These seats are installed just like a regular car seat, rear facing for infants under 20lbs, then front-facing up until approximately 35-40lbs. The Spelcast car seat is more upright and is available for loan through the pediatric orthopaedic clinic. The infant and or toddler can often fit into their regular seat or a toddler with some adjustments.
You can always reach us with questions or problems related to your child's spica cast. You can call us at (617) 726-8523 during regular business hours (Monday-Friday 8am: 4:30pm). You can also reach the orthopaedic resident on call at (617) 726-2000 [page operator].
We will often schedule a follow-up visit about two weeks after the spica cast is applied.
Any breaks or blisters of the skin under the cast or around cast edges
Toes are pale or blue in color and/or feel cold. If child is unable to wiggle toes, but was able to do so before the cast was applied. If child complains of tingling or numbness or toes
The infant/child has a persistent fever over 101F which cannot be explained by a cold, ear infection, or other viral illness
Any softening, breaks, or cracks in the cast
Prolonged, unexplainable fussiness or irritability
There is drainage you have not seen before or if there is an unpleasant or foul odor coming from the cast
Your child has new pain that does not get better with Tylenol or Motrin or with the comfort measures explained above (position changes, etc)
Something falls into the cast and gets stuck.
Erin S. Hart, RN, MS, CPNP
Maurice Albright, M.D.
Brian Grottkau, M.D.