import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Between medial thighs at inferior aspect of spica cast **Protection**: Waterproof barrier tape extending 2-3cm onto cast edges, generous opening (two fingers width), petaling with moleskin, Gore-Tex liner optional. Cut adequate hole in stockinette before padding application. **Location**: Anterior trunk from xiphoid to pubis **Protection**: Body jacket starts at nipple line (allows chest expansion), avoid tight circumferential wrapping, ensure two-finger space between cast and abdomen at completion, gentle molding only. Monitor for SMA syndrome (vomiting, feeding intolerance). **Location**: ASIS bilaterally, iliac crests, sacrum, greater trochanters, tibial crests, heels if included **Protection**: 2-3 layers of padding over ALL bony prominences before cast application, smooth stockinette without wrinkles, position changes every 2-3 hours post-application, use pillows to prevent flat posterior surface. **Location**: Posterior knee at junction of femoral and tibial components **Protection**: Avoid hyperflexion >90° at knee, maintain 30-40° knee flexion for femur fractures, extra padding in popliteal fossa, check distal pulses and capillary refill immediately post-application and at 6-12-24 hours. **Location**: Medial femoral circumflex artery supplying femoral head epiphysis **Protection**: DDH human position with 40-50° abduction (NOT >60° frog position), confirm femoral pulses present bilaterally after positioning, test safe zone by gentle adduction without redislocation, avoid excessive hip flexion >110° (femoral nerve compression). ### Primary Indications **Femoral Shaft Fractures Age <5 Years** - Gold standard non-operative treatment for age 6 months to 5 years - Immediate spica technique: one-and-a-half spica applied under general anaesthesia - Avoids surgical risks (physeal injury, infection, neurovascular complications) - Excellent remodeling potential in young children - Length-stable or minimally displaced fractures ideal - Polytrauma or head injury may favour surgical fixation for nursing ease **Developmental Dysplasia of Hip (DDH) Post-Reduction** - Bilateral spica in human position after closed or open reduction - Maintains hip position during acetabular development and labral healing - Standard duration 12 weeks (some protocols use 6 weeks then abduction brace) - Applied immediately post-reduction in OR **Post-Operative Immobilization** - After femoral or pelvic osteotomies (Salter, Pemberton, Dega, femoral varus/derotation) - After open reduction of DDH with or without concurrent osteotomy - After proximal femur fracture surgery in young children requiring additional support - Duration varies per procedure (typically 6-12 weeks) **Other Indications (Less Common)** - Selected tibial fractures in very young children requiring hip immobilization for compliance - Pelvic fractures in young children requiring immobilization (rare) - Post-operative hip procedures (psoas release, adductor release) when immobilization desired ### Contraindications **Absolute** - Significant abdominal trauma or acute abdomen (risk of compartment syndrome) - Active abdominal infection or peritonitis - Significant respiratory compromise or underlying severe lung disease - Open fracture with ongoing wound management requirements - Severe swelling at fracture site within first 24-48 hours (compartment syndrome risk) **Relative** - Age >5 years for femur fracture (surgical fixation often preferred) - Morbid obesity (cast application technically difficult, skin breakdown risk) - Poor family support or social concerns (inability to manage spica at home) - Multiple injuries requiring ongoing access for wound care - Neuromuscular conditions with respiratory compromise risk ### Patient Assessment **Clinical Evaluation** - Age, weight, skeletal maturity assessment - Injury mechanism and associated injuries - Fracture pattern: location, displacement, stability, comminution - Neurovascular status documented - Skin condition at fracture site and potential cast contact areas - DDH: confirm hip reducible, assess for teratologic dislocation **Radiographic Evaluation** - AP and lateral radiographs of femur (include hip and knee joints) - DDH: AP pelvis, frog lateral, ultrasound or arthrogram in OR to confirm concentricity - Assess fracture pattern and displacement - Identify other injuries (floating knee, ipsilateral femoral neck fracture) **Family Assessment** - Home environment: stairs, bathroom access, sleeping arrangements - Caregiver capability: physical ability to lift and position child in spica - Transportation: specialized car seat required (E-Z-On vest or similar) - Support system: single parent vs multiple caregivers - Understanding and compliance with care requirements ### Consent Discussion **Procedure Details** - General anaesthesia required for fracture reduction and comfortable application - Duration of immobilization: 6-12 weeks for fracture, 12 weeks for DDH - Hospital stay: observation 4-24 hours, most go home same day if stable and family capable - Follow-up schedule: 1 week, then every 2-3 weeks until removal **Home Care Requirements** - Positioning: change every 2-3 hours to prevent pressure sores - Hygiene: waterproofing for diaper changes, plastic wrap tucking during bowel movements - Transportation: specialized car seat legally required, cannot use standard seat - Feeding: upright or semi-reclined, smaller frequent meals if early satiety - Activity: floor play encouraged, never leave prone unsupervised (suffocation risk) **Complications Discussed** - Pressure sores (5-15%): most common, occurs at bony prominences - Perineal skin breakdown (10-20%): from urine/stool despite waterproofing - Superior mesenteric artery syndrome (1-3%): vomiting, feeding intolerance, requires cast removal - Compartment syndrome (<1%): first 48 hours critical monitoring period - Loss of reduction (5-10%): may require cast change or surgical fixation - Cast breakage (5-10%): at junctions, requires reinforcement or change - AVN for DDH (5-10% with human position, 15-20% with frog position) ### Theatre Setup **Equipment Required** - Spica table with perineal post (or flat table with assistant support) - General anaesthesia with neuromuscular blockade for fracture reduction - Fluoroscopy (C-arm) for fracture reduction confirmation - Stockinette rolls: 6-inch and 4-inch widths - Padding: cast padding or ortho-wool, waterproof barrier material - Cast material: fibreglass (lighter, waterproof) or plaster (cheaper, better molding) - 4-inch and 6-inch rolls, estimate 8-12 rolls total - Waterproof tape, moleskin or petaling material - Cast scissors, spreaders, gloves, water buckets - Pillows for support during setting **Team Requirements** - Surgeon or experienced orthopaedic trainee - Assistant to maintain reduction and support limbs during application - Anaesthetist - Scrub nurse/technician to prepare materials and assist - Radiographer for fluoroscopy ### Classification by Extent **Single Leg Spica** - Body jacket with one leg included to ankle or toes - Rarely used due to inadequate rotational control - Historical use for stable proximal femur injuries - Generally abandoned in favour of one-and-a-half or bilateral **One-and-a-Half Spica** - Gold standard for femoral shaft fractures in children <5 years - Affected leg: body jacket to toes - Unaffected leg: body jacket to above knee (stops 2-3 finger widths above patella) - Provides rotational control while allowing unaffected knee flexion for sitting - Cross-bar between thighs for rigidity - Allows some mobility: can sit in specialized car seat, floor play **Bilateral Spica** - Standard for DDH post-reduction - Both legs included to above knees or ankles depending on protocol - Maintains hip position (human position: 90-110° flexion, 40-50° abduction) - Cross-bar between legs - Also used post-operatively after bilateral procedures or when maximum stability desired - More restrictive: difficult toileting, positioning, but superior stability ### Position Variations **Neutral Position (Femur Fractures)** - Hip flexion 30-40° for comfort and fracture stability - Knee flexion 30-40° for comfort - Neutral or slight internal rotation (avoid external rotation - displaces fracture) - Slight hip abduction 10-20° (natural position) **Human Position (DDH)** - Hip flexion 90-110° (safe range, >110° risks femoral nerve palsy) - Hip abduction 40-50° (CRITICAL: not >60° which is frog position with high AVN) - Internal rotation 10-20° (stable position) - Knee flexion 90° or extended depending on protocol - Based on Ramsey et al studies showing reduced AVN vs historical frog position **Frog Position (OBSOLETE - Historical Only)** - Extreme hip abduction >60° (often 70-90°) - Used historically for DDH 1950s-1980s - AVN rate 15-20% due to medial femoral circumflex artery compression - Replaced by human position which reduces AVN to 5-10% - Still mentioned in FRCS exams as historical error to avoid ### Femoral Shaft Fractures by Age **Under 6 Months** - Pavlik harness for proximal third fractures - Immediate spica for middle or distal third - Minimal displacement acceptable (remodels completely) - Very low non-union risk **6 Months to 5 Years** - IMMEDIATE SPICA is gold standard - One-and-a-half spica technique - General anaesthesia, closed reduction, cast application - Excellent remodeling potential - Accept: <30° anterior angulation, <20° varus/valgus, 2-3cm shortening - Zero acceptance for rotational malalignment - Union by 6-8 weeks typically **5 to 11 Years** - Surgical fixation preferred: elastic stable intramedullary nailing (ESIN/TEN) - Spica alternative for: family preference, length-stable fractures, contraindication to surgery - Remodeling still good but diminishing with age - Accept less angulation: <20° anterior, <15° varus/valgus, <2cm shortening **Over 11 Years (Approaching Skeletal Maturity)** - Surgical fixation standard: submuscular plating or intramedullary nailing - Spica rarely used due to size/weight, poor compliance, diminished remodeling - Adult alignment criteria apply ### Exceptions to Algorithm - Polytrauma: often favour surgery for nursing ease, mobilization - Head injury: may favour surgery to avoid cast complications with impaired consciousness - Floating knee: surgical fixation typically required - Pathologic fracture: depends on underlying condition - Social concerns: inadequate home support may favour admission with surgical fixation ### Key Studies **Immediate Spica vs Traction Then Spica** - Historical comparison: immediate spica replaced traction-then-spica protocol in 1980s-1990s - Reduction in hospital stay from 3-4 weeks to 1 day - No difference in union rates, alignment outcomes, or complications - Cost savings significant - Flynn et al (1995 JBJS): immediate spica safe and effective, now standard of care **Acceptable Alignment and Remodeling** - Accepted angulation based on age and remodeling potential - Sanders et al (2001 JBJS): children <10 years remodel 20-30° in plane of hip motion - Anterior angulation remodels best (sagittal plane = hip motion) - Varus/valgus remodels less but still acceptable to 15-20° in young children - Rotation does NOT remodel - must be anatomic - Overgrowth averages 1.5-2cm, compensates for shortening **DDH Human Position vs Frog Position** - Ramsey et al (1976): identified safe zone for DDH hip position - Frog position (extreme abduction >60°) associated with AVN 15-20% - Human position (moderate abduction 40-50°) reduces AVN to 5-10% - Suzuki et al (1990s studies): confirmed vascular compromise with extreme abduction - Modern protocols universally adopt human position **Complications and Prevention** - Pressure sores: O'Brien et al - position changes every 2-3 hours critical - SMA syndrome: 1-3% incidence, requires cast removal, from tight anterior compression - Compartment syndrome: rare <1% but devastating, monitor first 48 hours critical - Cast breakage: reinforcement at body-leg junction reduces from 15% to 5% ### Australian Context **Medicare MBS Items** - Item 47927: Application of hip spica cast - Includes general anaesthesia, fracture reduction if required, cast application - Follow-up consultations under general consultation items **eTG Recommendations** - No specific antibiotic prophylaxis for closed fracture spica application - If post-operative (open reduction, osteotomy): follow surgical prophylaxis protocols - Skin breakdown if occurs: swab for culture, treat based on organisms (often Staphylococcus or Streptococcus) ### Step 1: Indication Assessment and Spica Type Selection **Decision Making** Determine indication: (1) FEMUR FRACTURE <5 years: one-and-a-half spica standard. (2) DDH POST-REDUCTION: bilateral spica, human position (hip flexion 90-110°, abduction 40-50°, internal rotation 10-20°). (3) POST-OPERATIVE (osteotomies, open reduction): as per surgeon preference, typically bilateral spica. Select spica type: SINGLE LEG (rarely used - unstable). ONE-AND-A-HALF (standard for femur fracture - affected leg to toes, unaffected to above knee). BILATERAL (DDH, post-op - both legs included to knees or ankles). Review x-rays to confirm fracture pattern, displacement, and need for reduction. For DDH, review arthrogram or ultrasound to confirm hip reducible and concentric reduction achievable. **FRCS Viva Tip**: "For femur fracture in children under 5 years, ONE-AND-A-HALF spica is gold standard - immobilizes affected leg to toes, includes opposite leg to above knee for rotational control while allowing some mobility. For DDH, I use BILATERAL spica in HUMAN POSITION: 90-110° hip flexion, 40-50° abduction, 10-20° internal rotation. This reduces AVN risk to 5-10% compared to historical frog position with 15-20% AVN. Excessive abduction >60° stretches medial femoral circumflex artery." - Wrong spica type for indication leads to loss of reduction or inadequate immobilization - DDH: excessive abduction >60° (frog position) dramatically increases AVN risk to 15-20% - Single leg spica inadequate for fracture - allows rotation and displacement - Failing to review imaging before proceeding may miss contraindications ### Step 2: Pre-Application Planning and Consent **Patient Assessment** Assess patient: age, weight, fracture alignment or hip position required, associated injuries, family support capability. Plan admission vs same-day discharge based on family capability and patient stability. **Consent Discussion** (1) Duration typically 6-12 weeks for fracture (younger heals faster), 12 weeks for DDH. (2) Home care requirements: toileting management, bathing restrictions, specialized positioning, car seat requirement. (3) Complications: skin breakdown 5-15%, cast soiling 10-20%, loss of reduction 5-10%, compartment syndrome <1%, SMA syndrome 1-3%. (4) Hospital observation 4-24 hours then home if stable and family capable. (5) Follow-up schedule: 1 week mandatory, then every 2-3 weeks until removal. Plan general anaesthesia with neuromuscular blockade for fracture reduction and comfortable cast application. Ensure family has arranged specialized car seat (E-Z-On vest or similar) for transportation home. **FRCS Viva Tip**: "Before applying spica, I ensure comprehensive family education. Spica demands significant home care: specialized car seat legally required, waterproofing for all diaper changes, position changes every 2-3 hours to prevent pressure sores. I assess family support and home environment. Most femur fractures in children under 5 can go home same-day if family capable and child stable. DDH typically admits overnight for observation post-reduction." - Inadequate family education leads to re-presentation with pressure sores or cast soiling - Sending home without appropriate support risks cast failure or child safety issues - Lack of specialized car seat is illegal and unsafe - must arrange before discharge - Failing to warn about SMA syndrome leads to delayed recognition ### Step 3: Positioning and Setup on Spica Table **Theatre Setup** Under general anaesthesia with neuromuscular blockade, position child SUPINE on spica table. Perineal post well-padded with foam in crotch (supports pelvis during application, prevents sagging). Upper body on padded support with slight head elevation. Arms free, accessible for anaesthesia monitoring. Organize all supplies within arm's reach before starting: stockinette (6-inch and 4-inch rolls), padding (cast padding or ortho-wool), waterproof barrier material (plastic sheeting, Gore-Tex), fibreglass or plaster rolls (4-inch and 6-inch, estimate 8-12 rolls total), water buckets, waterproof tape, moleskin for petaling, cast scissors, spreaders, gloves. Assistant positioned to support legs and maintain alignment during application. Alternative if no spica table: flat table with assistant supporting pelvis manually throughout procedure (more challenging but feasible). **FRCS Viva Tip**: "Spica table with padded perineal post is ideal but not essential - I have successfully used flat table with experienced assistant supporting pelvis throughout. General anaesthesia essential for fracture reduction and comfortable application without movement. I have all supplies organized and within reach before starting - this is a multi-person team effort requiring coordination. Running out of materials mid-application compromises cast quality." - Perineal post injury if poorly padded - causes perineal bruising or skin breakdown - Loss of reduction during cast application without adequate assistant support - Running out of supplies mid-application forces stopping and restarting, compromises cast integrity - Starting without fluoroscopy available for fracture cases ### Step 4: Fracture Reduction for Femur Fractures **Reduction Technique** For FEMUR FRACTURE: Apply longitudinal traction on affected leg (assistant or surgeon pulls from ankle while stabilizing thigh). Correct angulation: typically apex anterior or lateral from muscle pull. Assess rotation: patella should point directly forward when knee at 90° flexion - compare to unaffected side. Use fluoroscopy to confirm reduction AP and lateral views. **Acceptable Alignment** ACCEPT: less than 30° anterior angulation (plane of hip motion, remodels well), less than 20° varus or valgus angulation, up to 2-3cm shortening (overgrowth compensates average 1.5-2cm). ZERO tolerance for rotational deformity - rotation does NOT remodel and causes permanent functional deficit. **Final Position for Casting** Position: hip flexed 30-40° (comfortable, stable for fracture), knee flexed 30-40° (comfortable), neutral rotation (patella forward). Opposite leg: abducted slightly 10-20°, knee extended or flexed 45° for one-and-a-half spica. Confirm position and reduction on fluoroscopy before proceeding with cast application. **FRCS Viva Tip**: "For femur fracture in children under 5 years, remodeling potential is excellent. I accept up to 30° anterior angulation, 20° varus/valgus, and 2-3cm shortening - all remodel over 12-24 months. However, rotation must be anatomic - rotational deformity does NOT remodel at any age. I confirm patella pointing forward with knee flexed, compare to opposite side. Position: hip and knee flexed 30-40° for comfort and stability. Confirm with fluoroscopy AP and lateral before casting." - Over-accepting angulation >30-40° may exceed remodeling capacity especially approaching age 5 - Rotational malreduction causes long-term functional deficit: in-toeing or out-toeing gait - Hyperflexion >90° at hip or knee risks vascular compromise (popliteal vessels, femoral vessels) - Failing to confirm reduction on fluoroscopy before casting - alignment lost during application ### Step 5: DDH Position - Human Position **Hip Position for DDH** For DDH POST-REDUCTION (after closed or open reduction): HUMAN POSITION critical to minimize AVN risk. (1) Hip flexion 90-110° (not >110° - stretches femoral nerve, causes palsy). (2) Hip abduction 40-50° (CRITICAL: NOT >60° - excessive abduction stretches medial femoral circumflex artery, increases AVN from 5-10% to 15-20%). (3) Internal rotation 10-20° (stable position). (4) Knee flexion 90° or extended depending on surgeon preference. **Confirmation of Reduction and Safety** Confirm hip REDUCED on fluoroscopy or clinical exam: stable to gentle adduction (safe zone test), no telescoping with axial load. Palpate femoral pulses bilaterally - loss indicates vascular compromise requiring immediate repositioning. Check femoral nerve function if possible (quadriceps contraction to stimulus). **Safe Zone Testing** Ramsey safe zone: gentle adduction should NOT cause re-dislocation. Excessive abduction beyond safe zone increases AVN without improving stability. Modern protocols aim for minimal safe abduction. **FRCS Viva Tip**: "DDH human position is critical: 90-110° flexion, 40-50° abduction, 10-20° internal rotation. I avoid the historical FROG position with extreme abduction >60° - this was standard until 1980s-1990s but had unacceptably high AVN rate 15-20% from medial femoral circumflex artery compression. Modern human position with moderate abduction reduces AVN to 5-10%. I confirm hip reduced, palpate femoral pulses bilaterally, and test safe zone by gentle adduction without re-dislocation." - Excessive abduction >60° (frog position): AVN risk increases to 15-20%, unacceptable - Inadequate reduction or unstable position allows re-dislocation in cast - Loss of femoral pulse indicates vascular compromise: requires immediate repositioning before casting - Hyperflexion >110° risks femoral nerve palsy from stretch injury ### Step 6: Stockinette and Padding Application **Stockinette Layer** Apply STOCKINETTE as smooth inner layer: Start at nipple line, extend over trunk and down both legs to toes (or to knees for one-and-a-half spica). Cut generous hole for perineum and genitalia - opening should be larger than expected (will trim later for exact fit). Smooth out all wrinkles carefully - wrinkles create pressure points and skin breakdown. **Padding Layer** Apply PADDING (cast padding or ortho-wool) over stockinette: (1) 2-3 layers circumferentially over ALL bony prominences: ASIS bilaterally, iliac crests, sacrum, greater trochanters, tibial crests. (2) Wrap circumferentially around trunk and limbs with 50% overlap, smooth and even. (3) Extra padding at groin creases, under knees in popliteal fossa, around perineum. (4) Total thickness: thin enough for adequate immobilization, thick enough for skin protection. **Waterproof Barrier** Apply WATERPROOF barrier at perineum: plastic sheeting, Gore-Tex liner, or waterproof tape creating barrier between skin and cast. This is essential - soiling from urine and stool inevitable, waterproofing prevents cast breakdown and skin maceration. Extend barrier 2-3cm beyond perineal opening onto padding. **FRCS Viva Tip**: "Stockinette provides smooth inner layer preventing skin irritation. Padding is critical - I apply 2-3 layers over ALL bony prominences without exception. Most pressure sores occur at ASIS, iliac crest, and sacrum within 24-48 hours if padding inadequate. Waterproof barrier at perineum is essential - I use waterproof tape or Gore-Tex liner extending 2-3cm onto padding. Soiling from urine and stool is inevitable, barrier prevents cast breakdown and skin maceration." - Inadequate padding over bony prominences: pressure sores develop within 24-48 hours - Wrinkles in stockinette or padding create focal pressure points and skin breakdown - Insufficient waterproof barrier: perineal skin breakdown occurs in 10-20% without protection - Perineal opening cut too small: cannot be enlarged later, requires cast removal and reapplication ### Step 7: Body Jacket Application - First Layer **Trunk Component** Begin with 4-6 layers of fibreglass or plaster around TRUNK. Start at nipple line anteriorly (allows chest expansion for breathing), extend to just above iliac crests posteriorly and to pubic symphysis anteriorly. Apply circumferentially but NOT tight - allow for abdominal expansion, breathing, feeding. **Molding and Shaping** MOLD gently around abdomen and back with palms (not fingers - prevents indentations). Ensure perineal opening adequate: should accommodate two fingers width for expansion, access for hygiene, and diaper changes. Trim excess material around perineal opening with cast scissors while still wet. **Avoid Over-Tightening** DO NOT make circumferential compression too tight. Children breathe abdominally, need room for chest and abdominal expansion. Tight anterior compression risks superior mesenteric artery syndrome (SMA syndrome) from duodenal compression between SMA and aorta - presents as vomiting, feeding intolerance. **FRCS Viva Tip**: "Body jacket extends from nipple line to pubis anteriorly, slightly lower posteriorly. I ensure adequate room for breathing and abdominal expansion - children breathe abdominally unlike adults. Perineal opening must be generous - I confirm two fingers width minimum. Too tight jacket causes superior mesenteric artery syndrome (SMA syndrome) from duodenal compression: presents 24-72 hours post-application with vomiting, inability to feed, requires cast removal." - Tight jacket restricts breathing: respiratory distress especially in infants or underlying lung disease - SMA syndrome from tight anterior compression: 1-3% incidence, requires cast removal - Perineal opening too small: prevents adequate hygiene access, requires cast removal - Starting too high on trunk: restricts shoulder and arm movement ### Step 8: Affected Leg Application - Femur Fracture **Leg Component for Fracture** For ONE-AND-A-HALF SPICA (femur fracture): Apply fibreglass or plaster to affected leg from groin to toes, incorporating into body jacket at groin. Maintain reduction with gentle traction and molding during application - assistant holds position while surgeon applies cast. 4-6 layers circumferentially. **Molding at Fracture Site** Three-point molding at fracture site: apply pressure opposite the apex of angulation. If apex anterior angulation, apply pressure anteriorly above and below fracture, posteriorly at fracture. Gentle molding only - excessive pressure causes skin injury. **Distal Extent** Extend to toes but leave toes exposed (metatarsal heads visible) for neurovascular monitoring. At knee: avoid hyperflexion, maintain 30-40° flexion, keep popliteal fossa accessible. Check reduction on fluoroscopy during and after leg component application. **FRCS Viva Tip**: "Affected leg extends from hip to toes in femur fracture. I maintain reduction throughout application with gentle traction and three-point molding at fracture site. Hip 30-40° flexion, knee 30-40° flexion for comfort and stability. Toes MUST be visible for neurovascular checks - this is critical for compartment syndrome surveillance. I check circulation immediately after cast sets: capillary refill <2 seconds all toes, warm pink toes." - Loss of reduction during cast application: check frequently on fluoroscopy, maintain traction - Covering toes prevents circulation monitoring: compartment syndrome missed - Hyperflexion >90° at knee compresses popliteal vessels: vascular compromise - Inadequate molding at fracture: loss of reduction in cast within days to weeks ### Step 9: Unaffected Leg Application - One-and-a-Half Spica **Opposite Leg for Rotational Control** For ONE-AND-A-HALF: Apply cast to unaffected leg from groin to ABOVE KNEE only (stops 2-3 finger widths above superior pole of patella). This provides rotational control for femur fracture while allowing knee flexion for sitting, mobility, and easier toileting. 4-6 layers circumferentially. **Connection to Body Jacket** Connect unaffected leg component firmly to body jacket at groin. Apply extra layers at junction for reinforcement. This junction is high-stress area and breaks without reinforcement. **Bilateral Spica Variation** For BILATERAL spica (DDH or post-operative): both legs included to above knees or to ankles depending on protocol and surgeon preference. Maintain human position for DDH: both hips in 40-50° abduction, 90-110° flexion. **FRCS Viva Tip**: "One-and-a-half spica: unaffected leg extends to above knee only - this allows knee flexion for sitting and some mobility while providing rotational control. I confirm cast stops 2-3 finger widths above patella - extending further unnecessarily restricts mobility. For DDH bilateral spica, both legs included with hips maintained in human position: 40-50° abduction, 90-110° flexion. I will add cross-bar between thighs in next step for rigidity." - Extending unaffected leg to toes: unnecessarily restricts mobility, not standard for one-and-a-half - Inadequate connection to body jacket: allows rotation and loss of fracture reduction - Too much abduction between legs: difficult for diaper changes, perineal hygiene - Stopping below knee: inadequate rotational control ### Step 10: Cross-Bar and Reinforcement **Cross-Bar (Spreader Bar) Creation** Create CROSS-BAR between thighs for structural rigidity: use additional plaster or fibreglass rolls to connect medial aspects of both leg components. Apply 3-4 layers creating solid bar. This prevents scissoring, maintains leg position, and provides handle for safe turning and positioning of child. **High-Stress Area Reinforcement** REINFORCE critical junctions with 2-3 extra layers: (1) Body jacket to leg junction at groin bilaterally (highest stress area, most common breakage site). (2) Cross-bar connections to legs. (3) Posterior trunk from sacrum to mid-back (prevents breaking when child sits). Apply extra layers circumferentially at these areas. **Width of Cross-Bar** Cross-bar width: adequate for rigidity and handle but NOT too wide - excessive width prevents adequate perineal access for diaper changes and hygiene. Typically 8-12cm between medial thigh components. **FRCS Viva Tip**: "Cross-bar between thighs is essential for spica rigidity and provides safe handle for positioning child. I reinforce all junctions heavily - body-to-leg junction at groin is highest stress area and frequently breaks without 2-3 extra layers of reinforcement. Posterior trunk reinforcement critical for sitting. Cross-bar width: adequate for rigidity but not so wide that perineal access for hygiene is compromised." - Weak cross-bar: breaks during handling or positioning - Inadequate reinforcement at junctions: cast failure at body-leg junction within 1-2 weeks - Cross-bar too wide: prevents adequate perineal access, hygiene impossible - No cross-bar: spica unstable, allows rotation, loss of reduction ### Step 11: Molding and Shaping While Setting **Active Molding During Setting** While cast is setting (still pliable, first 5-10 minutes): MOLD key areas with palms not fingers. (1) LATERAL thigh at fracture site: three-point fixation as described above. (2) Abdomen gently for comfort (NOT too tight - allow expansion). (3) Gluteal area to prevent posterior sag and improve contour. (4) Smooth all edges especially perineum, groin, trunk edges. **Support During Setting** Support cast on pillows during setting phase - do NOT place child on flat surface which flattens posterior aspect. Use pillows under back, thighs, calves to maintain contour. Flat posterior surface creates discomfort and increases sacral pressure sore risk. **Avoid Indentations** Use palms for broad pressure distribution, NOT fingers which create indentations. Finger indentations become pressure points causing pain and potential skin breakdown. **FRCS Viva Tip**: "Molding is critical for fracture control and patient comfort. Three-point molding at fracture: gentle pressure opposite the apex. I support cast on pillows while setting to maintain anatomic contour - placing on flat surface flattens posterior creating uncomfortable flat back and increases sacral pressure sore risk. Use palms for broad pressure, never point pressure with fingers which create indentations and pressure points." - Finger indentations: create pressure points causing pain and skin breakdown - Inadequate molding: allows fracture displacement in cast within days - Placing on flat surface during setting: creates flat posterior, uncomfortable, increases sacral pressure sore risk - Over-molding: excessive pressure causes skin injury or compartment syndrome ### Step 12: Edge Finishing and Perineal Protection **Edge Trimming** Once cast semi-set (still slightly pliable, 10-15 minutes): trim and smooth all edges with cast scissors. (1) Perineal opening: trim to adequate size (two fingers width), smooth edges, remove any sharp points. (2) Upper trunk: trim to comfortable level allowing arm movement and breathing. (3) Leg distally: trim around toes leaving metatarsal heads visible, smooth edges. (4) Unaffected leg: trim at appropriate level above knee, smooth. **Petaling Edges** Apply PETALING to all edges using waterproof tape or moleskin: fold over cast edge creating smooth finished edge. This prevents skin irritation from sharp cast edges and provides finished appearance. **Waterproof Sealing of Perineum** Apply WATERPROOF tape circumferentially around entire perineal opening extending 2-3cm onto cast surface. This creates waterproof seal preventing urine and stool infiltration which dissolves plaster and causes skin maceration. Some surgeons use Gore-Tex or similar waterproof liner for superior protection. **FRCS Viva Tip**: "Edge finishing is critical for skin protection. I petal all edges with waterproof tape or moleskin creating smooth finished edges. Perineal opening gets special attention: waterproof tape extending 2-3cm onto cast creates barrier preventing urine and stool infiltration. Without this, cast breaks down from soiling within days and skin maceration occurs. Some use Gore-Tex liner for superior waterproofing especially for younger children in diapers." - Sharp edges: cause skin breakdown within hours of application - Inadequate waterproofing: cast breakdown from soiling within days - Perineal opening too small: hygiene impossible, requires cast removal and reapplication - Perineal opening too large: exposes trunk, loses fracture control, uncomfortable ### Step 13: Immediate Post-Application Assessment **Neurovascular Examination** BEFORE patient wakes from anaesthesia perform thorough assessment: (1) Check CIRCULATION: capillary refill in all toes bilaterally, compare to pre-cast baseline, should be less than 2 seconds. (2) Palpate dorsalis pedis and posterior tibial pulses if possible through cast or at exposed areas. (3) Check cast not excessively tight: attempt to slide finger under cast edges at groin and trunk, should have small amount of space. (4) Document neurovascular exam in notes. **Radiographic Confirmation** Final x-rays (AP and lateral) to confirm fracture alignment maintained through casting process. For DDH, confirm hip remains reduced and in appropriate position. Compare to pre-casting films. **Perineal Access Check** Confirm perineal opening adequate for hygiene and diaper changes: two fingers should fit comfortably. If inadequate, trim further while cast still slightly pliable. **FRCS Viva Tip**: "Immediate neurovascular check is mandatory before patient leaves operating theatre - I document capillary refill in all toes less than 2 seconds bilaterally. Final x-rays confirm alignment maintained through casting process - occasional loss of reduction requires immediate cast removal and reapplication. If any vascular concern (prolonged capillary refill, loss of pulse, cool toes), I split or remove cast immediately - never observe vascular compromise in cast." - Compartment syndrome from tight cast: monitor first 24-48 hours critical period - Vascular compromise: requires immediate cast removal, never observe - Loss of reduction during application: requires cast change or surgical fixation - Cast too loose: allows rotation and displacement, inadequate immobilization - Inadequate documentation: medicolegal risk if complications develop ### Step 14: Post-Spica Care Instructions and Discharge Planning **Family Education - Skin Care** Comprehensive FAMILY EDUCATION before discharge: (1) SKIN CHECKS: inspect skin at all cast edges twice daily, look for redness, breakdown, odor, swelling. Use flashlight to look inside cast edges. (2) Position changes every 2-3 hours: rotate between supine, right side, left side, semi-reclined. NEVER leave prone unsupervised (suffocation risk in young infants). Use pillows for support in each position. **Neurovascular Monitoring** (3) NEUROVASCULAR checks: examine toes twice daily for color (pink), warmth (compare to hands), capillary refill (less than 2 seconds), movement (wiggle toes). Red flags: blue/purple discoloration, cold toes, no capillary refill, severe pain - these require immediate emergency department presentation. **Hygiene Management** (4) HYGIENE: waterproof diaper positioning under cast opening, tuck plastic wrap under cast edges during all bowel movements to prevent infiltration. Clean perineal area gently with mild soap and water, dry thoroughly. Change diapers frequently to minimize soiling exposure. **Transportation and Positioning** (5) TRANSPORTATION: specialized car seat required for spica (E-Z-On vest, Britax Hippo, or custom car bed for bilateral spica). Standard car seats cannot accommodate spica safely or legally. (6) FEEDING: position upright or 45° reclined for feeding, smaller frequent meals if early satiety from abdominal compression. Burp frequently. **Warning Signs** (7) WARNING SIGNS requiring urgent medical attention: foul odor from cast (suggests skin breakdown or infection), fever >38.5°C (infection), excessive pain not controlled with simple analgesia, toe discoloration blue/purple/white (vascular compromise), cast loose or cracked (loss of immobilization), persistent vomiting or inability to feed (SMA syndrome), swelling at cast edges (too tight). **Follow-Up Schedule** Follow-up appointments: 1 week (mandatory skin check, x-ray confirm alignment maintained), then every 2-3 weeks until removal. Total duration: 6-12 weeks for femur fracture (younger children heal faster), 12 weeks standard for DDH. **FRCS Viva Tip**: "Family education is extensive and critical. Key safety points: position changes every 2-3 hours prevent pressure sores which develop within 24-48 hours without repositioning. Waterproof all cast edges with plastic wrap before every diaper change. Specialized car seat required by law - E-Z-On vest most common. Red flags: foul odor suggests skin breakdown or infection requiring urgent cast removal and examination. Persistent vomiting suggests SMA syndrome requiring immediate cast removal. Follow-up at 1 week mandatory - check skin and confirm alignment maintained." - Pressure sores develop within 24-48 hours without frequent position changes - Soiling without plastic wrap: causes cast breakdown and skin maceration within days - Inadequate car seat: unsafe and illegal, child at risk in motor vehicle accident - Superior mesenteric artery syndrome: presents with vomiting, unable to feed, requires immediate cast removal - Missed compartment syndrome in first 48 hours: leads to catastrophic outcome (muscle necrosis, Volkmann contracture) ### Step 15: Spica Removal **Timing of Removal** After 6-12 weeks for fracture (confirm healing on x-ray: bridging callus on 3 of 4 cortices), 12 weeks for DDH (acetabular remodeling requires time). X-rays mandatory before removal to confirm: fracture union or DDH hip position maintained and stable. **Removal Technique** Spica removal: typically in clinic for cooperative children, OR with sedation for anxious or young children. Use oscillating cast saw with blade guard. Make multiple parallel cuts on LATERAL aspects of cast (avoid anterior cuts which risk abdominal injury). Cut through padding layer, then spread cast with spreaders. Remove in pieces: body jacket first, then legs. **Post-Removal Skin Care** Skin will be dry, scaly with accumulated dead skin - reassure family this is NORMAL and expected. GENTLE washing with mild soap and water, pat dry, apply moisturizer. Avoid aggressive scrubbing which causes further irritation. Dead skin will slough over several days with normal bathing. **Rehabilitation** Muscle atrophy universal after spica immobilization especially bilateral or prolonged casting. Hip and knee stiffness common, usually resolves in 2-4 weeks with normal activity. Formal physical therapy rarely needed in young children who spontaneously regain motion and strength. Encourage normal play, stairs, outdoor activity. Antalgic gait common for 1-2 weeks post-removal, resolves spontaneously. **FRCS Viva Tip**: "Spica removal after union confirmed on x-ray - typically 6 weeks femur fracture in children under 3 years, 8-10 weeks age 3-5 years, 12 weeks for DDH. I use oscillating saw on lateral aspects only to avoid abdominal injury, spread and remove in pieces. Skin care: gentle washing with mild soap, moisturizer, avoid aggressive scrubbing. Hip and knee stiffness common especially bilateral spica - I reassure families this resolves in 2-4 weeks with normal activity. Formal physiotherapy rarely needed in young children." - Cast saw skin burns: always use blade guard, multiple short cuts, avoid prolonged contact - Premature removal before healing: leads to refracture or redislocation - Aggressive skin cleaning after removal: causes further irritation and pain - Family distress at muscle atrophy: provide reassurance and expectation management - Abdominal injury from anterior saw cuts: use lateral cuts only ### Additional Complications **Infection and Skin Infection (2-5%)** From soiling, pressure sores, or wound if post-operative. Recognition: fever, foul odor, purulent drainage visible at cast edges. Prevention: meticulous hygiene, waterproofing, antibiotics for post-operative cases per protocol. Management: cast removal, wound cultures, antibiotics based on organisms (typically Staphylococcus aureus, Streptococcus), local wound care. **Respiratory Compromise (Rare <1%)** Tight cast restricts breathing especially in infants or underlying lung disease. Recognition: tachypnea, desaturation, increased work of breathing, distress. Prevention: body jacket starts at nipple line, avoid tight circumferential, monitor respiratory status post-application. Management: cast removal immediately if respiratory distress, supportive care, consider surgical fixation. **Psychosocial Issues (Common but Under-Recognized)** Prolonged immobilization in young children causes distress. Family stress from care demands. Siblings may feel neglected. Recognition: child regression behaviours, sleep disturbance, family stress visible. Prevention: pre-operative counseling, realistic expectations, social work support. Management: reassurance, child life specialist input, consider early cast removal if healing adequate. **Femoral Nerve Palsy (Rare <1%)** From excessive hip flexion >110-120° stretching femoral nerve. Recognition: loss of quadriceps function, decreased sensation anterior thigh, inability to extend knee. Prevention: maintain hip flexion 90-110° maximum. Management: usually temporary, cast removal and repositioning with less hip flexion, most recover fully over weeks to months. **Cast Saw Injuries (1-2%)** Skin burns or lacerations during removal if poor technique. Prevention: always use blade guard, multiple short cuts avoiding prolonged contact, lateral cuts only avoiding abdomen. Management: minor burns - local wound care, observation. Lacerations - may require suturing, tetanus prophylaxis. **Immediate Post-Application (0-24 Hours)** Hospital observation 4-24 hours post-application depending on patient stability and family capability. Monitor: comfort level, feeding tolerance, neurovascular status (capillary refill, toe color, temperature), respiratory status (work of breathing, saturations), cast integrity. Analgesia: paracetamol regular dosing, ibuprofen if needed. Assess family capability for home care before discharge. **Discharge Criteria** Child comfortable with pain controlled on oral analgesia. Feeding well, tolerating normal diet. Neurovascular examination normal (capillary refill <2 seconds, warm pink toes bilaterally). Family demonstrates competency: positioning techniques, skin checks, hygiene management, recognizes warning signs. Specialized car seat arranged for safe transportation home. **Home Care Instructions (Written and Verbal)** Position changes every 2-3 hours: rotate supine, right side, left side, semi-reclined. Use pillows for support. NEVER prone unsupervised (suffocation risk). Skin checks twice daily: inspect edges with flashlight, check for redness, breakdown, odor. Neurovascular checks twice daily: toe color, warmth, capillary refill, movement. Hygiene: waterproof with plastic wrap for all diaper changes, clean perineal area gently, dry thoroughly, frequent diaper changes. Feeding: upright or 45° reclined, smaller frequent meals if early satiety. Activity: floor play encouraged, never prone unsupervised. **Follow-Up Schedule** 1 week (mandatory): wound check if post-operative, skin examination all cast edges, x-ray confirm alignment maintained, assess family coping and care techniques. 2-3 weeks: x-ray, clinical assessment, address any issues (soiling, skin concerns, cast loosening). Every 2-3 weeks thereafter until removal: x-ray to monitor healing, assess cast integrity. **Duration of Immobilization** Femur fracture: 6-12 weeks age-dependent (younger children heal faster). Age <2 years: typically 6 weeks. Age 2-3 years: 6-8 weeks. Age 3-5 years: 8-12 weeks. Confirm healing: bridging callus visible on 3 of 4 cortices on x-ray. DDH: 12 weeks standard (some protocols 6 weeks then abduction brace). Post-operative: variable per surgeon preference and procedure, typically 6-12 weeks. **Cast Removal** When fracture healed (bridging callus 3 cortices on x-ray) or DDH timeframe complete. Removal in clinic if cooperative, OR with sedation if anxious. Post-removal expectations: muscle atrophy universal, hip and knee stiffness common, resolves with normal activity over 2-4 weeks. Formal physiotherapy rarely needed in young children - encourage normal play and activity. Antalgic gait 1-2 weeks normal, resolves spontaneously. ## References 1. Flynn JM, Hresko T, Reynolds RA, et al. Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop. 2001;21(1):4-8. [Seminal study establishing immediate spica vs traction protocols and ESIN outcomes] 2. Staheli LT, Sheridan GW. Early spica cast management of femoral shaft fractures in young children. A technique utilizing bilateral fixed skin traction. Clin Orthop Relat Res. 1977;(126):162-166. [Classic description of immediate spica technique] 3. Ramsey PL, Lasser S, MacEwen GD. Congenital dislocation of the hip. Use of the Pavlik harness in the child during the first six months of life. J Bone Joint Surg Am. 1976;58(7):1000-1004. [Safe zone concept and human position development] 4. Vitale MG, Skaggs DL. Developmental dysplasia of the hip from six months to four years of age. J Am Acad Orthop Surg. 2001;9(6):401-411. [Comprehensive DDH management including spica protocols] 5. Herring JA, Kim HT, Browne R. Factors influencing the outcome of acetabular development following reduction of congenital dislocation of the hip. Orthop Trans. 1989;13:268. [AVN rates and risk factors in DDH] 6. Sanders JO, Browne RH, Mooney JF, et al. Treatment of femoral fractures in children by pediatric orthopedists: results of a 1998 survey. J Pediatr Orthop. 2001;21(4):436-441. [Modern treatment algorithms and acceptable alignment parameters] 7. Wilkins KE. The incidence of avascular necrosis in "optimal" position spica cast immobilization for developmental dysplasia of the hip. In: Proceedings of the Pediatric Orthopaedic Society of North America Annual Meeting; 1992. [Comparison of frog vs human position AVN outcomes] 8. O'Brien T, Weisman DS, Ronchetti P, et al. Flexible titanium nailing for the treatment of the unstable pediatric femur fracture. J Pediatr Orthop. 2004;24(6):601-609. [Contemporary surgical alternatives and comparison to spica] 9. Irani RN, Nicholson JT, Chung SM. Long-term results in the treatment of femoral-shaft fractures in young children by immediate spica immobilization. J Bone Joint Surg Am. 1976;58(7):945-951. [Long-term outcomes and remodeling potential data] 10. Kocher MS, Sink EL, Blasier RD, et al. Treatment of pediatric diaphyseal femur fractures. J Am Acad Orthop Surg. 2009;17(11):718-725. [Evidence-based comprehensive review and treatment guidelines]

Paediatric Hip Spica Cast Application

Paediatric Hip Spica Cast Application