Caring for a Child in a Spica Cast

Spica (body) casts are used to keep the thighbone (femur) and pelvis still. We call this immobilization. This cast holds the joint above the hip (the spine) and the joint below the hip (the knee) still, so that the femur and pelvic bones stay still to heal. It is used after a fractured femur (thighbone), after hip or pelvis surgery, or after tendon surgery around the hip. A spica cast covers the child from the armpits around the chest all the way to the ankle of one or both legs. If the cast only goes to one ankle, the other leg is in the cast to just above the knee. There is an opening in the diaper area. The inside layer is made of Gore-Tex to whisk away moisture, then there is cotton padding, and over all of that is fiberglass. There might be a bar between the legs, this is per surgeon preference.

Spica casts are almost always put on with the child sedated or under general anesthesia. The length of time is determined by your doctor and your child's healing process. Typical length of time for a spica cast is 12 weeks. Your doctor may want to perform a spica cast change in the operating room at 6 weeks. Your child will need general anesthesia to be put to sleep for the cast change. We do not typically change the cast more frequently then this because we do not want to expose your child to anesthesia unnecessarily. That being said, it is very important to properly care for your child's spica cast. Here are some tips to make caring for your child easier.

Safety

A child in a spica cast should never be left home alone!
Prop your child securely with pillows and folded blankets.
Check your child's toes daily. They should be warm and pink. When you press on the toenail, it will turn white. When you let go, it should turn pink in 2-3 seconds. If it takes longer, you child's cast may be too tight and you should elevate that leg for 15 minutes. Your child should be able to move his toes. The toes should not be swollen.

Traveling

Your child must wear a seat belt in a stroller, wheelchair or car. If your child needs a wheelchair, the Orthopedic Nurse Clinician will order one for you. It is your responsibility to return the wheelchair when you are done using it.
Do not allow walking in a spica cast. This may disrupt the healing process.
Some children do not fit safely in their car seat after they are in a spica cast. There are options to rent a car seat from the Trauma Department discussed in more detail later.

Cast care

Keep the cast dry. If the cast becomes wet, it can hurt your child's skin. Do not try to dry cast with something warm (i.e., a blow dryer) this may cause burns.
Do not put anything down inside the cast. This can cause a sore or an infection. Protect the cast with a towel or large bib from small toys, dirt or pieces of food. If something does get into the cast and you can see it, try to remove it with your hand. If you cannot see the object or can't reach it, call your doctor.
If your child complains of itching, use a blow dryer set on cool to blow air down the cast or try scratching another part of the body.
Your cast has a Gortex lining that helps to protect and "waterproof" the inside of the cast, especially around the groin area. There are special ways to "double diaper" to help protect from accidents. Your nurse can show you how to do this.
Do not allow the child to pull the padding out of the cast. The padding protects the skin from rubbing or sores.

Skin care

Do not use lotions, oils or powder on the skin under the cast.
Check the skin daily for sore areas. Use a flashlight to look inside the cast.
Change your child's position at least every 2 hours. Lying in one position in the heavy cast can cause skin sores under the cast.
Use pillows, blanket rolls or chair cushions for support. Put a pillow or blanket roll under the lower leg (not under the heel) to keep the heel off of the bed.
Don't forget that you can put your child on their belly as well to give their butt a rest! Place a folded blanket, sheet or pillow lengthwise under the chest and abdomen when your child is lying on their stomach. Move the child to the foot of the bed so that the toes hang over the edge of the mattress.
If you notice a rash on your child's skin, try to cleanse the skin with some mild soap and water on a washcloth and allow to air dry. Call the Orthopedic Nurse Clinician if you think it is getting worse or if you see bleeding.

Diet

Your child may want to eat small, frequent meals instead of three meals a day.
To prevent constipation, your child needs to drink a lot of fluids and eat foods with roughage. Some foods with roughage are raw carrots, fruits and cereals like oatmeal and graham crackers.
Be careful with small pieces of food. Your child may choke because they cannot sit up straight in the cast.

Going to the bathroom

If your child wears diapers
It is best to use a method called "double diapering." First, tuck the edges of the diaper up under the edges of the cast. This keeps urine and stool inside the diaper and keeps the cast from getting damp and dirty. You may need to use a smaller size diaper than usual. You can also cut a larger diaper in half. The diaper should cover the child's entire bottom. Then use a larger diaper on the outside over the cast can help keep the smaller diaper in place; you may need to tape it in place or use an adult-sized diaper.

Check the diaper often and at least once overnight.

For boys, you can also make an "envelope" to catch urine. Use a small disposable diaper. Cut a hole in the front, center of the diaper. The hole should be just wide enough for the penis to fit through. Keep the diaper folded, plastic side out, with the cut side towards your son. Insert penis into the hole of the diaper. Use diaper tapes to secure diaper to cast. Urine will collect in the small diaper. Put a larger diaper over the cast as usual so that both the smaller, cut diaper, and the rest of your child's bottom are covered.

If your child is potty trained
Depending on the position of the cast, your child may be able to sit on the toilet. If not, you will need to use a bedpan. Boys can use the urinal from the hospital. For girls, a paper cup with a small hole in the bottom may help to direct urine into the bedpan. It may help to use plastic wrap to protect the cast when potty-training children are using the bathroom.

What if the cast gets wet?
First, prevent another accident by reviewing the diapering method. If the cast gets soaked, it will take a very long time to dry. You can help speed this process up by using the blow dryer on the cool setting or taking the child out into the sun. Your child's own body heat will also help to dry the cast. Remember, it's important to reposition your child so that different areas have the opportunity to dry. The back of the cast is the most common place to get wet.

Bathing and hair washing

Your child will need to have sponge baths. If body odor becomes a problem, you can sprinkle a small amount of deodorant body powder on the cast or spray a small amount of under-arm deodorant on the cast. Do not spray the cast with household cleaners or deodorizers such as Lysol.

Washing your child's hair

You may lay a small child down with their head in the sink and wash the hair.
You may lay a child across a bed and place a bucket on the floor to catch the water as you shampoo.
Liquid no-rinse shampoos are available as well.

Clothing

Clothes should be loose and comfortable. T-shirts should be 1-2 sizes larger than usual to fit over the cast. Boxer shorts or sweat pants in a larger size can also fit over the cast. You may also want to cut shorts or sweatpants and sew in Velcro to allow older children to wear their regular clothing. Breakaway shorts (with snaps on each side) can be used with casts that have a bar connecting the legs of the cast. Your child may be warmer than usual. Light clothing may be all that's needed.

Daily activity

If your child complains of pain, give pain medicine as directed by your doctor. Pain medicine may be needed at night for 1-2 weeks.

Keep your child where the action is. You may want to bring the child's bed to the living room so they can be where everyone is. This will also save you from running back and forth.

Your child will not be able to stand on their injured leg but may be able to stand on the opposite leg. This will allow them to help with getting in and out of bed. A physical therapist can help show you this.

Some things for your child to do

Take your child outside, if possible. A wagon or stroller can be used for small children. Bigger children may need a wheelchair with a reclining back.
Ask school friends or neighborhood children and relatives to visit.
Read a favorite book.
Listen to tapes, TV, videos.
Play games, puzzles, computer or video games.
Do arts and crafts.

Returning to school or day care

Your child may need home instruction for the duration of the casting due to the amount of care needed during that time. The Orthopedic Nurse Clinician will help arrange this with your school district. The healthcare provider will tell you when your child can return to school. Generally your child should be off of narcotic medication during the day before returning to school.

When to call the doctor

Your child has severe pain and the pain medication does not help
You see a change in the cast: cracking, softening, and drainage from the inside.
You smell a bad odor coming from the cast
Your child's fingers are cold, blue/gray or swollen.
Your child feels numbness or tingling in the fingers
Your child cannot move their fingers
There is a change in the position of the fingers in the cast or the cast looks like it is slipping off.
Fever with no other signs of illness (temperature over 101.5 F) (no cold, ear ache, etc.)

Phone numbers

Weekdays: Please call the Orthopedic Nurse Clinicians at (510) 428-3238.
Nights or weekends: Call (510) 428-3000 and ask the operator to page the Orthopedic Resident on call.

Safe transportation for a child in a spica cast

If your child's surgery is scheduled in advance, you'll have time to arrange transportation ahead of time. The surgeon is usually able to tell you the approximate size of the cast, that is, how wide it will be, and how much it will bend at the knees. Depending on the width of the abduction of your child's legs, your child may not fit safely into their car seat. The Orthopedic Nurse Clinician can help you figure out what would be best.

Sometimes children in spica casts fit in a conventional convertible car seat with lower sides and a wider front especially one that will recline in both rear-facing and forward-facing positions. It will depend on your child's weight, height and age.

Here are a few options:

Radian 80 can semi-recline in the forward-facing as well as rear-facing position and has low sides though it is narrow.
Britax Marathon, Roundabout or Boulevard have wide seats with low sides.
Combi Victoria or the Avatar both have forward facing recline positions.
A Britax Frontier 85 booster seat may fit an older child.
Sometimes a small baby may fit into a car bed (available in the hospital loaner program) depending on how their cast is made.

What if my child does not fit in their car seat?
If your child will be in a spica cast following orthopedic surgery and needs a car seat, you may arrange to pick one up from the Trauma office by contacting: Bonnie Lovette, RN, MSN, PNP, Injury Prevention Coordinator, Trauma Services at (510) 428-3045. Please arrange for this as soon as you find out the date of surgery. The Trauma Department attempts to keep these in stock but cannot guarantee a supply.

Pick-up procedure

You will need to come into the Trauma office and sign the agreement for financial responsibility. You will be given guidance on how you can install the seat correctly and resources to have the car seat checked for proper installation in your vehicle.

Return procedure

You will need to return the seat to the Trauma office (or in the Emergency Department if Trauma is closed) at the time of your orthopedic follow-up appointment. Please do not plan to leave the car seat in the Orthopedic Department.

Child passenger restraints for children in spica casts

EZ-ON vest: Another option for children in spica casts is called the modified EZ-ON vest. This vest is for children aged 2 to 12 and weighing from 20 to 100 pounds. The 101M2 fits children better who are 5-12 years old, 65-100 pounds. The M203-XS fits snugger on children 2-5 years of age, 20-65 pounds. When using the modified EZ-ON vest, your child must travel lying down in the rear seat of the vehicle. See www.ezonpro.com for referral to a distributor in your area.

UCSF Benioff Children's Hospitals medical specialists have reviewed this information. It is for educational purposes only and is not intended to replace the advice of your child's doctor or other health care provider. We encourage you to discuss any questions or concerns you may have with your child's provider.