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Early Application of Hip Spica Cast PDF Print E-mail

Merv Letts, M.D., FRCSC
Children’s Hospital of Eastern Ontario
Ottawa, ON

Although the application of hip spica casts in the management of fractures of the femur in children has been a standard modality of treatment since the invention of plaster, the early application as a definitive method of fracture treatment has only recently been driven in popularity by the economics of health care. The traditional method of treating fractured femurs prior to the 1990’s in most paediatric centres was the application of traction followed by a hip spica cast once the fracture had consolidated with callus.  

As health care costs escalated in the 80’s and 90’s, innovative methods were used to decrease the prolonged hospitalization required by traction techniques, even though this type of management of a fractured femur is still very efficacious in obtaining a good long-term result and should always be considered for patients in whom other modalities of treatment are inappropriate due to the type of trauma or other complicating factors regarding the fracture. As with any type of treatment that is new and innovative, the pendulum always swings a bit too far and this was true of immediate application of hip spica casting for fractured femurs in children. In the initial frenzy of immediate casting and trying to decrease hospitalization for all such fractures, it was soon realized that as with any type of treatment, certain criteria need to be met to avoid complications of shortening, angulation and rotation. The following are guidelines that we have found useful at CHEO.

Table 1

Advantages of Early Hip Spica Casting

1. Decreased hospital stay and costs
2. Avoidance of complications of skin and skeletal traction
3. Decreased radiographic exams
4. Rapid return of child to family environment

Guidelines for Immediate Hip Spica Casting

1. Age
The younger the child, the more appropriate is this type of management for their fractured femur. Infants with undisplaced fractures of the femur in whom child abuse is not an issue can be casted with a hip spica and sent home from the Emergency Department. Children under the age of six years with fractures sustained by lower impact forces are often initially managed in traction for two or three days and a well moulded hip spica cast can then be applied under a general anesthesia. With the advent of malleable nail rodding of fractures in children, most children over six years of age will now have their fractures stabilized with this type of internal fixation and the application of a hip spica cast, if deemed necessary, is primarily for comfort rather than to maintain the reduction.

2. History of Trauma
If the child has sustained the fractured femur secondary to a violent injury, such as a motor vehicle accident or fall from a height, one can assume there has been considerable soft tissue injury and stretching, and hence the soft tissue envelop around the fracture is often less supportive. This very unstable fracture will be less amenable to immediate hip spica casting since loss of reduction and shortening is much more common. This type of fracture is better treated in traction or with a malleable intramedullary nail.

3. Associated Injuries
Associated large soft tissue wounds requiring dressing changes and observation preclude the application of hip spica cast and other treatment modalities such as traction or external fixation should be considered. Multiple trauma similarly would require other treatment modalities for the femoral fracture.

4. Fracture Shortening
Fracture overlap of two centimetres or more is usually indicative of considerable trauma and maintaining a one centimetre overlap in the hip spica cast is often difficult in this type of injury.

5. Pathological Fractures
Fractures occurring through a previously weakened area of bone secondary to such conditions as fibrous dysplasia, unicameral bone cyst or non ossifying fibroma, are ideal for the immediate application of a hip spica cast or if in the distal femur, simply a long leg cylinder cast. Swelling is usually minimal and displacement is rare.

Recommended Technique of Application
I. General anaesthesia administered with child in traction bed.
II. Following anesthesia, remove leg from Thomas splint and apply below knee cast in bed.
III. Transfer child to infant or child hip spica table.
IV. Apply longitudinal manual traction with knee and hip flexed to 60-70° with hip at 30° of abductor and leg in 15° of external rotation.
V. Spread mastasol thigh and apply long leg cast.
VI. Continue manual traction and check position of fracture with image intensifier.
VII. Complete the one and a half hip spica while manual traction continued.
VIII. Final check with image intensifier.

Complications
Complications of early spica casting of femoral shaft fractures usually have occurred in the first two weeks in our experience. Radiographs should be taken at weekly intervals to detect shortening or angulation. If shortening occurs to the extent of 2 cms or more, the child should be taken out of the hip spica and 90 - 90 skeletal traction instituted through the distal femur.

Angulation is less commonly encountered and is usually anterior or lateral. These angulatory deformities are amenable to cast wedging. Rotation deformity is seldom encountered.

Additional Reading
Buckley, S.L.: Current trends in the treatment of femoral shaft fractures in children and adolescents. Clin. Orthop Rel Res. 338: 60-73, 1997.

Kasser, J.R.: Femur fractures in children. Instr. Course Lectures 41:403-8, 1992.

MacKenzie, W.M.G.: Fractures of the Femoral Shaft in Management of Paediatric Fractures. Ed. Letts, RM. Chpt. 29 p. 543, 1994.

Martiney, A.G., Carroll, N.C. et al: Femoral shaft fractures in children treated with early spica cast. J ped Orthop 11:712-716, 1991.

Wright, J.G.: The treatment of femoral shaft fractures in children: a systematic overview and critical appraisal of the literature. Can J Surg. 43: 180-189, 2000.