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Spica Casting

Planning

B

Preoperative Plan

1

Template fracture

  • identify fracture pattern

2

Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • describe potential complications and the steps to avoid them
C

Room Preparation

1

Surgical equipment

  • casting materials
  • spica casting table
  • cast saw

2

Room setup and equipment

  • standard radiolucent table
  • c-arm fluoroscopy

3

Patient positioning

  • supine

Technique

D

Cover all areas to be casted with liner (stockinette or gore-tex)

P

1

For a traditional one and a half spica cast, cover from the nipple level to the distal tibia on the injured leg and to the distal femur on the uninjured leg

  • alternatively, cover proximally to the lowest rib

2

For a single leg spica cast, cover the inferior trunk and injured leg down to the distal tibia

Pearls
  • For many low energy mechanism femur fractures a walking spica cast can be used
E

Position on spica table

1

Transfer the patient to the spica table

  • secure the arms over the chest or to arm board on spica table
  • assistant holds the patient's legs in appropriate position
F

Reduce the fracture

P

1

Reduce fracture by optimizing positioning of the injured leg

  • goal is to have distal fragment match the position of proximal fragment
  • for mid-diaphyseal fractures, the proximal fragment is usually pulled into flexion, abduction and external rotation by psoas, hip abductors, hip external rotators
  • Therefore distal fragment needs to be flexed, abducted and externally rotated to match this
  • injured leg is positioned so that hip and knee are in mild flexion (more flexion if proximal fracture), in abduction around 20-30 degrees, and in external rotation around 10-15 degrees
Pearls
  • For mid-diaphyseal fractures, the proximal fragment is usually pulled into flexion, abduction and external rotation
G

Pad chest and abdomen with towels and overwrap stockinette/liner with cast padding

1

place folded towels over chest and abdominal area (up to 2 inches in thickness)

  • to allow full respiratory excursion

2

overwrap stockinette/liner with cast padding

  • 3 layers of cast padding, with additional padding on bony prominences (iliac crest, greater trochanter, patella, fibular head)
H

Evaluate reduction and apply fiberglass

P

1

Use c-arm fluoroscopy and determine if reduction is adequate

  • acceptable shortening: birth to 2yrs=15 mm; 2 to 5yrs =20mm
  • acceptable varus/valgus angulation: birth to 2 yrs=30 degrees; 2 to 5 years=15 degrees
  • acceptable anterior/posterior angulation: birth to 2 years=30 degrees ; 2 to 5 years =20 degrees
  • CHECK ROTATIONAL ALIGNMENT! an AP at the hip should match an AP of the knee and a lateral of the hip should match a lateral of the knee

2

Apply fiberglass to stabilize fracture alignment

  • overwrap the cast padding with fiberglass leaving approximately a half inch of uncovered cast padding at the edges
Pitfalls
  • Reinforce the lateral inferior buttock as this area often does not have sufficient fiberglass/strength
I

Mold the cast and reevaluate with c-arm fluoroscopy

P

1

Apply a strong valgus and recurvatum mold as these fractures tend to fall into varus and procurvatum when the patient wakes up and the psoas and abductors pull on the proximal piece

Pearls
  • Ideally intraoperatively the fracture is aligned in valgus and recurvatum demonstrating some overcorrection of this

2

Use c-arm fluoroscopy to confirm reduction is still adequate

  • if reduction is unacceptable, cast can be adjusted, e.g. cast wedging
  • if reduction is still unacceptable, options are to change cast or transitioning to external fixator or flexible intramedullary nails
J

Trim window for perineal care and ensure cast edges are not sharp

1

Trim window for perineal care

2

Remove towels over chest and abdomen

3

Ensure cast edges are not sharp - can apply moleskin to edges

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • injury mechanism
  • orders social work evaluation if any concern for abuse
  • check distal pulses
  • motor and sensory exam

2

Order basic imaging studies

  • AP and lateral femur radiographs

3

Perform operative consent

  • describe complications of surgery including
  • nonunion
  • delayed union
  • malunion
  • neurovascular injury
  • compartment syndrome
  • leg-length discrepancy
  • overgrowth
L

Perioperative Inpatient Management

P

1

Discharge patient appropriately

  • pain meds
  • parents instructed on cast care and positioning
  • spica car seat evaluation
  • monitor swelling
  • monitor neurological and vascular status
  • schedule follow up in 1 week

2

It is the authors preference to follow patients weekly for the first 3 weeks for evidence of loss of reduction. If present the cast can be wedged to try to optimize the reduction.

Pearls
  • Check radiographs weekly for the first 3 weeks for evidence of loss of reduction
  • If present the cast can be wedged to try to optimize the reduction

3

The cast remains in place until there is evidence of callus formation, typically 5 or 6 weeks

M

Intermediate Evaluation and Management

1

Recognize vascular, nerve or other associated injuries

  • document neurovascular status

2

Appropriately interprets basic imaging studies and recognizes fracture patterns

  • interpret radiographs of the femur

3

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

4

Provides post-operative management and rehabilitation

  • postop: 1-2 week postoperative visit
  • check radiographs, weekly for first 3 weeks
  • diagnose and management of early complications
  • postop: 4-6 week postoperative visit
  • check radiographs

5

Capable of diagnosis and early management of complications

  • cast problems
 

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