Lower Extremity Splints and Casts

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Chapter 14 Lower Extremity Splints and Casts

Hip spica cast

Overview

1. The hip spica cast is one of the most difficult casts to apply.
2. The hip spica cast generally is composed of an abdominal portion attached to long leg casts, which is a so-called “double spica cast.” When the unaffected extremity is placed into a thigh-only cast, the cast is termed a “1½ spica cast.” A “single leg” hip spica cast is composed of an abdominal portion attached to a single long leg cast of the affected leg. All three types of spica casts have been shown to be successful in treating diaphyseal femoral fractures in children younger than 6 years.
3. The following points regarding the application of a hip spica cast are controversial:

a. The type of spica cast that should be used (double, 1½, or single leg)
b. Whether the foot should be included in the cast
c. When to apply traction while casting
d. Whether to apply the abdominal or the leg portion of the cast first
e. Positioning of the extremity

Indications for Use

1. Pediatric femur fractures
2. General indications for type of spica cast:

a. Double spica cast: concomitant pelvic or hip injury
b. 1½ spica cast:

(1) Proximal or mid diaphyseal femoral fractures
(2) Older children

c. Single leg spica cast: distal femoral fractures

Precautions

1. The following complications of hip spica casting may occur:

a. Compartment syndrome has been reported in the 1½ spica cast with the hip and knee flexed to 90 degrees.
b. Femoral and peroneal nerve palsy can occur, respectively, from excessive hip flexion and valgus molding over the fibular head.
c. Skin breakdown and decubitus ulcers can occur.
d. Superior mesenteric artery syndrome can occur from excessive thoracolumbar lordosis in the abdominal portion of the cast.

2. Close monitoring of the patient for complications is necessary during the first 2 weeks after application of the cast.
3. Some authors argue that initial femoral shortening greater than 2 cm is a contraindication for treatment with a spica cast.
4. Families caring for children with spica casts must contend with numerous psychosocial issues, such as transportation and bathing.

Pearls

1. We prefer a relaxed leg position with the knee at 60 degrees of flexion and the hip in 45 degrees of flexion rather than the traditional 90-90 position. An assistant should help the patient maintain this position throughout the application of the cast to avoid any bunching or creasing of the casting material.
2. Application of the cast can be performed in the emergency department with use of conscious sedation or in the operating room (OR) with use of general anesthesia.
3. Although they may not always be available, use of waterproof Gore-Tex pantaloons and a cast liner significantly improves the ability of the family to care for a child with a spica cast.
4. A broomstick, a twisted bar of fiberglass casting material, or some other connecting bar can be used to confer additional stability and strength to the spica cast.
5. Placing the spica table into a 10 degrees of reverse Trendelenburg position, either by tilting the operating table or by placing a block of wood under the spica table, allows the child’s perineum to fit snugly against the perineal post of the spica table.

Equipment

1. Hip spica table
2. Two to four blue OR towels (or a towel folded so it is 2 inches thick)
3. A stockinette, with the size depending on the size of the child; typically, a 2-inch stockinette is used for the leg portions and either a 3-, 4-, or 6-inch stockinette is used for the abdominal portion.
4. A sawed-off portion of a broomstick or a fiberglass bar (Figures 14-1 and 14-2)
5. 4-inch cast padding
6. 4-inch fiberglass or plaster cast rolls
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Figure 14-1

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Figure 14-2

Basic Technique: 1½ Spica Cast

1. Patient positioning:

a. The patient should be placed on the hip spica table (Figure 14-3).

(1) The buttocks and perineum should be placed on the adjustable post.
(2) The thoracic spine should sit on the table extension.
(3) The shoulders and thorax should be on the platform portion of the table.
b. The knee should be held at 60 degrees of flexion and the hip in 45 degrees of flexion. The hip should be abducted 20 to 30 degrees and the extremity should be externally rotated 15 degrees.

2. Where to start:

a. A long leg cast is applied to the affected extremity starting with the foot.
b. The foot should be included and placed in a neutral position.

3. Where to finish:

a. The spica cast should extend proximally to the level of the rib cage.

4. Where to mold:

a. A valgus mold should be placed at the fracture site.

5. Steps:

a. Prepare a stockinette.
b. Place the patient on the spica table.
c. Position the stockinette.
d. Place two to four blue OR towels on the abdomen under the stockinette to allow for abdominal excursion after application of the cast.
e. Finish the cast edges.
f. Apply the long leg cast on the affected extremity.
g. Apply the abdominal portion of the spica cast and the contralateral thigh portion of the cast on the unaffected leg.
h. Apply longitudinal traction to the affected extremity to achieve reduction.
i. Incorporate the long leg cast into the abdominal cast.
j. Mold the cast.
k. Create a side strut for the affected extremity.
l. Complete the cast.

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Figure 14-3

Detailed Technique

1. Prepare a stockinette:

a. Cut two pieces from a 2-inch stockinette:

(1) One piece is for the long-leg portion of the spica cast, measuring from the inguinal crease to 2 inches beyond the foot.
(2) One piece is for the contralateral thigh.

b. Cut one piece from the 4-inch stockinette. This piece will be used for the abdominal portion of the spica cast and should measure from the nipples to the mid thigh.

2. Place the patient on the spica table. Have an assistant consistently hold the patient in the desired position.
3. Position the stockinette (Figure 14-4):

a. Place the abdominal stockinette on the patient with the stockinette extending from the nipples to the mid thigh. Posteriorly, the stockinette should be placed over the spica table extension (i.e., the table should be in contact with the skin of the thoracic spine).
b. Place the long-leg stockinette over the affected extremity and the unaffected-leg stockinette over the thigh of the contralateral leg.
4. Place two to four blue OR towels on the abdomen under the stockinette to allow for abdominal excursion after application of the cast.
5. Begin preparing the long leg cast on the affected extremity.
6. Wrap the extremity in cast padding (Figure 14-5).

a. Start at the gluteal fold and circumferentially wrap distally to the area immediately above the lateral malleolus.

(1) Use a standard 50% overlap technique (see Chapter 12).
(2) Two layers of wrapping are sufficient.

b. Span the joint line with cast padding at the anterior aspect of the tibiotalar joint (see aforementioned precautions for the long leg cast).
c. Return to the lateral malleolus and wrap over this area.
d. Continue distally to around the foot. Do not cover the heel at this point.
e. Once sufficient padding has been wrapped around the malleoli and the foot, the heel can be addressed.
f. Tear strips of cast padding and lay them on top of the heel (Figure 14-6). Repeat several times to ensure sufficient padding.
7. Create a cast padding cuff (see Chapter 12) for the metatarsal heads. This cuff should form a “V” at the lateral aspect of the foot to allow for the cascade of the digits (Figure 14-7).
8. Wrap the abdomen in cast padding (Figure 14-8). Ensure that the anterior superior iliac spine, posterior superior iliac spine, and sacrum are very well padded.
9. Wrap the contralateral thigh in cast padding. Start immediately proximal to the popliteal fossa and continue proximally to the gluteal fold.
10. Create a cuff of cast padding (Figure 14-9) and place it over the most distal part of the rib cage.
11. Create a cuff of cast padding.

a. Place the cuff over the distal portion of the thigh.
b. The knee should be able to bend to 90 degrees without impediment from the cast.

12. Finish the cast edges (Figure 14-10). All exposed areas should have the stockinette pulled up and folded over the cast padding.
13. Pay particular attention to the perineal portion of the cast.
14. Apply cast material as for a long leg cast.

a. Start distally at the metatarsal heads and extend proximally to the mid thigh.
b. Ensure that a significant amount of stockinette and cast padding remains to the level of the gluteal fold (Figure 14-11).
c. Be vigilant about the position of the foot.

15. Begin application of the abdominal portion of the spica cast and the contralateral thigh portion of the cast for the unaffected leg.

a. Begin proximally at the level of the abdominal cuff of cast padding and continue distally.
b. Carefully incorporate only the unaffected leg into the abdominal portion, using a figure-of-8 technique around the hip (Figure 14-12).
c. Do not yet incorporate the long leg cast of the affected extremity.

16. Apply longitudinal traction to the affected extremity to achieve reduction if necessary.
17. Incorporate the long leg cast into the abdominal cast (Figure 14-13).

a. Use a figure-of-8 technique.
b. Ensure that the perineum remains exposed.
18. Mold the cast (Figure 14-14):

a. Place one palm on the lateral aspect of the thigh immediately proximal to the fracture site.
b. Place the other palm on the medial aspect distal to the fracture site.
c. Mold the cast into valgus.
19. Create a side strut for the affected extremity if plaster is being used.

a. Take a roll of plaster and create a splint that is 10 layers thick extending from the mid abdomen to the mid thigh.
b. Apply the splint obliquely along the inferior lateral buttock area to act as a strut.

20. Apply a broomstick or bar of fiberglass to span both legs. Incorporate the strut and the bar into the spica cast with an additional roll of fiberglass (Figure 14-15).
21. Complete the cast (Figure 14-16):

a. Use colored fiberglass for a “Hollywood roll” if desired.
b. Remove towels from the abdomen.
c. Remove the child from the spica table.
d. Trim away any excess casting material.
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Figure 14-4

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Figure 14-5

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Figure 14-6

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Figure 14-7

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Figure 14-8

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Figure 14-9

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Figure 14-10

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Figure 14-11

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Figure 14-12

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Figure 14-13

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Figure 14-14

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Figure 14-15

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Figure 14-16

Long-leg splint

Overview

The design of the long-leg splint is identical to that of the AO splint described later, with a posterior slab and a stirrup, except that each of the slabs traverses the knee and extends to the upper thigh.

Indications for Use

1. Tibial shaft fracture
2. Tibial plateau fracture
3. Distal femur fracture

Precautions

1. As in any other splint that immobilizes the ankle and foot, the position of the foot within the splint is of paramount importance. Do not allow the foot to be in equinus except in the case of very distal tibial shaft fractures where dorsiflexion results in extension at the fracture site.
2. The long-leg splint is placed with the knee in 20 to 30 degrees of flexion.
3. Given the propensity for tibial shaft fractures to become very swollen and the associated high risk for compartment syndrome, Jones’ cotton typically is used.

Pearls

1. Before starting, ensure that adequate analgesia has been achieved, either with intravenous opioids or conscious sedation.
2. The long-leg splint is one of the most difficult splints to apply; having the aid of two assistants facilitates the process. If help is not available, use either the technique described below or this alternative method to elevate the limb (Figure 14-17):

a. Have the patient lay supine on a stretcher with side rails.
b. Raise both side rails.
c. Take two rolls of 6-inch rolled gauze and unravel them completely.
d. Lay one roll of rolled gauze under the patient’s thigh and the other under the calf, with equal lengths on each side of the limb.
e. Start with the roll under the calf:

(1) Tie one end to the side rail.
(2) Pull on the other side until the gauze is taut and the limb is elevated; tie the end to the side rail.

f. Repeat with the roll under the thigh.
3. It is recommended that cool water be used (to delay plaster setting) and that all three plaster slabs be prepared in water prior to application of the splint. This approach reduces the amount of time the patient needs to be elevated and thus reduces patient discomfort. It also reduces the amount of work that needs to be done by the assistants.
4. For high-energy injuries, we prefer to use Jones’ cotton in place of regular cotton cast padding.
5. Use of a “mega-ACE” bandage that is 11 yards long makes securing this splint much more manageable because it eliminates the need for multiple elastic bandages.
6. Premade 45-inch plaster slabs typically are an appropriate length for all three slabs necessary for this splint.
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Figure 14-17

Equipment

1. 4- or 6-inch stockinette
2. Jones’ cotton and/or 6-inch cast padding
3. 4-, 5-, or 6-inch plaster
4. 6-inch elastic or self-adherent bandage
5. 2-inch silk tape

Basic Technique

1. Patient positioning:

a. Supine on a stretcher

2. Where to start:

a. Upper thigh both medially and laterally

3. Where to finish:

a. Distal aspect of foot; may include the toes

4. Where to mold:

a. Supracondylar region and/or supramalleolar region to prevent migration of the splint distalward

5. Steps:

a. Measure the length of the splint.
b. Roll out the plaster.
c. Prepare the plaster in the usual fashion.
d. Position the patient.
e. Apply Jones’ cotton or other cast padding.
f. Apply slabs of plaster.
g. Apply a second layer of cast padding.
h. Overwrap with an elastic bandage.
i. Mold the splint.

Detailed Technique

1. Measure the length of the splint using plaster (Figures 14-18 and 14-19):

a. Use the contralateral uninjured side if necessary.
b. A single measurement will be taken using the lateral aspect.
c. Measure from the medial malleolus, circle around the foot, and extend until the upper aspect of the lateral thigh is reached.
2. Roll out the plaster.

a. The plaster slab should be 10 to 12 sheets thick.
b. Alternatively, use 45 × 5 inch prefabricated slabs.

3. Prepare the plaster in the usual fashion. Use the standard technique of wetting and laminating (see Chapter 12).

a. Use water that is slightly cooler than that used for other splints.
b. Hang the plaster strips from the stretcher or lay them out on a bed sheet.
4. Place a padded crutch beneath the mattress on the stretcher so that only a foot of the top of the stretcher remains visible (Figure 14-20).
5. Position the patient:

a. The patient is supine with his or her pelvis halfway onto the crutch (Figure 14-21). Make sure the patient and the crutch are secure.
b. Allow the limb to hang down, or support it by placing the patient’s foot on your thigh (Figure 14-22). If assistants are available, they can elevate the limb.

6. Apply Jones’ cotton or regular cast padding (Figure 14-23):

a. If using Jones’ cotton, start at metatarsal heads and wrap in a circumferential fashion proximally to the mid thigh with minimal overlap.
b. If using standard padding, begin proximally or distally depending on your preference.
7. Apply the splint.

a. Begin with the posterior slab:

(1) Start at the foot and extend proximally.
(2) Provisionally secure the splint with cast padding at the knee and then the thigh (Figure 14-24).
(3) Fold down any excess splint.

b. Apply the lateral and medial wraparound slab:

(1) Start proximally at the upper thigh and extend distally (Figure 14-25).
(2) Provisionally secure the splint with cast padding at the thigh and then at the knee.
(3) Overwrap with cast padding (Figure 14-26).

8. Perform a reduction maneuver if required.
9. Definitively secure the splint with an ACE wrap (Figures 14-27 and 14-28

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