Hip spica nursing care

See also

Background

Hip Spica is a plaster cast that extends from the torso down to the feet and is applied in theatre under a general anaesthetic. The objective of the hip spica is to immobilise the hip, pelvis and/or femur fractures, or post reduction for developmental dysplasia of the hip (DDH). Hip spicas are generally used for children from 6 months to 6 years of age and may be in place for 6 weeks to 6 months depending on the medical condition. Frequent neurovascular observations and pressure area care are required in the post operative period. The spica nappy area needs to be taped with sleek prior to discharge to assist in keeping this area as clean for as long as possible. The plaster cast should then be reinforced with scotching/fibreglass. Patients will need to be fitted into a car seat by an Occupational Therapist for all new Hip Spicas. For a change of existing hip spica or hip brace application Registered Nurses can undertake car seat fitting/modifications.

Aim

The aim of this CPG is to guide nursing staff on the assessment and management of children with a hip spica in the post operative period and to ensure that the hip spica is appropriately reinforced prior to discharge.

Definition of terms

Closed reduction: The hip is gently manipulated into the acetabulum by flexion, traction and abduction under a general anaesthetic and then immobilised in a hip spica cast.
Compartment syndrome: Increase in pressure of a closed muscle compartment that causes muscle and nerve ischemia.
Developmental Dysplasia of the Hip (DDH): An abnormality in the development of the hip joint. The size, shape, orientation, or organisation of the femoral head, acetabulum or both can be affected. The abnormality may be congenital or may develop during infancy or childhood.
Hip Spica: A plaster of Paris covering the torso and continuing down to the ankle on the affected side and to the knee on the unaffected side or covering bilateral legs to the ankle. There is an opening around the perineal area for toileting. Used to immobilise and maintain optimal position for abduction and flexion of the hips, pelvis, and/or femur.
Open Reduction: Usually performed after failed closed reduction in children greater than 2 years. Involves lengthening tendons, removing obstacles to reduction, and tightening the hip capsule.

Assessment

Patient assessment

Post-operative x-ray or CT is required to check the patient’s position in the cast and is usually performed in theatre, or post-operatively.
Patients require regular pain assessment using an age-appropriate assessment tool.
Neurovascular observations should be conducted on bilateral lower limbs 30 minutely for the first 4 hours, then hourly for the first 24 hours, then 4 hourly until discharge or more frequently if any deviation from baseline observations. Document findings on appropriate limb observation flowsheet.
Other assessments as per RCH Nursing Guideline: Routine Post Anasethic Observation and/or RCH Nursing Guideline: Nursing Assessment.

Skin and plaster assessment

Evaluate patients’ skin integrity regularly. Observe for any redness, irritation or burning sensation.
Children who have had an open reduction or osteotomy may have swelling in the groin area. Monitor swelling and plaster to ensure the cast is not too tight.
Limbs should be elevated with pillows to increase venous return, decrease swelling and reduce the risk of compartment syndrome.

Management

Positioning

Children in hip spicas cannot move themselves easily. The child should be repositioned 2-4 hourly, during the day and night.
The child can be placed supine, prone or on their side if comfortable, and must be supported with pillows and/or towels to alleviate any pressure from the plaster, and to provide support. Ensure the child is supervised while lying prone to ensure monitoring of airway.
With each change of positioning, check that the plaster is not causing pressure, and is not too tight around the edges (torso, ankles, groin, and knees).
Parents should be educated that at home the patient should lie prone once daily, for as long as tolerated (up to 2 hours), as this allows the skin to fall away from the back of the spica. Parents should be provided with a demonstration of this.

Toileting

Nappies need to be checked every 2 hours during the day and 3-4 hourly overnight. They must be changed as soon as they are soiled or wet to prevent soiling/ wetting the plaster, and to avoid skin breakdown and irritation.
Newborn nappies or sanitary pads should be tucked into the front and back of the toileting area and covered with a larger disposable nappy. Ensure you check that the nappy is fully tucked in with smooth edges to ensure appropriate coverage and to prevent pressure areas. See Figure 1
Children who are continent can use a bed pan and/or urinal bottle. When using a bedpan, elevate the child’s head and shoulders with pillows and/or bed mechanics. This will help prevent urine and/or faeces from running backward and inside the cast.

Figure 1. Example of sanitary pad tucked under spica and nappy application.

Cast care

Keeping the cast clean and dry is essential as wetness or soiling encourages microbial growth, which can cause skin irritation, odour and compromise the integrity of the cast.
Plaster can take up to 24- 48 hours to dry post application. If plaster is taking a long time to dry, the patient can be placed prone to help circulate air and may be dried with a cool hair dryer if required.
Observe the cast for cracks, dents, softening, increasing tightness or looseness, or drainage on the cast.

Sleeking

Once the plaster is dry, the groin area needs to be taped with sleek prior to discharge to assist in keeping this area as clean and for as long as possible.
If orthopaedic foam or pink felt is present this should be removed from the groin area prior to sleeking.
Sleeking is performed by applying sleek tape around the edges of the plaster in the groin area. Do not sleek the ankles or waist.
Using sleek tape cut several 10 cm long pieces and tuck one end of the tape under the cast and pull the free end over the cast surface. Continue to overlap strips of tape until all edges are covered, See figure 2.
You may need to wait for swelling to decrease before sleeking.
Sleek tape may need to be replaced if it is wet or soiled or as it comes off overtime, parents should be educated on how to sleek and supplied with sleek tape on discharge.

Figure 2. Applying waterproof tape to edges of the groin area.

Scotching/Fibreglass

Scotching is completed by applying a thin layer of fibreglass over the plaster to make it stronger. Plaster should be dry before scotching usually 24-48hrs post-surgery.
When scotching DON gloves then start at the abdomen first then scotch each leg after.

Diet/Constipation

Place child upright during meals. Small frequent meals should be recommended if the child is uncomfortable after eating due to the pressure on the stomach from the hip spica.
Constipation can occur due to immobility and medication use therefore aperients may be required and parents should be encouraged to ensure good oral intake and foods high in fibre.

Potential Complications

Potential Complications	Description/ Symptoms	Management
Pressure Areas	Pressure areas can develop on parts of the body where the blood flow is reduced because of prolonged pressure caused by the hip spica or positioning. May cause pain or a buring sensation, local hear and an offensive smell.	Alert the orthopaedic team if any pressure areas are noted. Please see RCH Nursing Guideline: Pressure Injury Prevention and Management
Pruritus	Itchiness under or around the hip spica cast	Antihistamines or Barrier cream may be advised by the Orthopaedic team to help relieve pruritus or prevent chafing around the edges of the cast.
Plaster Issues	The hip spica has become soiled, cracked, or damaged	Notify the Orthopaedic team for assessment to determine if the hip spica will need to be replaced.
Neurovascular Compromise	Increased pain, decreased sensation, decreased motor function, decreased perfusion	Immediately report to the orthopaedic team for urgent review and management. *Compartment syndrome is considered a surgical emergency and patients must be reviewed urgently by the surgeon if compartment syndrome is suspected.* If neurovascular compromise occurs the orthopaedic team will need to revise, trim, or modify the cast.

Discharge Planning and Assessment

Physiotherapy

Patients should be referred to physiotherapy for fitting of all prams/strollers and wheelchairs.
Families should be provided with the appropriate education to support them in transferring the child without causing injury to themselves.

Occupational Therapy

All children in a new hip spica for the first time will be referred to an orthopaedic occupational therapist to address areas, such as toileting, bathing and car seating.
Children must be fitted into a safe and appropriate car seat. Parents need to be advised to bring their car seat to the ward as soon as possible for assessment and modification.
For patients having an application of a new hip spica cast Occupational Therapy are responsible to fit and modify car seats. These patients are not able to be discharged until this has been completed.
For patients having a hip brace application or have had a change of an existing hip spica nursing staff are required fit children into their car seat or undertake a fit check.
Please see figure 3 for reference to when Occupational Therapy should be referred to for car seating vs nursing staff.
Please see OT Car Seating for Hip Spicas and Hip Braces guide for detailed instructions on fitting children to car seats and completing the required documentation and letters for families.
If the patient is unable to be fitted into an appropriate restraint for transport home, the orthopaedic team should be notified to discuss alternative options.

Figure 3. Nursing and Occupational Therapy referral for car sea fitting pathway.

Follow-up / Review

The patient will normally require a follow-up appointment 6 weeks post-surgery, with an x-ray to be performed prior to seeing the doctor.

Removal

Removal of a hip spica is done at the discretion of the orthopaedic team. Removal can be done in theatre under a general anaesthetic or in an outpatient setting.
Hip spicas are removed using a plaster saw. The spica is cut down the lateral and medial aspect of the legs.
This can be distressing for the patient. Analgesia and positioning for comfort should be considered.
It is encouraged to maintain the same position of the patient’s legs until the muscles relax following removal. This will decrease patient distress.

Parent Information

Parents should be given the Hip Spica Plaster Kids Health Information handout which provide written and visual care instructions.
Educate and involve parents in ADL’s, positioning and transferring early in care.
Early discharge planning and education is best to increase parental confidence.
Document education provided in the Education section in the ADT Navigators Activity

Reference List

Clinical Practice Guidelines

Other Resources

Evidence Table

Please click here to view the evidence table.

Please remember to read the disclaimer.

The revision of this nursing guideline was coordinated by Ebony Larter, CSN, Platypus Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated April 2023.

The Royal Children's Hospital Melbourne

Nursing guidelines