Hip Dysplasia and Hip Spica Casts
The hip is a large ‘ball and socket’ joint which forms as part of normal growth and development as a baby becomes weight bearing.
Hip dysplasia occurs when the ball moves out of the socket. Also called developmental dysplasia of the hip (DDH), it is a congenital disorder which is present at birth in which one hip is dislocated or easily dislocated.
The disorder is about five times more common in infant girls than in infant boys, and the left hip is three times more likely to be affected than the right hip. Sometimes, both hips are affected.
Left untreated, hip dysplasia tends to worsen as the child grows and becomes more active and, if not treated, may result in the child learning to walk with a limp or unusual waddling gait.
As an adult, the condition could cause severe pain and may require hip replacement surgery.
All newborn babies are checked for hip dysplasia. This is done by a doctor or nurse placing the baby on their back and rotating the hips to check for the disorder. In a baby with hip dysplasia, the socket that holds the ball of the hip (the joint) is too shallow, making it easy for the hip to slip out. Hip dyplasia is easy to recognize with a clunking sound when the hip is rotated being the most obvious sign.
Other signs include:
- Reduced joint mobility
- Unusually wide perineum (the stretch of skin between the anus and the genitals)
- The skin creases of the buttocks don’t match
- One knee joint looks higher than the other
If the doctor believes that the mobility of your baby’s hips is not quite right, an x-ray will be arranged to confirm if your child has hip dysplasia.
Most babies (under 6 months of age) diagnosed with hip dysplasia are successfully treated with a device called a Pavlik harness which holds the baby’s hip in a position that allows the joint to develop normally. The harness is usually worn for 6 – 12 weeks.
Older children are a bit more difficult to treat and may require corrective surgery to put the hip bone back into the socket.
Bilateral VDRO http://www.hipdysplasia.org/developmental-dysplasia-of-the-hip/child-treatment-methods/
After surgery, a hip cast (also referred to as a hip spica) may be necessary to keep the hips in place.
All You Need to Know about Hip Spica Casts
Your child will have to be wear the hip spica cast for a period of approximately 3 months. This period may be shorter but if this is the case you will be advised by your Orthopaedic Surgeon. When in a hip spica, the legs are usually plastered quite widely apart. The affected hip will be plastered to the ankle. The unaffected hip may only be cast to above the knee. There may also a stick incorporated into the cast which sits between the thighs/knees. This stabilises the cast to ensure the limb remains in the correct position. The plaster is applied when the child is under a general anaesthetic in theatre. A nurse from Orthopaedic Outpatient Department assists the doctor with the application of the cast in theatre where padding, plaster and fibreglass are applied. You and your child may also be given the opportunity to choose the colour of the fibreglass before going to theatre.
To see how a hip spica cast is applied click here.
Care of a Hip Spica Cast
A hip spica cast should be kept dry at all times. Prior to discharge, the nurses in the ward should tape around the groin areas with Sleek tape (a waterproof adhesive strapping); also referred to as ‘petaling’ the cast. This protects the child’s skin from the rough edges of the cast around the diaper opening and also adds an extra layer of protection in case urine or faeces gets through or around the diapers. If the tape does get soiled it can be removed and replaced with clean tape. This is especially important at the diaper cut-out area of the cast.
To do this at home after discharge from hospital start with a piece of Sleek tape about 10cm long and wrap it, short side, over the edge of the cast. Add another piece remembering to overlap the pieces as you go all around the opening of the cast. As more pieces of tape are added, they resemble the petals of a flower; this is why this technique is called petaling.
Further supplies of Sleek tape should be arranged by your Homecare Nurse or Community Nurse. A referral to these people should be arranged by the ward nurses on discharge.
Personal Care whilst in a Hip Spica Cast
Disposable nappies are preferable for a child in a hip spica cast as they tend to hold urine better than cloth nappies and there’s less chance of moisture seeping into the plaster. If your child is still in nappies you can continue to use these, however you may need to use a larger size. It is also advisable to use a smaller sized continence pad, sanitary pad(s) or nappy with the tabs removed tucked into the groin outlet under the nappy. Every child is different so you probably have to experiment with various nappies and incontinence pads until you find the right one for your child. Nappies should be changed frequently as this assists in keeping the cast clean and dry. If the cast gets wet, dry it with a blow dryer on cool setting. You will be supplied with nappies and pads during your stay in hospital but it is a good idea to be prepared ahead of time for returning home.
You many also find that whilst your child is in a hip spica, a urine odour may develop over time. This is normal and is simply due to the length of time that your child is in plaster. In extreme cases, some children may need to return to theatre for the hip spica to be changed.
For further information on changing nappies and for personal care of your child click here.
Older children may not be able to sit on a toilet during the time they are in a hip spica. If your child was using the toilet before going into the hip spica and nappies are not appropriate to use, you can use a slipper pan for girls. For boys, you can trial a bedpan and urinal bottle. Occasionally a commode chair can be successfully used.
You can purchase nappies from the Nurse Maude Association at a lower cost than in the supermarket for the duration that your child is in the spica.
Hip Spica Casts and Bath Time
It is not possible to bath your child whilst they are in a hip spica, so they will need a thorough wash (top and tail) with a damp cloth at least once a day to keep them feeling fresh but bath time can still be fun even if your child is in a hip spica cast, it just needs a little more thought and planning !
- Lay a baby on a padded change mat or soft surface next to the kitchen sink
- Fill the sink with water and wash exposed skin with a damp washcloth
- Pull baby to the edge of the change mat with your hand cradling his or her head to wash and rinse hair. Never leave your baby unattended – even for a second
- You can also reach under the cast with a damp washcloth, and then a towel to keep things dry
For toddlers and older children
- Lie your child on a soft surface and position so they are comfortable
- Using a container for warm water and damp washcloth, wash exposed skin and under the cast
- Towel dry
Hip Spica Casts and Washing Hair
Hair washing is one of the most difficult problems especially in the younger child who cannot support him or herself. Depending on the length of your child’s hair, you may use a wet cloth for hair washing. Cover the plaster with towels and make sure that water does not drip down the plaster.
For longer hair, you can use a bucket or bowl whilst your child lies on a bed. Some parents have also found dry shampoo helpful. Most chemists stock these.
Sleeping with a Hip Spica Cast
Your child should be kept on an incline while sleeping, use a wedge or tri-pillow. This is especially important for children who suffer from oesophageal reflux. Folded towels should be placed under your child’s feet or knees or as advised by your Occupational Therapist. If your child is in nappies, raise the head end of their bed to help urine run down into the nappy and not up the back.
When in a hip spica, some children can wake up distressed which can be very worrying, particularly when a young child cannot explain what is wrong. But for the most part, it is usually cramp. Just massage and flex the ankles and feet if these are not also in plaster.
Your child may well also be too hot, this is particularly relevant for children with Spina Bifida who often have trouble regulating their body temperature because of the Chiari II Malformation. The plaster is like cavity wall insulation and your child will need fewer blankets. A sheepskin rug can help soothe and prevent heat rash because it absorbs a third of its own weight in moisture.
Potential Problems for a Child with Spina Bifida whilst in a Hip Spica Cast
For children with Spina Bifida there may be a reduction in skin sensation. Any areas of skin irritation caused by cast rubbing or pressure areas should be closely watched to prevent secondary infection. Duoderm can be used to provide temporary coverage of these areas. Ask your Homecare or Paediatric Nurse for supplies.
If you see any pressure areas caused by your child’s hip spica cast don’t be afraid to contact the Orthopaedic Department and discuss your concerns. In most cases issues can be fixed without too many problems by the Orthopaedic Plaster Nursing team.
Other things to watch
- Do not put things in the cast and keep a close eye on small children who may place objects inside the cast in the course of normal play activity.
- Do not use baby powder or oil on the skin because these will cake and build up and may cause skin irritation.
Hip Spica Casts and Seating/Positioning Options
If your child spends most of their time propped up on pillows or in their pram lying on their back, the pressure of the cast on their spine can cause the skin to become sore. To prevent this you must change your child’s position frequently (approximately every 2-4 hours) by turning your child on their side or tummy.
Plenty of pillows under the body and the plaster help to make your child more comfortable. The most vulnerable areas in the hip spica are the ankles and the waist, particularly around the spine. The plaster edge often digs in here causing greater discomfort. To ensure the hip spica doesn’t push into your child’s back put a pillow under the back of their legs when lying on their back and when lying on their stomach, place a pillow under the chest to prevent the hip spica pushing into the chest.
It is important that children of all ages have “tummy time” as this allows the pressure on their back and bottom to be relieved.
A bean-bag chair is almost a “must-have.” It moulds around the child and you can place them in almost any position you need from semi-reclined to almost straight up so it can be used for entertainment purposes or whatever you need. Small bean-bags can be used as padding to support the child.
If your baby is in a hip spica cast they may not be able to sit normally in their high-chair because of the way their legs are cast. As an alternate option you can use a stroller in place of a high chair to feed your baby and it folds easily for travel. Use a pillow behind the baby to prop him or her up and always use the belt for safety.
A variety of baby slings have been successfully used by parents to carry babies in hip spica casts. Remember that the cast adds weight and bulk, so make sure you feel comfortable when carrying your baby and that you are not straining your muscles. If your baby’s cast has a bar between the legs, a sling might not work.
Hip Spica Casts and Breastfeeding
You can breastfeed with an infant in a hip spica cast. You might look a little awkward, but it can be done. In general, one leg is by your ear and one leg is by your waist. Also, a 5kg baby becomes an 11kg baby in a hip spica cast, so use pillows to support your arms and wrists so they don’t get tired.
Diet and Meal Times
Your child may no longer fit in their usual high chair so you may need to find an alternative way of sitting them up whilst eating. It is a good idea to completely cover the whole plaster to ensure it remains clean and to stop food getting inside the cast. It is also useful to use a straw or a cup with a lid to avoid spillages.
Many parents find that their child’s eating habits are unaffected by being in a hip spica although they can get constipated as they are spending so much time lying down. You can help avoid this by ensuring their diet has plenty of fibre and make sure they drink lots of water as well. If the problem persists and makes your child uncomfortable it is best to seek medical advice.
Clothing your Child in a Hip Spica Cast
Due to the size and shape of a spica, dressing your child will be more difficult than usual.
For small babies, the easiest type of clothing for your child to wear whilst they are in a hip spica are babygrows that are a few sizes larger than usual.
Girls’ dresses usually fit over the plaster with no problems with adapted knickers (if nappies are not suitable).
For both boys and girls, if the spica cast is coloured the cast itself can act like a pair of trousers. Just use a pair of shorts or vest with poppers to cover the nappy area or you can use blankets, altered underwear or adapted pants to go over/around the spica.
To alter trousers to allow for the hip spica follow these directions
- Open the trousers right down the outside seam of one leg.
- Attach Velcro at intervals down opened leg with a “hook” and “loop” pieces on opposite sides so that they attach together.
You can alter underwear in the same manner with Velcro. Just remember to buy bigger sized underwear to accommodate the width of cast around the child’s abdomen.
You can also use knee-length socks if the cast allows. If your child’s cast comes down to their ankles remember their feet can be cold even in warm weather so they may be more comfortable wearing socks. Baby leg warmers are also useful.
In the initial stages, shoes are not recommended as there may be swelling in the toes and feet.
For more information on dressing your child in a hip spica click here
Hip Spica Casts and Child’s Play
It is very important that your child continues to engage in developmentally appropriate play. This may require more input than usual from parent(s), sibling(s), extended family/whanau and friends, as your child will not be independently mobile and will therefore require toys and games to be brought to them.
If your child attends a day care/pre school/kindergarten or is at school, it is a good idea to take them to see friends and engage in appropriate activities in this setting if you are able.
Remember that the cast must not get wet and should not have anything put down inside it eg sand, play-dough, paint, toys, food, etc. as this can harm both the child’s skin and the cast and could create a pressure area within the cast. It is also important to keep in mind, issues around toileting if you are taking your child out anywhere.
Hip Spica Casts and Travel
Getting out and about can be challenging but it is essential for your own emotional well-being.
Dependant upon your child’s age and shape of the hip spica, they may fit into their own pram/buggy.
Whatever style of pushchair you use it is essential that your child is always strapped in securely using the harness provided. If your child’s feet stick out at the sides, you will need to take extra care not to bang them going through doorways or other people walking into them.One of the best forms of pushchairs available are the twin side by side ones but these can be expensive to buy unless you can borrow one or buy second hand.
You will also need to be prepared if it rains as it’s important that the hip spica does not get wet. You may need to be inventive as the waterproof raincover provided with your pushchair may not fit over the cast. An adult raincoat works well – use the arms to cover your child’s legs and tuck the body around his/her upper body.
Mobility options for older children should be discussed with your Occupational Therapist.
The law in New Zealand requires you to have all children under 7 years of age (effective 1 November 2013) restrained in a child car restraint for every ride. The restraint must be a child restraint appropriate for the height and weight of the child, the vehicle safety belt on its own is not enough.
But after your child has been fitted with a hip spica cast it may not be possible for them to be seated comfortably in their carseat. It is a wise idea to take your carseat into hospital with you and ask for it to be assessed by an Occupational Therapist prior to (but not on the day of) discharge.
There have been cases where parents have been forced into the unnecessary expense of purchasing a suitable carseat due to a lack of planning and communication.
Most hospitals have access to a pool of hire carseats that are designed for children in hip spicas but accessing these takes a day or two and no parent wants to spend more time in hospital than is absolutely necessary. Ask the Occupational Therapist about availability of a hire seat.
Plunket also have a Disability Allowance – reimbursement for carseat expenses
If you are having trouble accessing a carseat in time for discharge, ask to be transferred home via St Johns Ambulance Service.
Looking After Yourself while your Child is in a Hip Spica Cast
Like most parents of children with Spina Bifida you are probably well used to hospital admissions but it is important to acknowledge that although this is just another procedure, it is hard to prepare yourself for your child having a hip spica. For the majority of parents this seems like an insurmountable hurdle and it can be a physically and mentally hard time. Having a hip spica cast applied is often more distressing for parents than it is for your child.
During the first few weeks you may feel overwhelmed and isolated as you adjust to life with your child in a hip spica and the difference it makes to your family life and routines. This is completely normal; BUT you are not alone and your reactions are likely to be similar to other parents who have also been in the same situation. Every family seems to find their own solutions to the challenges that life in a hip spica brings but if you are feeling overwhelmed please contact us we are here to support and assist you. We will be able to match you with another family who has been through this procedure. They will be able to share their experience, problems and solutions with you.
Alternatively you may like some emotional support from an external source. Contact your local Child Development Centre for regional support service providers.
Waikato Region True Colours Charitable Trust
Hip Spica Cast Removal
The day you have been looking forward to has arrived and your child will have his/her hip spica cast removed. Their first real bath in some time will be happening soon!
The hip spica cast will be removed by an Orthopaedic Nurse using with a cast saw that vibrates instead of making a circular motion. The vibration cuts through hard cast materials, but not through the padding underneath the cast. The cast saw is loud when operating and the Orthopaedic Nurses will get your child to wear headphones or ear muffs.
Some children with Spina Bifida are very sensitive to sound and noise levels, so if you are aware that your child is affected by this, then preparatory play ahead of cast removal using headphones or earmuffs is wise.
For more information on hip spica cast removal click here
What happens after the cast removal is completely dependent upon your particular child’s needs and your Orthopaedic Specialists treatment plan for your child. Sometimes a child is weaned off the Spica Cast by having a period of time where the child is fitted with a hip abduction brace. This may be for a further 4-6 week period. Whether or not this is necessary will be advised by your Orthopaedic Specialist. You are likely to have questions about resuming normal life after a hip spica cast is removed. Write these questions down prior to seeing your Orthopaedic Specialist.
For more information on hip abduction bracing click here.
Risks Associated with Hip Dysplasia
There is a risk that children who have treatment for hip dysplasia may develop arthritis in their hips later in life.