1. Horn, Pamela L.
  2. Badowski, Elizabeth


Spica casts are utilized to immobilize young patients who have sustained femur fractures or who have undergone hip procedures/surgery. These casts typically need to stay in place for 4-6 weeks. Improper postoperative care can lead to unplanned, increased morbidity and sequelae. We show that with appropriate education using a video module teaching method, learners who are less familiar with the specific care of these patients and casts will gain an improved comfort level and increased knowledge base. This will translate to better patient care and more complete caregiver education for home.


Article Content

History and Use of Spica Cast

A spica cast is an orthopaedic cast applied to immobilize part or the entire trunk of the body or part/all of one or more extremities. It is used to treat various fractures of the hip and/or femur and/or to correct or maintain the correction of hip deformities after reduction or surgery. Lower extremity spica casts can include both legs entirely, one-and-a-half legs, or a unilateral long-leg spica cast can be applied (Mosby, 2009).


Casting with plaster of Paris was developed in 1851 by a Dutch military surgeon named Antonius Mathijsen. Other casting methods utilizing plaster of Paris (gypsum) were previously attempted; however, these casts were heavy and cumbersome. Mathijsen impregnated cotton bandages with a powder form of plaster of Paris by incorporating water. This method was embraced worldwide and became the standard of care. His work was published in 1852 in a Dutch medical magazine (van Gijn & Gijselhart, 2011). This process slowly evolved over time to include larger body mass areas.


In 1925, Dr. Cole, a surgeon with St. Louis Children's Hospital, studied children with femur fractures for 3 years with regard to remodeling. Initially, these patients were placed in traction and then transitioned to plaster casts. He noted the appropriateness of treating younger children in long plaster casts for femur fractures. These children healed well, remodeling over time without long-term morbidity (Cole, 1925). Another early medical entry regarding the use of a spica cast to treat femur fractures is found in Orthopedics in Childhood. This was published in 1931. The authors note that femur fractures are reduced, and patients can be placed in a molded plaster cast from their toes to their ribs (Sneed, 1931). This practice has continued to this day. Spica casts have also been used in patients with hip dysplasia, post-hip procedures, or surgical procedures to immobilize hips and the joint below typically. In the 1970s, a change in casting material from plaster to fiberglass was used in most instances because it was lighter in weight and it dried much quicker without increasing space due to plaster expansion (DeMaio et al., 2012).


Tachdjian's Pediatric Orthopaedics (Herring, 2014) states that patients 8 years and younger are placed in spica casts for the treatment of femur fractures when there is less than 3 cm of shortening. Bone healing is usually complete in 6-8 weeks, with very few patients needing cast adjustments or a return to the operating room (OR) for a repeat reduction (Herring, 2014). More often, morbidity ensues from skin injury and an increase in return to the OR along with an increase in charges resulting from these injuries. There is little documentation regarding spica cast and skin complications; however, one study notes that its occurrence is not uncommon (DiFazio, Vessey, Zurakowski, Hresko, & Matheney, 2011). Social settings such as abuse cases with inconsistent foster care, inappropriate home care linked to patients who are not toilet-trained, and transportation issues for follow-up care are listed as leading predictive factors relating to risk of these events (DiFazio et al., 2011; Herring, 2014). Herring (2014), DiFazio (2011), and Czertak (1999) state that spica casting is a safe and effective treatment option for femur fractures in young children. Use of spica casts can prevent surgery that can lead to pin tract infection, scarring, wound dehiscence, or the need for additional surgery for instrumentation removal. The results showed that the post-spica application cost for patients (aged 6 months to 6 years) with skin injuries was significantly higher than for those patients without skin injury. The conclusion noted that future research should be completed to "investigate patient education and casting interventions that reduce skin complications" (DiFazio et al., 2011, p. 17).


Context of Quality Improvement Project

Over a 1 year period in a Level 1 urban pediatric facility, children (n = 10) with postoperative spica casts (n = 72) were found to have inappropriately placed waterproof tape and moleskins pieces (petals). These patients were noted to have a higher incidence of abrasions, macerated skin, rashes, and/or fungal infections. This was considered to be a new problem, as the noted incidence seemed to be higher than that in previous years. The problem was thought to be related to the hiring of new nurses on the inpatient orthopaedic unit and in the orthopaedic clinic. In addition to these nurses, other nurses from the float pool and surgery centers (both on campus and off-site facilities) were evaluated to have never been properly trained. We proposed to devise an educational tool that would be available to every orthopaedic clinic nurse, in addition to hospital and surgery center nurses who care for this patient population. The aim was for nurses to gain an improved level of comfort and knowledge with spica cast care that would improve patient safety (fewer skin issues), patient documentation, and caregiver education


Quality Improvement Approach

The goal was to develop an educational tool that would build competence in spica cast care. The American Academy of Ambulatory Nursing states that competence is "having the ability to demonstrate the technical, critical thinking, and interpersonal skills necessary to perform one's job" (Laughlin, 2013, p. 513). Both cognitive and physical abilities need to be utilized when implementing a new skill. The basis of becoming competent is a sufficient knowledge base (Levine & Johnson, 2014).


Independent self-learning modules via computer or self-learning packets are efficient methods of educating RNs about a new skill and help build a foundation for the future. Nurses can learn at their own pace, repeating the information several times if needed. This can free up mentors initially and then they can provide hands-on training to multiple RNs in real time once they have completed the module (Bryant, 1997).


It was decided that an online educational video approach would be most appropriate, as it could demonstrate actual techniques in managing the spica cast and illustrate interactions with caregivers and be easily accessible in all practice areas. The emphasis of the video learning module was on proper treatment of a patient in a spica cast immediately after placement as well as throughout the duration of casting to prevent skin issues such as the aforementioned complications: abrasions, macerated skin, rashes, and/or fungal infections. Two orthopaedic nurse practitioners properly scripted and filmed the 30-minute educational video on the history and background of the spica cast, explained its uses, and demonstrated the proper way to "petal and waterproof" this type of cast. A life-size spica cast model was used for the demonstration (see Figure 1). At the end, a pretend mother asked questions that were pertinent to home care, which were appropriately answered. The video was uploaded to the facility's online education module system along with test questions and an evaluation. The video provided step-by-step instruction on how to properly petal and waterproof a spica cast (see Table 1). "Petals" are approximately 2-4 in. long and 2-3 in. wide, depending on the size of the child/cast. These soft moleskin pieces have been cut from a large roll into shapes like flower petals (see Figure 2). A waterproof tape is used in the groin area (see Figure 1). Both types of protective barriers remain in place throughout the duration of casting. The RN teaches the caregivers that the material is replaced only if it becomes extremely soiled or very loose. Cast repair may take place in the orthopedic clinic or at home and that is part of RN teaching learned while viewing the video. It is necessary to provide complete caregiver education both visually (hands-on in the hospital) and in written form as part of RN education.

Figure 1 - Click to enlarge in new windowFigure 1. Spica cast model.
Figure 2 - Click to enlarge in new windowFigure 2. Moleskin roll and petals.
Table 1 - Click to enlarge in new windowTable 1. Correct Sequence of Postoperative Spica Cast Care

This online video was approved for 0.5 contact hours, which was an added benefit to the RNs.


Quality Improvement Rollout

Participating RNs were employed by the aforementioned pediatric hospital: RNs from the orthopedic inpatient unit, overflow medical-surgical unit, outpatient orthopedic clinics, inpatient and outpatient surgery centers, and RNs from the float pool. A total of 76 RNs viewed, the video.


Participating RNs were asked to take a survey before watching the video teaching module (which included the video, test, and evaluation), and again following completion of the video (see Table 2). There was no area for the RN's name, nor was there identifying information about the unit of employment. There was a section for comments at the end of the second survey. Surveys were collected as RNs completed them, and information was recorded on a weekly basis. At the end of 3 months, the scores were tabulated (see Table 3). A total of 54 pre- and posttest sets of surveys were collected.

Table 2 - Click to enlarge in new windowTable 2. Spica Cast Care Questionnaire Regarding Knowledge Base and Comfort
Table 3 - Click to enlarge in new windowTable 3. Results of Postoperative Spica Cast Care Project


As shown in Table 3, there was a statistically significant improvement in nurses' comfort level with spica cast care. There was a section for comments at the bottom of the posttest, and they were all positive. RNs felt their comfort level improved, their knowledge base was expanded, and they felt ready to complete the task with certainty and confidence. Cast techs (n = 10) who remove casts in the orthopaedic clinic noted that cast care was consistently appropriate after RN education. To date, there have been no adverse skin events related to spica cast care since the rollout of the project 5 months ago.



Based on the response to the video and its potential benefit on overall care outcomes, this video will be added to the yearly educational checklists for all appropriate RNs to review. In addition, it will be made mandatory for all new RNs.



Spica casts are a common treatment option for children with femur fractures or for those undergoing hip procedures or surgery. It is vital to patient safety and to reduce morbidity that RNs are armed with the knowledge base and feel comfortable and confident taking care of this patient population. Initial training with a video education module is efficient, thorough, and likely less costly for the institution. Once RNs are instructed, a mentor or preceptor can conclude the training with hands-on experience and complete competency can be gained from practice. Given the volume of patients in spica casts the pediatric hospital cares for, the knowledge gained from the module will form the base of the education process and allow RNs to feel comfortable, which will, in turn, lead to improved patient care. The authors feel this project was a great success, and it has been decided that this method of teaching can be replicated and utilized in the hospital setting for other educational endeavors.




Bryant G. (1997). Suggestions for a competency-based orientation for an orthopaedic unit. Orthopaedic Nursing, 16(2), 67-75. [Context Link]


Cole W. (1925). Compensatory lengthening of the femur in children after fracture. Annals of Surgery, 82(4), 609-616. [Context Link]


DeMaio M., McHale K., Lenhart M., Garland J, McIlvaine C., Rhode M. (2012, October 17). Plaster: Our orthopaedic heritage. The Journal of Bone and Joint Surgery, 94(20):e152. doi:10.2106/JBJS.L.00183 [Context Link]


DiFazio R., Vessey J., Zurakowski D., Hresko M., Matheney T. (2011). Incidence of skin complications and associated charges in children treated with hip spica casts for femur fractures. Journal of Pediatric Orthopaedics, 31(1), 17-22. [Context Link]


Herring J. (Ed.). (2014). Tachdjian's pediatric orthopaedics. Philadelphia, PA: Elsevier Saunders. [Context Link]


Laughlin C. (Ed.). (2013). Core curriculum for ambulatory care nursing (3rd ed.). Pitman, NJ: American Academy of Ambulatory Nursing. [Context Link]


Levine J., Johnson J. (2014). An organizational competency validation strategy for registered nurses. Journal for Nurses in Professional Development, 30(2), 58-65. [Context Link]


Mosby. (2009). Mosby's medical dictionary (8th ed.). St. Louis, MO: Elsevier Health Sciences. [Context Link]


Sneed W. (1931). Orthopedics in childhood. Philadelphia, PA: JB Lippincott. [Context Link]


van Gijn J., Gijselhart J. (2011). Mathijsen and plaster casts. Nederlands Tijdschrift voor Geneeskunde, 155(42), A3757. [Context Link]


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