Introduction
Over the years, concerns have been expressed by carers of children
in hip-spicas. The social distress caused by the offensive odour
emitted from the cast, causes many families to remain house-bound,
due to a lack of public understanding. Hip-spica casts cover the
body from above the waist to the ankles immobilising one or both
hips. This type of cast when used in paediatric orthopaedics varies
from femoral fractures, developmental dysplasia of the hip (D.D.H.),
hip and pelvic osteotomies to tendon llengthening. The conventional
application of the hip-spicas used at this hospital is Duoderm™
to the spine, undercast wrap, Plaster of Paris then synthetic casting
material. When dry, all edges of the hip-spica are sealed with waterproof
tape. The carers are instructed on feeding habits, cleanliness,
an appointment in the orthopaedic clinic is scheduled for assessment
of the hip-spica, skin and social dilemmas. As a health care professional
this is when we start to see problems. The main one, even after
just one week, is the odour, which to some carers is intolerable.
An attempt is made to reassure the carers, for obvious reasons a
change of the hip-spica is undesirable. If feasable, weekly visits
are encouraged for examination of the hip-spica and the baby's skin.
The normal time frame of a hip-spica being replaced due to skin
excoriation and odour, not orthopaedic reasons, is two to four weeks.
The Aim
The aim of using this material, was to reduce the following:
• Distress experienced by carers, caused by odour from conventional
casts
• Skin deterioration on the baby
• Altered treatment plan. The material used was PANTALOON protective
liner. A one piece design that creates a barrier protecting the
padding from soiling, thereby reducing the odour normally associated
with the conventional method. As the liner is waterproof, careres
can clean both the baby's skin and the inside of the hip-spica gently
with moist wipes. With most of the odour emitted and skin kept clean
and dry, unscheduled changes of the hip-spica would be avoided.
In two clinically controlled studies, the incidence of skin excoriation
under children's hip-spica casts were significantly reduced.
The Killian Study, published in 1992 provides the following statistical
information:
• Casts without PANTALOON liner: 28% skin excoriation
• Casts with PANTALOON liner: 2% skin excoriation
The Wolff & James Study, published in 1995, provides similar
results:
• Casts without PANTALOON liner: 31% skin excoriation
• Casts with PANTALOON liner: 2.8 % skin excoriation
Application of PANTALOON Protective Liner for D.D.H
The appropriate sized one piece PANTALOON liner is fitted with
a tummy pad onto clean skin after any surgical incisions have been
covered. Duoderm is applied to the spine, the baby is then positioned
on a hip-spica table (see Figure 1). Creases in the liner do not
appear to cause any skin deterioration. Under cast padding is applied
with Rest-on™ foam to the top of the hip-spica and ankles.
A well-moulded cast is applied using synthetic cast material (Plaster
of Paris may be used). After the first layer is applied, the PANTALOON
edges are folded back being anchored with another layer of synthetic
cast material. The child is then removed from the hip-spica table
and the tummy pad removed. The carers are instructed on how to care
for the liner and skin by using moist wipes (not showering) around
the perineum opening and anus. Also the usual carrying and feeding
instructions are given. Two of the children involved in the procedure,
also had the conventional hip-spica first.
This is their medical history.
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Female. Twin 2. Breach. Heart Murmur.
D.D.H. treatment started at ten months in a Pavlik Harness.
• Cardiac catheter at ten months for Tetralogy of Fallot
• Repair of Tetralogy of Fallot at eleven months
• Eleven and a half months -open reduction of hips, conventional
hip-spica applied
• Four outpatients visits in two weeks due to conceern of the
hip-spica odour and skin deterioration
• Two weeks after application, hip-spica removed due to soiling
and skin irritation
• Hip-spica reapplied using PANTALOON liner. Hip-spica in situ
for five weeks, skin in good condition with very little odour on
removal. See Figure 2. Carers were most impressed with the application
of the PANTALOON, as they had the need for only one orthopaedic
clinic visit for hip-spica check, prior to the removal of the hip-spica
after five weeks.
Female. breach. No Other Complications
D.D.H. noted at six weeks. Pavlik Harness for four weeks.
• Conventional hip-spica for eleven days
• Hip-spica changed due to acute diarrhoea and urinary tract
infection, causing cast to be heavily soiled.
Hip-spica re-applied using PANTALOON liner, which was in situ
for seven weeks. On removal, skin was found to be in excellent condition.
See Figure 3.
• The baby's comfort and skin integrity were not compromised
• The carer was very appreciative that hospital visits were
kept to a minimum
• Cast cleanlinesswas easy to maintain and odour free.
Conclusion
The aim was to use materials that would not undermine the medical
and surgical treatment of babies with D.D.H. in hip-spicas. Over
a six-month period, five babies were cast with the PANTALOON liner
under the hip-spica of which only one had an unscheduled change.
This was due to a growth spurt, where the hip-spica became tight,
not due to odour or skin excoriation. Of all parties concerned (orthopaedic
consultants, casting staff, carers, and babies), all were pleased
with the result. Lack of odour, skin problems, unscheduled hip-spica
changes and less hospital visits made for a more successful treatment
of D.D.H.
There are still modifications that can be made by staff to ensure
an even better result. This only comes with continual use of the
product and the participation and co-operation of all medical staff
and carers.
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