Hip spica is one of the most commonly used casting constructs in India. It is either used as a primary treatment modality or as an adjunct for treatment for nearly all paediatric hip pathologies like femur fracture in young children, proximal femur osteotomy, septic arthritis of the hip and developmental dysplasia of the hip (DDH). [1] The application of a hip spica is a skill which is a must-know for every paediatric orthopaedic surgeon. The technique of application has evolved over time to suit the economic condition of the patient, comfort of the surgeon and mechanical stability of the spica. Variations in this regard are broadly seen in the following aspects 1) Setup of operating room for application, 2) Materials used and 3) Usage of a connecting bar. There are a number of devices and operating room setups used to apply a hip spica. A metal bar, hammock suspension, arm board and wooden plank are some of methods described in literature. [2,3,4] All of these are used by paediatric orthopaedic surgeons all over India. Plaster of Paris is a low-cost material which is used for the making of a hip spica. This is not mechanical very strong and incidence of breakage is high. If the spica is made thicker, it leads to increased weight of the cast and is not comfortable for the patient. Fibreglass is a lighter material. It is more durable but is expensive and not suitable in a low economic society. Hybrid cast is a better option which is as durable as a pure fibreglass spica but is not as expensive. [5] A connecting bar between the limbs of the spica adds mechanical stability and reduces failure rates without increasing the cost. [6] This reinforcement can be taken using a wooden bar or any cost effective material. Thus, the focus, in India, is on reducing the cost of the set up so that it can be established in a peripheral centre in rural parts of the country without comprising on the quality of spica applied. In this study, we analyse the different casting methods, setup for spica application and the use of connecting bar implemented across India. This will help us know the general consensus among experts in these methods and the advantages and disadvantages of the variations.

After approval of the local ethics and scientific committee, a cross-sectional survey was conducted using a digital online questionnaire or a recorded telephonic conversation among 40 Paediatric Orthopaedic surgeons across India. Those orthopaedic surgeons who have completed a minimum of 1 year of fellowship in Paediatric Orthopaedics were included. The survey questionnaire (Table 1) comprised of questions pertaining to the technique of application of spica, materials used and the usage of connecting bar.

i. Average spica’s applied, indications and maximum age applied A paediatric orthopaedician in India, applies an average of 3 hip spica’s a month. With trauma (neck femur and shaft femur) of appropriate age group being the commonest indication (100%) followed by DDH (90%) The oldest child for which a spica, applied being 16 years, with a mode of 12 years. ii. Setup for spica application A commercial paediatric hip spica table is available with 18 of the 40 respondents, 4 have customised a spica table and the rest 18 use a simple wooden board. iii. Material used for spica application A vast majority 78% apply hybrid spica’s, with only 2 of the 40 respondents using fibreglass alone. iv. Connecting rod About 28 respondents use a connecting rod in their spica’s and the top three cited reasons being older, heavier and hyperactive children. The reasons for not using a connecting rod being hinderance to perineal care and the fact that a hybrid spica is structurally quite stable. v. Time taken The average time taken to apply a hip spica being 27 minutes, there being no significant difference in the time taken for spica applied using a commercial spica table (27 minutes) and plank technique (25 minutes) With respect to the materials used a hybrid cast takes the least time (23 minutes) followed by fibreglass (25 minutes) and POP (33 minutes).

Application of hip spica is a skill developed by a paediatric orthopaedic surgeon over time. Surgeons often adapt techniques based on individual experience and clinical context. Our survey shows that a spica table is commonly used among surgeons in India. Set up of a spica table is technically demanding and expensive, hence more commonly seen in urban practioners. This hinders its use in a peripheral set up in rural India. A wooden board or a plank is the next common appliance used. This is cost effective and easy to manufacture. Specific dimensions of the plank are also being studied. Our findings reveal that while commercial spica tables are used by nearly half of the respondents, their cost and technical demands limit widespread adoption, particularly in rural or resource-constrained settings. In contrast, wooden planks offer a cost-effective and easily replicable alternative, making them a practical solution for peripheral centers. Ongoing efforts to standardize plank dimensions may further enhance their utility and safety. Materials used for the spica cast influence its strength and durability. Stronger fibreglass casts are more expensive. Less expensive Plaster of Paris casts are not strong and durable. Our survey shows that hybrid of plaster of Paris and fibreglass casts is most commonly used. These hybrid casts are found to be as durable and strong as the fibreglass ones but not as expensive. [5] Hence hybrid casts are shown to be a better option and the most used among Paediatric Orthopaedic surgeons in India. Material selection plays a critical role in cast durability and patient comfort. Although fiberglass offers superior mechanical strength and reduced weight, its high cost restricts its use. Plaster of Paris (POP), while economical, is heavier and prone to breakage. The hybrid approach—combining POP and fiberglass—emerges as the preferred choice among 78% of surveyed surgeons. This method balances strength, cost, and application time, aligning well with the socioeconomic realities of Indian practice. A connecting bar between the two limbs in a one and a half spica or both leg spica adds additional mechanical stability. [6] This study reveals that most surgeons use it in hyperactive or obese patients who pose a risk of breakage of spica. The reason for this is found to be that a hybrid spica or a fibreglass spica is said to provide a high level of mechanical stability and there is no requirement of a connecting bar. A connecting bar also is found to be a hindrance to the perineal care of the patient. This has not been described in any study so far. CONCLUSION Our study shows that a spica table or a wooden plank is most commonly used technique of application of a spica in an Indian setup. Hybrid casts are the most commonly used material. Connecting rods are being used only in bulky children requiring higher stability and not in all children as it hinders perineal care. Overall, the survey underscores a pragmatic approach among Indian pediatric orthopedic surgeons—favoring hybrid materials and adaptable setups to optimize outcomes while minimizing costs. These insights can inform training programs and guide resource allocation, especially in low-resource environments. This survey shows the most common techniques used by trained paediatric orthopaedic surgeons across India and hence can be considered as an input to young trainees. However, every surgeon introduces new variables based on experiences in daily practices and responses from the patients and colleagues.

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