Septic Shock with Skin Ulceration and Infection After Use of a Synthetic Hip Spica Cast for Treatment of Congenital Dislocation of the Hip

Introduction

Plaster of Paris and synthetic cast materials can hide infection, pressure sores, and skin injury under the sharp edges of the cast.¹ Although a synthetic cast is not compromised by water, the padding material underneath can become wet, resulting in skin maceration and breakdown with secondary superficial skin infection.^2,3 We describe a case of a 5-month old girl who developed severe, widespread skin ulceration and infection after application of a synthetic hip spica cast for treatment of left congenital dislocation of the hip. The case was complicated by the development of septic shock that threatened the life of the patient.

CASE REPORT

A 5-month old Saudi girl was admitted to the pediatric orthopedic clinic with congenital dislocation of the left hip. A concentric closed reduction was achieved under general anesthesia, and a bilateral hip spica synthetic cast was applied. The patient was discharged home on the same day.

After 12 days, the child presented in the emergency room with fever and irritability. There was redness of the skin around the upper margin of the spica cast with pressure sores at the edges. The cast was very dirty, with wet padding and a bad smell. She was admitted and IV antibiotics were started (clindamycin 90 mg/8h and gentamicin 17.5 mg/8h). In the evening of the same day, septic shock developed, the patient’s condition deteriorated, and she was transferred to the paediatric intensive care unit (PICU). When the cast was removed the skin was found to be macerated and sloughed over most of the lower abdomen, buttocks and both thighs, which were covered by dirt, pus and live maggots. A culture swab yielded Pseudomonas aeruginosa sensitive to gentamycin and ceftazidime. The patient recovered from septic shock and was discharged from the PICU to the orthopedic ward after 4 days. Treatment of the skin ulcers was successful, with complete healing of all wounds after a hospital stay of 5 weeks. The patient was left with residual scars in the deeply infected and sloughed areas. Treatment eventually resulted in a reduced stable hip.

DISCUSSION

Fiberglass casts are radiolucent, lightweight, strong, and set quickly, but are not without disadvantages compared with plaster casts.^4,5 Synthetic materials cost at least five times as much as plaster of Paris³ and have poor molding capability. Skin abrasions or macerations can occur as a result of sharp cast edges or wet padding.^5,6 Moderate allergenicity may add to skin complications.⁴

Earlier reports of skin problems with use of fiberglass casts describe mild-to-moderate cases treated by removal of the cast and local application of skin creams or lotions. General methods for avoiding minor skin problems are well known to orthopedic surgeons and plaster technicians.^3,4,6 These include use of adequate padding, particularly around the edges, use materials of low allergenicity and producing less heat during setting, use of cold water during washing to avoid skin burns, and taking measures to keep the padding dry. If the cast accidentally gets wet, drying it with a blow dryer may prevent skin problems. Since infants and young children cannot clearly point to areas of pain and irritation, mothers should be given very clear written instructions on how to care for the case and recognize problems. Patients should not be discharged until the patient or guardian is awareof possible complications and preventative measures. They should be told not to ignore early signs of skin problems since a few days delay could lead to serious harm, including loss of life.