In the words of one of the nurses at Princess Margaret Hospital: “Spica’s are notoriously hard to work with.” This was in response to the state of Lucy’s skin when her spica was removed last week – two weeks before it was scheduled to come off.
While we are doing everything we can to get Lucy’s hips better, Lucy’s body seems to be sabotaging our efforts. It refused to be shackled by the Pavlik Harness (read about that story here) and it reacted very badly to being in a cast for what should have been three months.
About a week and a half into the spica, Jon and I discovered that Lucy’s skin on her lower back/top of bottom was looking badly chafed. We weren’t sure how to treat it because we’d been told that no creams or powders were allowed. We decided the best thing would be to create a barrier between her skin and the cast so we placed a cloth nappy insert to line that area. Fortunately there was enough space to do so. I know a lot of casts fit too snugly for this method to work.
The skin was looking terrible and started peeling and then Lucy developed a temperature. On the second day of her temperature reading above 38 degrees celcius I decided to take her in to the hospital to be seen to in case she had developed an infection. Typically, it happened to be a Saturday which meant I could only take her to the Emergency wing rather than Orthopaedics.
The staff on duty weren’t too familiar with spicas and we were due to take Lucy for a 3-week check-up with her specialist in a few days’ time. After examining Lucy, they concluded that her temperature was unlikely to be linked to the condition of her skin and advised me to give her Panadol to keep her fever down. They also took a skin scraping to send to the lab to check for a fungal infection, and said I should discuss it further with the specialist on Wednesday.
Fortunately her fever came down on the third day and by the time we went for her check-up the skin was looking a lot better. (The cloth nappy insert proved to be a very effective addition to our nappy system and we used it for the duration of the spica, changing it at least twice a day. Lucy never had another skin problem in that area.) When I raised the issue with the specialist he wasn’t remotely concerned about it and said that he had seen some pretty ghastly skin conditions in his dealings with spicas but that it was worth it for the good achieved by the spica. He didn’t even take a look at her skin! The lab results showed that the skin didn’t have a fungal infection. Interestingly, he said we should go ahead and use the usual Sudocrem or similar to treat any rashes (even though all the info I’ve read from various sources advises against doing so!)
I must say I was a bit taken aback by the callous manner of the specialist and the way he told me- basically – to suck it up and let the spica do its job. So when we encountered our next skin-woes we felt that we should try and manage it as best we could rather than take her back to the hospital. This time, after about a month of being in the cast, we noticed that Lucy’s skin on her upper thighs were starting to weep a bit. It was tricky to see exactly what was happening inside the cast but a yellowy-fluid was making its way out the cast and onto the edges of her nappy. We used a damp cloth to try clean the skin then dried the area before placing sanitary liners on the inside edges of the cast to soak up the fluid and create a barrier between the cast and the skin. We noticed an improvement after a few days of doing this.
Less than a week before she was due for her 6-week spica change, her skin took a turn for the worse and this time, not only was it weeping but it started to smell rotten. Again, it was on the weekend when this happened so I called the plaster room at the hospital to ask them what I should do. They said to wait until her cast change on Wednesday and the doctors would decide whether to put the new cast on or let the skin heal for a few days before fitting the new cast.
Cast change day was a long ordeal (more details here) and when Lucy came out of theatre she had on a new cast. I assumed that either her skin wasn’t too badly affected or they had doctored it in some way so that they could still put the new cast on.
The first two weeks of the new cast went by incident-free and fresh-smelling but week three brought a return of the weeping skin. Again we tried to manage it ourselves and this time used diluted dettol to clean the skin and prevent infection. We used bamboo nappy liners on the inside edges of the cast and changed them morning and night. The dettol seemed to work and when we went for Lucy’s three week check-up the staff at the plaster room had a look under the cast when I raised my concerns with them. Firstly they told me off for putting the liners inside the cast, then they said that all they could see was dead skin and that that was perfectly normal. When I explained the weeping skin to them they said they had never seen that before. I was told to bring her back in if it happened again.
ENOUGH IS ENOUGH
Well, it did happen again. And with a vengeance. We tried our usual cleaning and disinfecting and drying and bamboo-lining but it got worse. One morning the smell had become so bad and the colour of the liquid oozing from her cast had turned a brown colour and I knew that the spica had to come off. I took her to the hospital and sat in the waiting room for over three hours before we finally made it into the plaster room. The staff took one look (and smell) of the liner I pulled out and they agreed with my verdict.
THE CAST COMES OFF EARLY
The sight of Lucy’s skin under the cast was not a pretty one. Her left thigh was bright red and oozing and angry. One of the nurses asked me if no one had told us not to put anything down the cast, implying that we had caused this breakdown of skin. At the time I was trying to console my screaming baby and didn’t have the strength to defend myself against her accusation masked as concern. Later on at home when I had a chance to properly examine Lucy’s skin, I could see that the areas we’d been able to reach to clean and disinfect were a lot better off than the unreachable areas so I don’t think we did too badly in nursing her at home. Unfortunately you just can’t see what is happening under most of the cast so you’re pretty powerless to fix it all.
The hospital gave us some loose dressing to place on her skin under the Rhino brace and advised that the best thing for the skin was air, rather than something like Sudocrem which forms a barrier on the skin. For the first few days we didn’t put any leggings on Lucy so that as much air as possible could reach her skin and promote healing.
I’m not a doctor therefore not qualified to explain why Lucy’s skin reacted the way it did to being in the spica. I know that when she first went into the cast she had a fungal nappy rash. Perhaps this had something to do with it? With the second cast, the left side was a much tighter fit than the right side so less air was able to get in there and dry up the inevitable urine that sneaks in no matter how careful you are. I also suspect that on the day her spica was changed the doctors should have opted to leave it off for a few days to give it a chance to heal. It was late in the day and her procedure had almost been cancelled but the anaesthetist had pushed for them to go ahead with it. They probably just hoped for the best rather than delay her treatment.
THE ROAD AHEAD
I have been amazed by how quickly her skin has healed. It looked dreadful the first few days as the skin dried and peeled but after just a week it is almost completely better.
We are having an x-ray this week on the day that her spica was supposed to come off. In the meantime we have been told to keep her in the Rhino brace for two weeks on top of the six weeks full-time and six weeks nights only that was originally prescribed.