Once anesthetized, a Gor-Tex liner of appropriate size is placed (Figure 21-1).

The patient is then placed on the spica table, taking care to place the shoulder blades against the torso support with the arms straight out to the side and use Webril to wrap them with the arm boards (Figure 21-2).

The pelvis is then supported on the pelvic bolster on the spica table.

The position of the child should be held in a sitting position with the hips and knees flexed at 90° and the hips abducted 45° each side to allow for diapering/peroneal care.

The assistant should sit at the foot of the child straddling the bed and hold the patient at the ankles in the appropriate 90-90 position

For the majority of femur fracture, we will aim to have the cast end at the xyphoid process and include the entire portion of the fractured leg down to the ankle. The uninjured side should be included just above the knee.

Gentle traction should be applied throughout by the assistant holding the legs with two people wrapping the cast, preferably an MD and a cast technician.

Felt cast padding is applied and secured by Webril to the following areas (Figures 21-3 and 21-4)

Circumferentially at the top at the level of the xyphoid. Prior to this, there should be a belly pad placed below the Gor-Tex which will come out after the cast is applied. This assures not wrapping the abdominal contents too tight. It can be fashioned by placing surgical towels in a square manner.

Circumferentially above the knee on the uninjured leg.

Circumferentially around the ankle padding the malleoli on the injured leg.

A wrapped piece, which lies on the sacral coccygeal area posterior and wraps around to pad the groin region