Additional Resources

Car Seat Restraints for Patients in Casts and Braces

Motor vehicle deaths are the leading cause of injury and death among age groups 3 to 14 years old (1-3). A contributing factor is the continued misuse or nonuse of child restraint systems or car seats of children involved in motor vehicle crashes (4,5), with misuse rates of 73% to 90%. Such misuse can be exacerbated by medical conditions requiring specialized restraints such as spica casts. A study (6) published in the Journal of Trauma (July, 2009) looked at difficulties in securing children with spica casts in car seats. The added weight of casting materials also affects the performance of different restraint systems.
Key Points  For physicians

  • As much as possible it helps to maintain flexion and adduction for the best sitting position in a car seat.
  • If the child is in an excessively reclined position, i.e. less hip flexion, excessive pressure could be placed on the cervical spine and occiput leading to forward neck flexion and difficulty breathing. (see picture) ·
  • 45 to 60 degrees of knee flexion improves seating by allowing the child to sit farther back ·
  • Place the cross-bar on the anterior surface whenever possible. This may allow the child to sit back farther in the seat  (see picture) ·
  • A certified car seat safety specialist can help ensure the child is discharged from the hospital safely. ·
  • Lower crash test injury data was associated with an anterior thoracic cutout for “cast disease”/SMA syndrome rather than the space created with a towel pack.  (see picture)

Key Points For parents ·

  • You may need to extend the straps/belts to use the full length of the straps to fasten buckles.
  • The buckles MUST be completely fastened – double check the connection ·
  • If the strap is too tight as it goes through the legs, or over the genitals, you may need to place a small pad or washcloth under the strap.  (see picture) ·
  • If the child is reclined in the spica, place a pad in the space created between the back cushion and back of the cast to protect the neck/head. (see picture) ·
  • Keep in mind the extra cast weight may be outside the range of allowed weight by the original restraint device. Check the weight limits of your seat belts and child safety systems ·
  • In seats that have variable slots available for shoulder and crotch straps, the straps may need to be readjusted. Most often, the crotch strap needs to be in the farthest forward position. ·
  • Use all tethering devices provided to attach the restraint device to the car. ·
  • Casting material (plaster or fiberglass) is rough and you may scratch your fingers trying to buckle the straps – consider the safety of your child – buckle it correctly!

Options for safe transport:
Links to websites for products are posted on Other Resources for Parents on this website.·

  • Conventional child car seat
    • Depending on how the legs and hips are casted, smaller children may still fit into a conventional safety seat. o       Even if the child’s body fits into the seat physically, the straps must be able to be secured properly for safe transport.
  • A seat with low sides and short wide seat cushion
    • Accommodates children 5-65 pounds  (2.3-29 kg) and up to 49 inches (122.5 cm) tall
    • May be used front or rear facing
    • Note that this seat has a high base and must be attached to the vehicle using the top tether.
    • Studies of the seat done without the tether has shown a three fold increase in injury force data in crash testing.
    • Cost $400-$500   ·
  • Rear seat harness
    • E-Z-On Modified Vest – Model M203 or 101M2
    • Accommodates children 2-12 years and 20-100 pounds
    • Child is lying down on rear seat – particularly good for hips casted in extension (straight)
    • See E-Z-On-Products for a distributor in your area   ·
  • Car beds
    • For newborns and very small infant or child is lying down within bed. Bed is secured on rear seat
    • AngelRide™ Infant Car Bed available at Adaptivemall
    • Accommodates infants under 9 pounds (4 kg) and 21.5 inches (51 cm)
    • Cost $120-$150   ·
  • Ambulance
    • If a proper safety seat/harness/bed cannot be obtained, the child may need to travel between the hospital and office appointments via ambulance.   ·

Whichever method is found safe, be certain it complies with FMVSS-213 standards. This also includes all children be positioned in a rear facing direction until 20 pounds (9 kg) AND at least 1 year old.  Chest clips should be at armpit level.  Refer to www.car-safety.org/basics.html for an excellent summary of  general recommendations for infant/child restraint devices. Ratings for infant safety seats can be found at http://www.nhtsa.gov/portal/nhtsa_eou/info.jsp?type=all 

References:   1. Administración Nacional de Seguridad del Tráfico . Datos de Seguridad del Tráfico 2005 Children. Publication No. HS 810 618. Washington, DC: USDOT/NHTSA; 2005.   2. Administración Nacional de Seguridad del Tráfico . Datos de Seguridad del Tráfico 2004 Children. Publication No. HS 809 919. Washington, DC: USDOT/NHTSA; 2004.   3. Administración Nacional de Seguridad del Tráfico. Datos de Seguridad del Tráfico 2003 Data. Publication No. HS 809 762. Washington, DC: USDOT/NHTSA; 2003.   4. Decina LE, Lococo KH. El mal uso de sistemas de retención infantil. Publication No: DOT HS 809 671. Washington, DC: USDOT/Administración Nacional de Seguridad del Tráfico; 2004.   5. Scherz RG. Los sistemas de retención para la prevención de lesiones a los niños en accidentes automovilísticos. Am J Public Health. 1976;66:451– 456.   6. Zielinski JA et al. Casting technique and restraint choice influence child safety during transport of body casted children subjected to a simulated frontal MVA. J of Trauma.  2009; 66(6): 1653-1665.

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