Professional Resources

Car Seat Loaner Program and Services for Children in Spica Casts

A Hospital-based Program ProCarSeatSafety.com. A Resource provided by Dr. James DeCarli that serves Patients, Physicians, and Hospitals. Disclaimer: While there is a fee involved for additional services. the information and insight offered is free.

Car Seat Restraints for Patients in Casts and Braces

Most hospitals have a car-seat loaner program or a program to provide safe transportation for children with special needs. Special restraint systems are often needed for children in spica casts.

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.

Options for Safe Transport

Crash testing of car restraints for children in spica casts have shown that several systems meet current safety requirements. These restraints are far safer than leaving a child unrestrained and should be used any time the vehicle is in motion. The University of Indiana has provided useful information regarding the safe transport of children with special needs. Their information is available here.

Links to websites for products are posted on Other Resources for Parents on this website.

Available options:

• Conventional child car seat — also see next item
  • Depending on how the legs and hips are casted, smaller children may still fit into a conventional car safety seat that has lower or shallower sides. Even if the child’s body fits into the seat physically, the straps must be able to be secured properly for safe transport.
• A conventional car 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.
  • A tether is essential as with all modern car seats. Studies of seats done without the tether have shown a three-fold increase in injury-producing force during crash testing.
  • Cost $400-$500
  • Several models are available such as R82 Quokka and Diono Radian.
• 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 is also acceptable after one year of age and is particularly good for hips casted in extension (straight)
  • See E-Z-On-Products for a distributor in your area  
• For infants younger than one year in a spica cast, here are two options
  • The Wallenberg Car Seat is available from Merrittcarseats.com
  • 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 to 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 https://www.nhtsa.gov/portal/nhtsa_eou/info.jsp?type=all 

Key Points for Physicians

• As much as possible it helps to maintain flexion and abduction 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!

References: 1. National Highway Traffic Safety Administration (NHTSA). Traffic Safety Facts 2005 Children. Publication No. HS 810 618. Washington, DC: USDOT/NHTSA; 2005. 2. National Highway Traffic Safety Administration (NHTSA). Traffic Safety Facts 2004 Children. Publication No. HS 809 919. Washington, DC: USDOT/NHTSA; 2004. 3. National Highway Traffic Safety Administration (NHTSA). Traffic Safety Facts 2003 Data. Publication No. HS 809 762. Washington, DC: USDOT/NHTSA; 2003. 4. Decina LE, Lococo KH. Misuse of Child Restraints. Publication No: DOT HS 809 671. Washington, DC: USDOT/National Highway Traffic Safety Administration; 2004. 5. Scherz RG. Restraint systems for the prevention of injury to children in automobile accidents. 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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