Picture this: you have a young child who has had hip surgery and is now in a hip spica cast. That's a cast from the waist down to the toes. Sometimes it is two-legged (goes down both legs). In other cases, it is one-legged and sometimes one and a half-legged (covers one leg down to the toes but only goes down to just above the knee on the other side). Some spica casts are flexed (or bent) in what looks like a semi-seated position (for fractures). Others children are cast in extension (no flexion).

Now imagine getting that child safely buckled up in a car. How is that possible? The typical child car seat won't work because the child can't bend at the hip or knee. You might lay him or her down on the seat and strap the seatbelt across the body or legs but that is not safe. What do other parents do when faced with this dilemma?

That's what this study is all about. Parents of 31 children treated at St. Christopher's Hospital for Children in Philadelphia, Pennsylvania were asked how they transported their children home from the hospital. The children ranged in age from five years up to 13. Most of the children had hip fractures but a few were treated for hip dysplasia (shallow hip socket leading to hip dislocation).

Before leaving the hospital, each child was evaluated by a physiotherapist for travel safety suggestions. The therapist did not recommend the use of a standard car seat for any of the children.

There is a specially designed car seat available for this type of transport. Some of the children qualified for this seat. Others were advised by the therapist to use an ambulance. The only other choice was a vest type restraint but that could only be used by older children. In all cases, families were faced with the additional expense of either buying the special car seat or restraint or hiring an ambulance.

How many actually followed the therapist's recommendation? Less than one-fourth of the group (23 per cent) was safely transported. There were all kinds of methods used -- taxis, vans, SUVs, sitting in a parent's lap, or simply without restraint. Five of the children were placed in their regular car seats as best as possible. Only three families used ambulance transportation.

In the weeks after discharge from the hospital, half of the children were only in a motor vehicle for doctor's appointments. One-fourth of the group were transported somewhere every day. The rest traveled about one to two times each week.

Fortunately, no one was involved in a car accident. Although it's the law everywhere that children must be properly restrained, only one mother received a ticket for a traffic violation (the child was on her lap).

This isn't a problem faced by every parent, but it is still a dilemma for those whose children end up in a spica cast for any reason. What can be done? Insurance companies don't pay for the added expense of a specially made care seat system designed to hold a child in a hip spica cast.

Unless a hospital has a loaner program or special funds available, most families choose to "make do" with what they have. When asked why parents didn't follow the safety recommendations, they said a) cost was too high, b) no insurance coverage, or c) no access to the special car seat.

The authors did a little checking on costs parents might face in this type of situation. They found that some insurance companies were willing to pay the $500 to 600 cost of a single ambulance ride but would not cover the cost of purchasing (or renting) the special car seat.

When available (and often they were not), the specialized car seats went for a $250 deposit and $50/month rental fee. Most of the time, the car seats weren't even available because too many people failed to bring them back. Or brought them back in such poor condition, they could not be salvaged and had to be replaced. The replacement cost was put on the shoulders of the rental agency.

How can this problem be solved? The answer is not obvious. Pediatric clinics and hospitals can't afford to give these car seats away. A loaner program would face the same problems rental agencies discovered with the upfront cost purchasing the seats, non returns, and destruction of the property. There is also the additional cost of hiring staff to administer the program and providing storage for the seats.

In summary, car accidents are the leading cause of death among children in the United States. There are laws in place requiring the use of appropriate safety seats for infants, toddlers, and children. But children in spica hip casts pose a separate problem for which most parents and families are not prepared. Barriers to safe motor vehicle transport are discussed in this article. Solutions to the problem must be carefully considered.

Reference: Martin J. Herman, MD, et al. Motor Vehicle Transportation in Hip Spica Casts: Are Our Patients Safely Restrained? In Journal of Pediatric Orthopaedics. June 2011. Vol. 31. No. 4. Pp. 465-468.