Fig. 1 In this AAOS Orthopaedic Video Theater video, Barbara Minkowitz, MD, FAAOS, and colleagues demonstrate how to apply waterproof one-leg spica casts for pediatric femoral shaft fractures.


Published 4/26/2024
Michael DeRogatis, MD, MS; Paul S. Issack, MD, PhD, FAAOS, FACS; Joseph Gabrieli, OTC

OVT Video Demonstrates Application of Fully Waterproof Spica Cast for Femur Fractures

Editor’s note: The following article is a review of a video available via the AAOS Orthopaedic Video Theater (OVT). AAOS Now routinely reviews OVT Plus videos, which are vetted by topic experts and offer CME. For more information, visit

Waterproof casts are increasingly prevalent, although existing literature primarily addresses waterproof cast protectors rather than the casts themselves. These casts have garnered high praise from patients, parents, and physicians due to their notable advantages, including enhanced comfort and minimal associated risks. However, it is important to acknowledge potential drawbacks, such as the possibility of elevated temperatures during cast removal and an increased risk of the cast saw coming into contact with the patient, as waterproof casts lack the protective layer of cotton padding. The cost of a waterproof cast (totaling $100) is comparable to that of a non-waterproof AquaCast pantaloons.

The AAOS OVT video “Fully Waterproof One-Leg Spica Cast for Femur Fractures” serves as the first demonstration of a waterproof one-leg spica cast. The cast is applied to a patient aged 2 years with a femur fracture, resulting from an incident where the patient experienced leg pain after being jumped on by his brother. Radiographs revealed a spiral femur fracture with minimal shortening.

The procedure involves the use of seven 3-inch AquaCast liner rolls for padding, replacing traditional cotton. Additionally, two 3-inch rolls and five 2-inch rolls of fiberglass casting tape are utilized in the process.

In the OR, under general anesthesia, the patient assumes a supine position on a radiolucent table. The C-arm is employed to reduce the fracture through axial traction, with the knee flexed at 45 degrees. The application of the AquaCast liner begins at the inguinal crease, overlapping by 50 percent down to the distal tibia. Extra padding is applied around the groin. Subsequently, a 3-inch fiberglass is applied with a valgus and procurvatum mold. After the fiberglass hardens, the AquaCast liner and 2-inch fiberglass are continued to the midfoot, excluding the forefoot to prevent fracture displacement.

The patient is then transferred to a standard spica cast table, where padding with towels facilitates eating and breathing space. A 3-inch AquaCast liner is applied around the abdomen, and three layers of extra padding are added over the posterior buttocks, sacrum, and lateral buttocks. To minimize skin irritation, a folded AquaCast liner is used to create a cuff around the abdomen. Fiberglass is subsequently rolled around the abdomen, with three 2-inch struts connecting the abdomen band to the long leg cast. These struts are incorporated into the cast with 2-inch fiberglass, and they are placed in an anterior-to-posterior, posterior-to-anterior, and buttock-overlapping configuration. The cast is finalized by folding of the proximal and distal edges of padding and secured with an additional layer of fiberglass.

Upon completion of the procedure, the patient is removed from the spica table, and abdominal padding is taken off. Duct tape is applied around the abdomen to prevent fiberglass delamination. A diaper can be comfortably placed under the cast at the conclusion of the procedure.

Two weeks after cast application, the fracture displays positive signs of healing, and the patient is able to partake in bathing and swimming activities (Fig. 1).

This video provides a very detailed and practical method for waterproof hip spica cast application in toddler femur fractures. The authors identify all necessary supplies, steps, and even a cost comparison to non-waterproof hip spica casts.

In conclusion, the application of waterproof spica casts improves the recovery process for patients and caregivers. Although their benefits are clear, it is imperative to remain mindful of potential challenges, such as thermal discomfort during removal and potential technical difficulty of using the AquaCast liner.

Michael DeRogatis, MD, MS, is an orthopaedic surgery resident at St. Luke’s University Health Network in Bethlehem, Pennsylvania, and serves as a resident member of the AAOS Now Editorial Board.

Paul S. Issack, MD, PhD, FAAOS, FACS, is a clinical associate professor in the Department of Orthopaedic Surgery, Weill Cornell Medical College, and a trauma and adult reconstruction orthopaedic surgeon at New York–Presbyterian Lower Manhattan Hospital. He is also a member of the AAOS Now Editorial Board.

Joseph Gabrieli, OTC, is an orthopaedic technician at Children’s Hospital of Philadelphia.

Video details

  • Title: Fully Waterproof One-Leg Spica Cast for Femur Fractures
  • Authors: Barbara Minkowitz, MD, FAAOS; Eytan Mendelow, BS; Jennifer Rachelle Ristic, PA-C; Violet Wallerstein
  • Published: March 01, 2020
  • Time: 7:14
  • Tags: Spica, Cast, Waterproof
  • Visit view this award-winning title and more than 1,600 other videos from across orthopaedic topics, institutions, practice management, and industry.