orthopaedic plaster cast related content

Thursday 6th April 2017


Casting Standards


Orthopaedic casting services in the UK are provided with widely variable standards. The utilisation of casting services would be substantially improved by providing the services to a known standard. The only standard for cast technicians in the UK is a five week taught course, entitled The Theory and Practice of Musculoskeletal Casting and Splinting and this course was previously known as the British Casting Certificate. This standard is neither a mandatory requirement, which is evidenced by the fact many hospitals and institutions do not regard it as a necessary prerequisite to work in the plaster room nor is the standard required by many institutions nationally. Untrained staff can be seen applying casts on an ad-hoc basis in many different NHS Trusts.


According to its nationally available website, the British Orthopaedic Association (BOA) expects orthopaedic technicians to interpret prescriptions from the wider multidisciplinary team. The BOA also states that orthopaedic technicians have to practice autonomously. It is highly unlikely that the skills required to interpret prescriptions and practice autonomously are skills that will be developed by the perfunctory tuition (merely a five week taught course) of the mechanical skills of cast and splint application. Cast technicians are not accepted as allied healthcare professionals by any of the current regulatory bodies in the UK. There is no recognised career pathway nor is there any clearly defined promotion structure for staff undertaking the work. I have witnessed pay rates varying from a lowly band two up to a stratospheric band seven.


It is thought that about 80% of all orthopaedic trauma is treated non-operatively in the UK. Of the remaining 20% which is treated surgically, the majority will have to have a cast applied to the involved limbs in order to support the surgical intervention, especially during the initial phase of healing. Information relating to the clinical practice of cast technicians is not routinely gathered nor collated. No repository of knowledge that is relevant to the clinical work of cast technicians has been developed in the UK. The role of cast technician, inter alia, usually encompasses the application and removal of casts for orthopaedic trauma.


Additionally the role may include the application of serial casts for congenital conditions including talipes equino-varus, idiopathic scoliosis and idiopathic toe-walking. It is relatively common for cast technicians to remove sutures or clips, dress surgical wounds, remove Kirchner wires, adjust and remove external fixators and dress pin-sites for external fixators and spatial frames. A working knowledge of elementary biomechanics, anatomy and physiology, the musculature, surface anatomy, simple neurology and basic physiotherapy are valuable and adjunctive. The ability to read and interpret trauma radiographs for the appendicular skeleton and being able to assess the impact of several non-operative options, that will support effective treatment; are essential skills.


What is missing from the role of cast technician is the necessary consistent clinician expectation and direction as to the manner in which the prescribed treatment should be completed. This highlights the failure of the orthopaedic community to provide adequate or appropriate training to cast technicians. The most effective technicians will constantly add to their knowledge of the nuts and bolts of non-operative trauma treatments. They will have improved their associated mechanical skill sets and be a useful and actively contributory member of the local orthopaedic clinician team.


Having attended an AO course in Kenya for the non-operative treatment of fractures, I can see how it highlighted the considerable benefits of a clinician-led approach to casting services provision. The Kenyan health service is a severely resource-limited environment. It provides just one senior orthopaedic clinician for every 40,000 patients. Patients were all assessed and treated by cast technicians, physiotherapists, occupational therapists and nurses; where they could manage them locally. Patients were skilfully prepared for transportation and treatment whenever skilled orthopaedic clinician input was required.


Every non-medically trained participant in the treatment of orthopaedic patients was educated by and subscribed to the local clinician initiated philosophy of emergency orthopaedic care. The substantial benefit was that patients were not harmed by their initial encounter with the health service staff; where a specialist orthopaedic clinician and the associated operating theatre facilities were initially unavailable. Consultant orthopaedic clinicians taught the course and well-researched and understood methods of work were applied. This tuition enabled primary care services to provide care that dovetailed precisely with the later requirements of the leading orthopaedic clinicians. The model of care provision is appropriate to the UK for it would lead to a consistent approach to non-operative orthopaedic trauma care by the clinicians who are charged with providing the service to their patients.


The future of casting and splinting services in the UK relies on well-trained personnel. New skills should be accrued via modular courses which are made readily available in approved centres of study. Cast technicians would progress through several levels of accomplishment. The cast technician would ultimately know enough to become a useful team member. They may even be able to act as an orthopaedic clinical assistant for the whole of the local orthopaedic team. The role of clinical assistant has been shown to be an effective one for the provision of orthopaedic services.


The role of the cast technician is a confused one, with its history buried deep within the job title of 'plaster porter'. The plaster porter originally held a limb while it was being plastered in theatre; while the orthopaedic clinician did the actual work. The work may have taken place in the orthopaedic theatre initially and thereafter it was extended to A&E departments and eventually fracture clinics and plaster rooms. Subsequently, the plaster porter was trusted to complete the work themselves and they were called a 'plaster technician'.


Eventually; the term shifted from ‘plaster porter’  and ‘cast technician’ to the more appropriate and familiar term, ‘orthopaedic technician’ which is the terminology that is currently favoured by the BOA. The nomenclature used and applied by the providers of the taught five week casting course is ‘orthopaedic practitioner’. While some technicians provide services that appear to include something of the role of the orthotist and the physiotherapist, the practitioner segment of the label suggests far more capability than is actually deliverable by the freshly graduated student of the five week casting course. The selection process variability guarantees some candidates will never be capable of studying or working at an independent practitioner level. Selection failure is a potential brake on the development of the orthopaedic practitioner role.


Sir John Charnley stated the following in his seminal work, ‘The Closed Treatment of Common Fractures’. “Many failures in conservative treatment can be traced to inadequate plaster technique.  The surgeon who aspires to skill in conservative method must subject himself to a long apprenticeship in plastercraft. Skill is not to be learned from books but only by continuous repetition for at least one year, and the casualty officer who regards the application of plasters as a menial task to be delegated to juniors or to the nursing staff will be well advised to transfer his attention to another specialty”.


Charnley's observations are no less relevant today. Cast application requires the person who applies the cast to exhibit a high degree of mechanical skill, a comprehensive and complete technical understanding of non-operative orthopaedic treatment theory and the ability to understand the context in which they are applying the cast. The training ought to reflect the complexity of the task. The syllabus should be set, taught and overseen by consultant orthopaedic clinicians for it to become widely known and accepted as the standard which cast technicians must meet. The UK can emulate the same sense of coherence that was exhibited by the Kenyan orthopaedic services provision once the appropriate training in the UK is provided by leading orthopaedic clinicians.


The current standard for casting is the woefully inadequate and rehashed Framework For Casting Standards which was published by the Royal College of Nursing in 2000. The latest version of the document is at least freely available as a PDF file, which the old framework document certainly was not. You can view and download the current BOA National Casting Standards here.


The national casting standards document is still based upon nurses undertaking the cast technician role. It is as highly prescriptive as the previous copy and still exists as heavily pushed templates for completion of the work. My extensive critique of the casting framework document (upon which the current BOA one appears to be based) still stands unanswered and my new analysis is appended here.


They appear to have missed the publication of a huge and comprehensive work entitled Casts, Splints and Support Bandaging - Non-operative Treatment and Perioperative Protection,  which was published by Thieme at the end of December 2014. The authors are both orthopaedic clinicians; Klaus Dressing and Peter Trafton and they were supported by the cast technician, Jos Engelen. This comprehensive book is part of the AOTrauma series and it deserves to be on the shelves of every cast-room. It covers the basic principles and practice of cast application and permits the practitioner to choose the most appropriate method of work, in contradistinction to our own casting leaders who refuse to discuss such matters but would rather impose them.


Discussion is healthy and I remain unwilling to re-invent the wheel, which has been so thoughtfully provided by Messrs. Dresing and Trafton. 654 pages, 2497 separate illustrations and photographs and 55 different video presentations represents an excellent starting point for a casting guideline that exudes credibility. AOTrauma are dedicated to the cause of pursuing timely and correct orthopaedic treatment and the teaching of future orthopaedic clinicians. It is beyond reason that our leaders prefer to stifle any rational debate about the parlous state of orthopaedic practice, as it relates to casting in the UK, and our so-called national standards and systems of work. In the face of the AOTrauma approach, I would suggest that both the BOA and the BOA casting committee are unwise; specifically where they do not work more closely with the clinicians who teach and practice the methods and philosophy of AO.  


The standards of orthopaedic casting nationally are little short of a disgrace. The failure of both the BOA and the much vaunted National Casting Committee, to address the obvious gaping holes in the training of orthopaedic technicians and oversee the application of rational clinical work, has gone on for decades. Our work is neither standardised nationally nor is it recognised by an overarching registration body. The hallmarks of a profession are absent from our professional work.


The current document suggesting that a cast technician is capable of completing the required work is: The Theory and Practice of Musculoskeletal Casting and Splinting (British Casting Certificate) It is not a formally recognised qualification by every hospital or NHS Trust in the UK neither is it mandatory to hold the certificate if one wishes to work in a plaster room.  Professional registration would imply that certificate holders work in a known manner and apply their knowledge from a nationally regulated framework of care standards. Sadly, cast technicians are not a formally regulated profession. The Health and Care Professions Council (HCPC) has not accepted that cast technicians are potential HCPC registrants.


The full list of HCPC registrants demonstrates that cast technicians are not on it.


These issues ought to have been addressed long ago by any of the following organisational bodies: The BOA Casting Committee, (BOACC) the Association of Orthopaedic Practitioners, (AOP) or the Orthopaedic & Trauma Alliance  (OTA). Without formal standards and many more training opportunities, the highly specialised work of the expert cast technician will languish and fade into obscurity. This unwanted outcome is becoming visible at many NHS hospitals where it is off-the-shelf splints, rather than bespoke casts, being fitted by band two graded HCAs; who have little to no practical clinical understanding of orthopaedics or the damage that can be created with carelessly applied splints.


In one recent hospital in which I worked as a locum, I noted an orthotist being used to treat acute fractures and the treatments and the patient outcomes were poor with sub-optimal care being delivered. Stopping the rot requires the combined will of each of our supervisory organisations to facilitate an improvement in what we do and how we do it. Unless the organisational leadership, who oversee the work of the cast technician, are proactive then our work and the required attendant skills will be lost to new NHS money saving initiatives and unseeing management. It is then that orthopaedic clinicians and patients will have to become accustomed to very poor treatment.