orthopaedic plaster cast related content
Thursday 6th April 2017
Occasionally, it will be the case that cast technicians/orthopaedic practitioners are requested to undertake work which appears to be wrong-headed. What do we do in such cases? It is wrong and unprofessional to argue with the decisions made by orthopaedic clinicians. Nevertheless, we have an obligation to the patient to ensure that we do not do anything which would harm their effective recovery and the future function of their injured limbs.
The British Orthopaedic Association (BOA) code of conduct for cast technicians requires us (inter alia) to comply with several concepts when we are uncertain about the correctness of the work requested. These include the following clauses which appear under their respective headings…
a) Promote and maintain the highest possible personal conduct and professional standards for the purpose of delivering the highest possible standard of quality care in the best interest of the patient and user groups.
b) Report to an appropriate person any circumstances in which safe and proper care for patients cannot be provided.
a) Provide and maintain a high standard of care to all.
b) Carry out all care episodes in such a way as to promote and protect the rights of patients.
c) Deal safely with the risk of infection and all other clinical practice risks carrying out risk assessment where
d) Communicate effectively and share your knowledge, skill and expertise with other members of the team.
e) At all times let no action or omission on your part place at risk the care afforded to any patient.
f) Recognise any limitations of competence and decline any duties unless trained and deemed competent to
perform them in a skilled, safe manner. Refer if necessary to another professional.
a) Duties should be carried out in a professional and ethical manner promoting equality and valuing diversity.
b) Be trustworthy and honest.
c) Inform an appropriate person or authority of any conscientious objection which may be relevant to professional practice.
d) Uphold and enhance the good reputation of the profession.
I was faced with a case recently where a child of seven years had sustained a simple buckle fracture to the distal third of the radius. The instruction from the junior SpR grade clinician was to place the arm in an above elbow cast. This appeared to be a little extreme to me, especially as the child did not exhibit any pain. I drew the attention of the clinician to the issue by asking them if they had really wanted me to apply the above elbow cast. Sadly, the clinician was of the opinion that their plan of treatment had to be followed.
The pioneering work in fracture pathway redesign at Glasgow Royal infirmary would not have seen this injury placed in an above elbow cast. The information sheet, which details the discharge advice provided to the relatives of patients, is clearly written and easy to follow.
The evidence for simple splinting versus casts is available. A randomized controlled trial of removable splinting versus casting for wrist buckle fractures in children. This study demonstrated significantly better functioning in the splint group of 42 patients versus 45 patients in the cast group. The image below depicts the type of fracture which is being discussed. It has been a common practice for me to apply a volar splint or a futura type splint to this type of injury, since the advent of the virtual fracture clinic. Prior to that, I would have been applying a softcast below elbow circumferential splint.
The evidence demonstrates that patients recover function better in a splint and above elbow casts are not required even where a fracture has been surgically reduced. It is a difficult dilemma... for the cast technician who is faced with a clinician who is deaf to new approaches based on recent evidence. The BOA code of conduct would have cast technicians indicate when there are risks to the patient. If the clinician does not accept that the cast technician's concerns are legitimate then there is little which can be done.
I would not suggest that cast technicians start an argument with clinicians nor do I think it appropriate to refuse to carry out the work or the treatment prescribed. What may be helpful is a place where these events can be detailed, and subsequently collated, so that the scale of the problem can be determined. It appears to be yet another area where the BOA is remiss when it comes to the status and the work carried out by cast technicians. If the present BOA code of conduct for cast technicians is to stand as accepted, the potential conflict between cast technicians and orthopaedic clinicians is inevitable in cases such as that which is detailed above.
I note that our current code of conduct dates from more than six years ago; from February 2011. That is one obvious measure of just how little interest; and how tardy the organisations which purport to oversee the work and training of cast technicians/orthopaedic practitioners has been… and still remains.