orthopaedic plaster cast related content
Saturday 15th April 2017
The image posted below is an example of a lightweight cast application which it would be a kindness to label as “utterly dreadful”. The patient is in the second decade of life and had sustained a distal radius fracture. The lateral radiograph demonstrates the distal half of the radius superimposed upon the ulna. The lightweight cast and the position of the wrist joint is also shown.
Lateral Forearm Radiograph
The wrist joint position shows that the distal radial fragment is displaced by 15 - 20% of the width of the radius and angulated towards the volar aspect of the forearm. The distal radial fragment is overlapping the larger proximal fragment of the radius. The overlap, of approximately 1 centimetre, implies a shortened radius and is a predictor of the effect that it will have on the future alignment and function of the articular surfaces.
The lightweight cast does not follow the contours of the soft tissues and the volar aspect, opposite the radial styloid process, shows excessive compression evidenced by the skin folds. There is far too much space between the cast edges and the soft tissues, caused by excessive padding. The cast was removed (it had been in situ for ten days) and changed for a closely fitting cast, which was applied with bi-manual compression on the dorsal and volar aspects of the limb; in a neutral position. The distal radial fragment was aligned anatomically and pulled out to length.
The potential for sequelae, with a cast this poorly applied, includes pressure ulcers, pain from inadequate fragment fixation, potential median nerve compression, restriction of range of wrist joint movements, reduced functionality of the wrist joint and the possibility of developing complex regional pain syndrome. It is rather disappointing to have to note that this clearly unsuitable cast was applied by a qualified British Casting Certificate holder, who had apparently been asked to apply a cast with 'dorsal moulding'.
It is worth repeating, as often as is necessary, to get cast technicians to understand the point: The most important rule bar none; if we are to protect patients from this kind of operator incompetence is this: we must know when we don't!
The failure to recognise our own limitations (and ask a senior clinician for some assistance when we need it) of knowledge, skill and experience is entirely unprofessional and unacceptable. The level of ignorance (detailed in the image above) is an unsuitable trait for workers aspiring to become competent orthopaedic practitioners.