Bricolage

orthopaedic plaster cast related content

Saturday15th April 2017

 

Responsibility

 

Working as a locum orthopaedic practitioner provides me with a wide variety of experiences. I worked in one hospital recently where the local practice was to permit cast room personnel to see patients in their own plaster room clinic. In the case where a cast is the reason that a patient has had to contact the plaster room for advice, it may appear to be simply that a cast adjustment or change is required. With the proviso that every clinical care episode is documented adequately and that the event is written into the patient's clinical care record, this could easily be considered to be the normal work of the plaster room.

 

The case under scrutiny is that of a young woman who had sustained a fracture through the radial styloid process. The bony fragment was minimally displaced and there was an additional minor disruption to the chondral surface. On the AO classification of fractures to long bones, the injury fell into the classification category 23-B1 and the fracture would have been expected to heal without problems, within a six week period.

 

 

 

 

 

 

 

 

 

 

The patient had sustained the fracture and attended an A&E department where she was prescribed a posterior slab and she was also given an appointment to attend the fracture clinic three days later. At the fracture clinic, her injury was assessed and she was prescribed a below elbow cast for a six week period. This form of treatment is the current standard and should have resulted in an unremarkable recovery. That is to say that the anatomical alignment would have remained intact, the bony injury would have been healed and it would have become functionally strong enough to permit normal activity.

 

The patient had experienced some discomfort at around three weeks and was a given an appointment to attend the plaster room clinic to see a cast technician. The patient's clinical care record was made available and the patient was seen at the appointed time by the cast technician. A cursory examination led the cast technician to the conclusion that the cast had to be changed and this was done. It was recorded in the clinical care record but the principle and presenting patient complaint (of excruciating pain and discomfort) was not detailed. This omission was instrumental in failing to record a history of a very well known complication possibility.

 

The patient was sent home again after the cast change yet her complaints were not dealt with adequately. She requested another attendance because of her unbearable pain and was seen in the plaster room clinic two days later. The same cast technician who had seen her previously saw her again. The complaints about incredible discomfort and severe pain of the limb, especially under the cast, were made yet again by the patient. The cast technician made some show of wiggling her fingers around and ignored her pain. It is not clear whether the cast was changed again at this point for there was nothing written in the patient's clinical care record, despite it being pulled specifically for that particular cast technician's clinic.

 

The patient was sent home with an appointment to attend the plaster room clinic in three weeks time. This appointment was at the the limit of the six week duration, for which she had been prescribed a below elbow cast. I was working as the locum orthopaedic practitioner on duty at the patient's cast technician clinic appointment time. It was impossible to follow the incomplete and incoherent clinical record of the cast technician nor did I understand the patient's previous clinical care which had been delivered after the original fracture clinic attendance and treatment prescription.

 

The patient’s clinical care record did not reflect every attendance or treatment session in the plaster room clinic in two crucial respects. 1) There was no written record of delivered care for every dated cast technician's clinic attendance. 2) What had been written in the patient's clinical care record did not accurately reflect the patient's own account (to me) of the events following her initial fracture clinic appointment.

 

The patient presented to me with a complaint of very severe pain under the cast and when she moved her fingers. She felt that the cast was pressing on her forearm with unbearable pressure and she was clearly very distressed. What was surprising to me was that she had said that she had been experiencing the very severe pain for several weeks. Her clinical care record had not mentioned the pain and her account of each plaster room visit was not accurately recorded.

 

I could not physically examine her hand or arm because of the exquisite pain she was experiencing. I examined her radiographic images and could easily see the lucent line which denoted that she had sustained a minimally displaced fracture through the radial styloid process. The lucency extended into the  articular surface between the radius and the carpal bones, denoting significant chondral surface damage.

 

I carefully removed the cast and made a short duration and very gentle examination of around five seconds duration. Gentle palpation and passive movement of her wrist and forearm elicited excruciating pain. At six weeks, the simple wrist fracture should have been substantially healed and pain free. The marked allodynia was a clear sign that there was a problem. I thought it possible that the patient was displaying early signs of Complex Regional Pain Syndrome (CRPS).

 

I requested a consultant clinician to arrange for the patient to undergo a detailed clinical examination. She was seen by a senior SpR grade clinician and a formal diagnosis of CRPS was made. The patient had a new radiographic examination and a referral to the physiotherapy department.

 

This case demonstrated that there are obvious limitations to the work which can be carried out by cast technicians. The attendance at clinics, by patients who are experiencing difficulties with their treatment, which are staffed only by cast technicians is a disturbing trend which I would not wish to see increase. The clinical background of cast technicians can only be described as utterly inadequate when it comes to deciding on particular treatment options for specific injuries; when compared with the knowledge and experience of senior orthopaedic clinicians.

 

There is absolutely no clinical imperative, nor can any coherent business case be made, which would justify patients being ‘treated’ by cast technicians instead of formally trained clinicians. The case detailed above was and remains an unmitigated disaster for the patient. The long term affects on the patient are unknown. The cast technician was wrong-headed in failing to seek competent clinician involvement at the very first sign of a significant complication in the progression of the patient's treatment. Knowing when we don't is a vital component in the safety of the patient and protecting the integrity of the prescribed treatment.

 

Clinicians are legally responsible for the treatment of the patient. Even though they may delegate limited aspects of that treatment to cast technicians, that does not imply that they are abrogating their clinical responsibility for the patient by the act of prescribing a cast for a fracture.

This image is not that of the patient’s injury; it is representative of the actual injury sustained. It had looked completely innocuous on X-ray but the patient had gone on to develop very severe Complex Regional Pain Syndrome. This was a simple case of needless, iatrogenic harm and it was supervised by a lazy and dim-witted cast technician