Casting injured limbs is an occupation which requires a high degree of technical understanding. Poor casting technique leaves the patient at risk of further harm and the potential for iatrogenic damage is high. Poor healing may leave the patient with a lifelong disability.
In hard-pressed emergency departments, the initial fracture care may have been sub-optimal. It is integral to the role of the orthopaedic consultant clinician (and by extension to the cast technician) to prescribe and apply the correct treatment as early as possible during the cycle of the healing bony injury.
The case depicted below demonstrates what may happen where sufficient care was not taken by the cast technician while applying a definitive cast during the patient's initial fracture clinic attendance.
The work which was required in this particular case was to simply remove the plaster of Paris (POP) posterior splint. The prescribed treatment was then to apply a circumferential lightweight cast to the distal radius and ulna fracture. This type of work constitutes the routine of any cast room and it should not prove difficult.
The radiograph above shows a fracture through the metaphysis of the distal radius. There is also a misshapen distal ulna which suggests a comminuted fracture through the ulna styloid process. The forearm was imaged through a POP splint placed on the dorsal aspect.
The ulna variance is negative and the distal radius may well be considered to be out to length. The POP splint appears to be high and appears to extend beyond the metacarpal head-on the ulnar aspect. The air between the splint and the soft tissue suggests that too much undercast padding was used because the splint does not mimic the contours of the soft tissues.
The lateral image shows that the distal radial fragmented had been translated dorsally by about 2mm. The angulation of the articulating surface could be improved as it is usually tilted about ten degrees towards the volar aspect. The large dark space over the metacarpals shows that far too much padding was used. Up to two centimetres of space under he splint will eliminate any possibility of using the dorsal splint to control movement of the metacarpals.
The dorsal aspect photograph above shows a cast which is close to the absolute boundaries for a BE cast. It extends to just beyond the metacarpal heads and it is within one and a half finger’s width of the antecubital fossa. The folds over the stockinette have left sharp edges to the cast at either end. The lateral and medial cast contours are neither smooth nor do they follow the expected pathway. The lumpy appearance is because of the failure to pad with undercast padding correctly.
The lateral view of the cast above shows that its boundary extends over the metacarpal heads and almost to the proximal interphalangeal joint. At the thumb the cast restricts the 1st digit by extending to just proximal to the interphalangeal joint. The ripples on the surface of the volar aspect, at the level of the wrist joint, strongly suggest that the cast technician did not understand when to use a specific technique to obtain palmar flexion; nor how a degree of cast flexion is applied. Sharp cast edges with which the patient may damage themselves have been left.
The volar aspect photo below confirms that the thumb is restricted by the extent of the cast. The one centimeter wide bar of casting tape between the first web space will usually create a pressure injury on the volar aspect of the base of the thumb and it incorrect creation is to be deprecated as an unsound clinical practice.
The cast extends to beyond the 2nd metacarpal heads on the lateral aspect of the hand and just on top of or slightly proximal to the other metacarpal heads. The restriction of movement will usually lead to a fixed flexion deformity because the patient cannot flex their fingers to the fullest extend of the flexor and extensor tendons. They will sit with their hand of the injured limb in a slightly relaxed position while the flexor tendons shorten throughout the duration of the cast treatment. The depression from the fingers of the operator can be detected on the volar surface just proximal to the felt. It indicates incorrect handling of the cast during its application and setting.
The lateral radiograph above, taken at the end of the treatment just before cast removal, demonstrates that the ulna head has collapsed. The air gap between the cast edge and the soft tissues show clearly that the cast does not fit the patient. This is due to inordinate amounts of undercast padding being used. The skin fold at the carpal tunnel denote careless application of palmar flexion
The final PA radiograph below shows a metaphyseal transverse fracture through the distal radius and a comminuted and collapsed ulna head. Once again the cast does not fit the soft tissues because of a surfeit of undercast padding. The final radiographs were taken at six weeks before cast removal.
The work of the BCC holding cast technician was sub-optimal and it was the principle vector for iatrogenic harm. This failure to appreciate the harm which can arise from the lack of clinical expertise, knowledge, skill and techniques armoury is the rationale which demonstrates unequivocally that the BCC course is moribund and is no longer fit for purpose.
Why do we insist on teaching this unthinking and unquestioning approach to cast application? The results are the sordid documents which appear all too frequently in these pages. Again, I find myself publishing yet one more appalling example of the work of a so-called Qualified Cast Technician; who has undertaken the BCC casting and splinting course. Why are qualified people turning out this completely unacceptable standard of work?
I call upon the BOA, the NCTA and the AOP and all of the BCC course organisers to wake up!
PLEASE... accept that the BCC course of nearly four decades existence is wholly inappropriate and creates a laughing stock out of the cast technicians who actually know enough to know why this appalling work standard must change. Many of the candidates who come from backgrounds which are non-clinical have blithely graduated from the BCC course without any understanding of the work. They are clearly not fit for purpose. The complexity of the work is unable to be imparted in five weeks of a taught course, during which the primary emphasis is on casting technique.
The refusal of the BOA or the BOACC and the NCTA to acknowledge that the problem exists, and has existed for many years; is the main problem. The NCTA and BCC course organisers refuse to engage with any of the skilled people who can actually tell the difference between a well applied cast and a hole in the ground.
This unfortunate myopia is the reason that cast technicians are not a profession in the UK and why they will never be regarded as professionals. The iron grip of the ancient RCN/SON nursing hegemony is responsible for this clear lack of progress in the last 40 years. It is the principle reason why there is still not one single relevant module of advanced training offered or provided to interested cast technicians.
It is now long overdue that the NCTA and the course providers of the BCC either made radical and far-reaching changes or stood aside. In my view, the AO organisation (or any other august body with their considerable credentials) must be used to determine what is appropriate casting knowledge and which working standards should be applied.
Every cast technician should then be trained to those standards, globally. Unfortunately, the inactivity of the BOA in this particular issue, cf Can We Do Better?, has rendered the BOA complicit in permitting this ridiculous and highly embarrassing situation to exist for so long.
I will happily work with any member of the BOA, BOACC, the NCTA, the AOP or AO in an effort to address this ludicrous situation and produce a complete solution. Not being engaged by the establishment and the great and good of the casting fraternity is really frustrating, especially when the low standard of work being turned out (by the BCC qualified staff) can be seen on a daily basis in almost any cast room location.
The latest awful example posted in these pages had begun life in one of our national schools of casting practice. It was a shock to me that even in a school for casting (where we should rightfully expect the very highest standards of work and best clinical practice) inappropriate clinical work is being produced.