It should be the case in our national schools, where cast technicians are taught how to apply casts, that staff produce only the very best work. That is to say that the clinical rationale used to create a cast should represent the current best clinical practice and this standard should be evident in all of the work completed.
The work emanating from schools for cast technicians should be an exemplar (to inspire each of us who aspire to improve upon our own cast technician work) and we are entitled to expect that the work would be completed to the very highest of clinical standards. Evidently this is not the case and I was dumbfounded by the low standard of clinical work which was carried out in the case depicted in the illustrations below.
The patient had sustained a fracture of the proximal tibia and the distal fibula. There was some anterior translation of the tibia equating to around 20% of the AP depth of the tibia.
The injury of the involved limb was first placed in a POP above knee posterior slab and then the slab was completed with a polymer casting tape. The casts were both applied at a hospital which serves as a national training centre for cast technicians.
The patient had arrived at the local hospital fracture clinic two weeks after the initial injury and was the subject of a consultant orthopaedic clinician's review. It was apparent that the patient was in severe discomfort and that much of the problem could be attributed to the cast on the injured leg.
The case was discussed between myself and the lead clinician and it was clear that changing the cast for a close fitting, clinically appropriate cast could potentially create a situation where a significant surgical solution (intramedullary nailing of the tibia) would be the only alternative.
It was decided that I would do my utmost to correct the deficiencies in the cast and after a further time of two weeks had elapsed, a new cast would be applied. The list of complaints expressed by the patient was long and clinically sound interventions required nearly an hour to apply.
The patient had a complaint about the weight of the cast causing a continuous strain of the groin area when standing or attempting to walk. The crutches were not correctly fitted. The foot was in about 22 degrees of equinus and continually brushed the floor when standing and attempting to mobilise. The leg was held in a completely straight position placing a continuous strain on the hamstrings and creating pain which was unrelieved by (and not susceptible to) the range of standard analgesic therapies.
The undercast padding was not held by an application of urethane pre-tape and the orthopaedic wool had both migrated and bunched together in clumps at various points under the length of the cast. The discomfort from migrating and clumping undercast padding was one which could not be addressed by the patient. Most of it had occurred too far from the edges of the cast for any realistic adjustment to be made by the patient.
The cast edges were sharp and poorly padded. On arrival, the patient had lost whatever cast padding had been applied to the cast edges. The risk to the skin from pressure and abrasion injuries was considerable. The patient had not received adequate instructions for use of the toilet, shower or the use of crutches. The patient had no idea how to manage the abrasive effect of the cast on the contralateral leg.
Treatment In Cast Room
The image above shows the cast (just as the patient had presented to the clinic) at the top of the thigh. The cast is finished with three layers of polymer which were unprotected. There is an amount of orthopaedic undercast wool visible and it will be obvious to any practising cast technician that it has clumped together and migrated under the cast; because it was not adequately applied or fixed into position.
The temporary solution was to move, straighten and spread the undercast padding as well as possible and a far as possible under the space between the thigh and the cast. The sharp edges of the cast were padded with 2 millimetre thick adhesive orthopaedic felt and the adhesive backing was inserted inside the cast as far as possible so as to fix the edges of the orthopaedic undercast wool.
The depicted leg section (above) of the cast was completely straight as it had been placed in a position of 0 degrees. The risk to the patient's injury if the cast was removed and replaced was judged to be rather high. Accordingly, the cast was left in situ as it was and it was agreed to replace it at the earliest possible opportunity, when the risk of movement of the fracture fragments was considerably reduced.
The lumpy appearance of the cast suggests that very little care was taken when applying the polymer casting tape over the top of the POP splint. It is usually the case that completing a cast (part POP slab and part polymer casting tape) provides an ill-fitting complete cast. There was no protection for the contralateral leg against abrasion from the polymer cast material.
This is because the injury oedema will have changed from the time of the original POP splint application. There will be voids and bumps on the inside of the slab that will prevent the completed slab from being comfortable or accurately fitting. Completion of a slab implies that the patient will wear the completed slab for some period of time.
It is a poor practice to complete POP slabs which have been applied merely as a first aid measure (rather than the initiation of a specific orthopaedic treatment) and it should be deprecated. It is usually advisable to wait 10 to 14 days for the vital injury oedema to resolve and then apply a definitive cast. This new cast will actually fit the patient and they will be more comfortable and recover well because they will feel the progress rather than the discomfort of their injury.
The final image above shows the foot placed at 22 degrees of equinus. The edges of the cast extended over the proximal half of the toes and the cast edge was unprotected and raw. This image was created after BSN's Delta Terry Net adhesive felt was placed around the trimmed cast edges. The cast edge was trimmed back and removed from the toes and the excessive undercast padding was removed where it had migrated under the cast edges and become lumpy.
When the POP splint was covered with polymer, it would have been useful (essential) to remove the foot section of splint and place the ankle in a neutral position. An improvement would have been for the original POP slab to have been applied correctly; that is to say with the anatomy placed in the ideal position for ongoing treatment to be continuous. This approach to clinical treatment would not have required the previous emergency first aid work to be removed and exchanged for an appropriate cast.
The failure to understand the effect of an extended foot on the patient's ability to mobilise (without having to hitch the hip so that the foot did not drag on the floor) strongly suggests that the operator should not have been permitted to practice the work of a cast technician unsupervised. The issue of crutches that were too short punctuates and underlines this opinion.
Issuing crutches without instructing the patient in their use is negligent. This patient had three flights of stairs to negotiate to get into their room at home! No information was given with regard to using the toilet or a shower and this too was a needless omission from the patient care one would expect from any institution, let alone a centre of excellence which teaches cast technicians to do their work.
The final act after making the patient as comfortable as possible was to apply adhesive orthopaedic felt to a depth of 5mm along the length of the anterior tibial aspect of the cast and the medial surface which could be seen in contact with the contra lateral leg.
It is a given and essential that the centres of excellence (the hospitals which teach casting practice to potential candidates) such as RNOH Stanmore or Bradford Royal Infirmary, do not produce casting work to such a low standard. It is a poor example for student cast technicians to follow and it represents a low standard of patient care.
That such dreadful work emanates from one of our national schools of casting caused me to echo the words of John McEnroe and entitle this piece in sheer disbelief. What are we going to teach new and existing cast technicians by permitting this appalling standard of work to be applied?
It is difficult to discern exactly where the failures occurred in this case because I am not privy to any of the details. I will say that the tale related by the patient made me concerned for the way the work was carried out at the original treating hospital. The rather depressing leitmotif throughout this blog is that we must all know when we don't. This is the only way we will advocate on behalf of the patient's care and prevent ourselves from doing them harm.
Who could not issue crutches and yet did so, ensuring that they were too short for the patient's height but failed to instruct the patient in their correct and safe use? Who failed to recognise that an equinus foot will prevent the leg length from being even thus causing the patient to raise their hip with every step?
The consequence of walking with this enforced and unnecessary deformity is muscle tiredness and pain from exertion. Who gave no thought to the padding supplied under the cast nor how to appropriately protect the cast edges, with the end result that pressure injuries and abrasion injuries to the patient's skin were inevitable?
No abrasion resistant felt was applied to the cast to protect the contralateral limb. No thought was given to the social circumstance of climbing three flights of stairs to get home and a heavy, straight legged cast was applied. The pain of groin strain and hamstring stretching was not considered. The undercast wool was not fixed into position and so it became uncomfortable rapidly.
The lack of assistance in helping the patient to overcome the limitations imposed by the injury insofar as toilet use, shower use and rest and elevation of the injured limb. Overall, this patient had poor care on many different levels... from a centre of excellence as far as casting practice goes.
It now becomes much easier for me to understand the rather low standards of delivered patient care which I have witnessed being provided by BCC qualified cast technicians; given that one of our cast technician teaching institutions provides work of the calibre being discussed.
Rather than shooting the messenger, I implore the BOACC/NCTA and the AOP to take this particular complaint seriously. It is a symptom of what I have seen during my four decades of clinical practice. I have worked for most of that time as a clinical nurse specialist in trauma and orthopaedics and as a cast technician.
As stated elsewhere, it is essential to the continuation of cast technician as an occupation that these issues are addressed. I am willing to work with any person in the uk who wishes to see a substantial and significant improvement in the way that casting is taught and practiced.
If you keep on doing what you have been doing then you are going to keep on getting the same result.