This blog inter alia aims to highlight areas of cast technician clinical practice which may appear to be controversial. Cast technicians in the UK are usually isolated from each other in geographical terms and we may not get to speak with our colleagues very often. Discussions (of advanced or developing clinical practices) with our peers are few and far between.
One of the areas which could use publicity is the way in which we use our specialist knowledge and skills to prevent patients from undergoing needless surgical procedures. Be in no doubt that the advanced clinical skills used in these cases requires excellent orthopaedic knowledge and a comprehensive understanding of possible sequelae.
The cases illustrated in this article are not detailed in an effort to encourage cast technicians to make a casual attempt at improving any specific set of clinical circumstances. There is no case to be made for flying 'by the seat of your pants'. Both of the cases detailed here are depicted because they show what can be achieved with solid orthopaedic knowledge.
They underline the application of sound mechanical knowledge. The endpoint is that there is a much better service for the patient. Consultant orthopaedic clinicians will be able to assign certain technical work to their cast technicians and know that it will be completed in an approved manner.
Radiographic images are the bread and butter of cast room work and cast technicians cannot work without an excellent knowledge of how to interpret the images that accompany our patients.
The first radiograph below shows an AP image (mortise view) of the distal tibia and fibula. This view is required to accurately assess the articulation of both the medial and lateral malleoli as well as the tibial plafond with the talar dome. The image provided also displays the distal interosseous membrane, the syndesmotic joint, the soft tissues, the tarsals and the proximal metatarsals.
There should be no talar shift; evidenced by the talar dome shifting laterally under the tibial plafond. The joint space created by the malleoli and the tibial plafond should appear evenly spaced. There should be no separation of the fibula and the tibia and the distal ends of these bones should also be in close contact.
This demonstrates that the syndesmosis is intact. The joint space around the talus does not appear cleanly in this image and this was probably because the foot was still in equinus. It can be difficult to visualise a clean talotibial joint space if the foot is not in a neutral position and the X-ray tube is not placed accurately.
The gap between the talar dome and the tip of medial malleolus is subtly widened and it suggests a small degree of talar shift even though there is not any malleolar fracture. (N.B. The Danis-Weber fibula fracture classification is both unsuitable and unusable in this case) The widening is a sign that the deltoid ligament may have been involved in a Lauge-Hansen supination-external rotation injury.
The Lauge-Hansen stage 3 classification describes a posterior malleolus fracture and the stage 4 classification is assigned when there has been a deltoid ligament rupture. The degree of soft tissue oedema on the medial side would indicate a significant injury of the soft tissues.
Do not make the mistake of treating the radiograph. It is important to see and examine the patient clinically and to take a clear history of the injury before arriving at a working diagnosis.
The next radiograph is a lateral image (mediolateral) depicting the distal tibia and fibula. Other bones visualised are the calcaneum, talus, navicular, cuboid and fifth metatarsal base. The soft tissues which may appear on this image are the Achilles tendon, Flexor Hallucis Longus and Soleus.
This lateral view implies that there is a small injury to the posterior malleolus of the tibia. These fractures are probably better described as tibial plafond fractures; since they involve the articulating surface of the tibia. The foot is also in equinus.
The next image shows the corrected AP mortis view.
The gap between the medial malleolus and the talar dome has closed. The soft tissue oedema appears to be reduced. The final image in this series is another lateral image taken from the mediolateral aspect.
The radiograph above shows the foot from the mediolateral aspect. It is in a cast and the foot is in a neutral position. The tibial plafond shows a small fragment of the tibia is damaged in accordance with a diagnosis of posterior malleolus fracture.
Things to note: The cast is in a neutral position and it fits the patient as closely as possible. The soft tissue oedema has resolved to a point where the cast can be fitted to the patient more accurately. The requirement for a surgical fixation has been removed by accurately casting the injury. Additional orthopaedic felt padding was applied over a prominent calcaneal tuberosity.
Where an injury is amenable to bi-manual compression techniques, it is important to realise that trying to affect the injury when it is effectively enclosed in a bag of fluid, can be futile. I had to compress this injury, while holding the foot in a neutral position, for about twenty minutes.
The deformation forces had to be applied while compressing the tissue oedema. It was moderately painful for the patient but they were very keen to avoid surgery. The application of slow and rather deliberate continuous bi-manual compression, while adjusting for anatomical position, is how I apply this type of correction.
Too fast an application of corrective pressure or too much compression will adversely affect the outcome. The patient will have undergone pain for no particular benefit. Cast technicians can be trained to reach a high degree of competence. In my view we should all be trained to this standard. It may require some years to understand our work at this level and to go on to achieve this type of result predictably.
The next case illustrates a common clinical presentation. The patient had developed an injury while playing rugby. The 4th metacarpal is damaged and the lateral radiograph demonstrates the fracture. A spicule of bone can be seen pointing backwards and protruding dorsally. To aid clarity, I have edited the image and removed the cast outline.
The lateral radiograph shows the proximal phalanges and the metacarpals. The carpal bones, the distal radius and ulna are also visualised. The provided radiographic images are not of diagnostic quality and are included merely to illuminate the issues.
The patient was in the third decade of life and employed in the type of work that required two functioning hands. The injury was sustained by their dominant hand and they did not want to have any surgical solution applied.
The PA view demonstrates a diaphyseal fracture of the 4th metacarpal. There is approximately .5 of a centimetre shortening overlap of the fragments and possibly .25 centimetre medial translation of the distal fragment. Soft tissue oedema (++) was noted.
The lateral view of the hand in the cast shows that the 4th metacarpal is now sitting corrected. The cast is clearly holding the distal fragment in place. The X-ray image was taken one week after the cast was applied.
The PA image of the metacarpals demonstrates good alignment and apposition. The patient was pleased with the outcome. There was no clinical consequence to the injury. No detectable malrotation and the patient thought the pain, which was tolerated when casting, was worth the outcome without surgery.
It is noted that 15 minutes of discomfort had to be endured by the patient while the cast was being applied. The process was explained and the patient's permission and agreement was sought before the application of any corrective force.
The question for both senior orthopaedic clinicians and cast technicians to answer is this: should cast technicians be trained in the techniques demonstrated and which have yielded the results shown here? The application of these techniques by a cast technician within a cast room environment begs several questions.
1. Is this type of approach to fracture treatment desirable?
2. Should cast technicians be the agency by which it is applied?
3. Does this type of casting constitute fracture manipulation?
4. What additional cast technician training load would this place upon the BOA?
5. Does the time saved from theatre lists add real value to casting techniques?
6. Are the cost savings able to be used for the wider good of the NHS service?
7. Could these casting techniques be considered to be best clinical practice?
There are many other questions raised by these advanced clinical practices. Cast technicians are a group of ancillary workers who could be trained to produce work in the vein illustrated above. Whether we should (as a collective group of staff) do so is entirely a matter for individuals at the moment.
I have chosen to use my training and my skills to provide my patients with the very best clinical practices which I can deliver. Much of my extensive and extended training has been completed outside of the BCC course via the good offices of AOTrauma (of which I am a fully paid up member) and willing clinicians. Not having surgery to correct injuries which can be corrected without undergoing surgery may prove to be a worthwhile approach. Training to correct such injuries is just one more tool in my personal armoury of clinical approaches to orthopaedic trauma.
The recognition for my skill set is always restricted to the local situation. It is my contention that if the work shown above truly represents good clinical practice, it should be taught to the cast technicians who would wish to learn how to do this work. It should be offered as an advanced skill and ultimately, it should be recognised via the work title of the employee. Senior orthopaedic clinicians would need to determine the value of this type of approach to commonly seen orthopaedic trauma.