These images represent the case of a male in his 4th decade. He sustained a pressure injury which was all too clearly caused by the careless application of a cast.
The radiographic image is neither ideal nor is it of diagnostic quality; but both views demonstrate that the patient had sustained a minimally displaced distal radius and ulna fracture with slight axial compression. The just visible lighter line following the soft tissues of the volar aspect (seen on the lateral image) denotes the cast extent.
A similar light line can be seen running along the dorsal aspect of the lateral image. The upper end of the volar line shows considerable creasing of the skin at the wrist joint level and just proximal to it. This is the first fracture clinic radiograph and no reduction was applied in the A&E department. The excessive palmar flexion had been applied in the plaster room, by a BCC certificate holding cast technician, evidently on instructions from the treating clinician.
The cut cast edge shows the volar aspect of the cast to be deeply rippled at the level of the wrist joint. The peak of the ripple pressed into the wrist at the level of the distal wrist crease. The left hand side of the image shows four layers of orthopaedic wool padding. The right hand side of the image shows that the cast was poorly laminated; level with and beyond the Hapla felt.
The cast had been worn for just two weeks. The patient was attending the fracture clinic for a routine appointment. My questions to the patient revealed that the injury had remained painful under the cast since the cast was first applied. The patient had complained to me of sensory parasthesia in his hand; along the distribution of the median nerve. When questioned as to why he had not contacted the plaster room or hospital, he said that he had expected the injury to be painful until the cast was removed at 6 or 8 weeks.
The pressure ulcer is graded as 'stage one' according to the European Pressure Ulcer Advisory Panel scale. A quick reference guide to pressure injury treatment is a useful document to print and keep in the plaster room. Access to comprehensive tissue viability services is a necessary adjunct to good cast room work because wearing a cast is one of the prime reasons for the development of pressure ulcers. A pressure ulcer grading tool is a very useful quick guide to the injury. What follows is a downloadable Scottish adaption of the tool provided by the European Pressure Ulcer Advisory Panel.
The image of the wrist lesion sustained by the patient shows the very clearly bruised area, just proximal to the hypothenar eminence, centred on the distal wrist crease. There is also erythema extending for about 2cm along the volar aspect of the forearm. The orthopaedic wool was providing a tight circumferential band around the wrist and a line of pressure is clearly seen. Finally, the stockinette has left pressure markings along the length of the forearm. In short, the cast was uncomfortable at its initial application and it became progressively more uncomfortable.
Casting Technique Points:
- The incorrect and dangerous application of excessive palmar flexion. (arguably this was not required at all)
- Poor cast application technique. The ripple in the cast throughout the structure should never have been present.
- The use of excessive undercast padding created an ill-fitting cast.
- Failure to ensure lamination of the casting tape created weak points in the cast construction.
- No comfort check was made after cast was applied and patient was uncomfortable when the cast was completed.
- Patient was unaware of necessity to contact cast room for any reason e.g. pain or discomfort
- No effort was made to offer cast instructions in the Lithuanian language of the patient.