Bricolage IS WRITTEN by Jeff Cable and is based in the United Kingdom.

This blog aspires to provide COHERENT and relevant Material for all cast TECHNICIANS. 

Unthinking Compliance Risks

Facts:
A patient with multiple serious co-morbidities (thereby excluding surgical solutions) had sustained an injury to an elbow. The elbow joint was completely disrupted and an above elbow (AE) posterior slab was applied in the A&E department. The patient was admitted and routinely consented for an ORIF procedure for total joint replacement. Surgery was not carried out because of the contraindications encompassed by the co-morbidity complications. Three days post admission, a change of slab to a full above elbow cast was prescribed.

The patient had appeared in the plaster room with an instruction to change the posterior slab to a full cast. There was no clear prescription, diagnosis or treatment objective. The soft tissue damage and oedema was extensive following the very serious elbow joint injury. My immediate assessment of the radiographic evidence was that the fracture pattern was highly unstable and that the broken humeral bone fragments were highly likely to move. Additionally they were very likely to cause severe pain to the patient if the elbow was handled outside of the existing splint. The slab was acting as a temporary splint and there was very little pain experienced by the patient because the injury was being held and supported by the slab. 

I had contacted the prescribing clinician, who had appeared to be very irritated by my asking what was the objective of the cast change. The exchange proved circular and fruitless and I concluded by telling the trainee orthopaedic clinician that I would contact the consultant. I had wanted the clinician to hold the limb and the joint in as stable a position as was possible, while I applied a more comfortable posterior slab. The clinician argued with me and was repeatedly obstructive to my completion of the work; which had co-incidentally been prescribed by that self-same clinician. 

Some time passed and a more experienced trainee orthopaedic clinician appeared in the plaster room. I explained that the oedema around the injury and the highly unstable fracture pattern was making me fearful that I would hurt the patient needlessly, for what could only be no improvement or change in the clinical picture. The clinician agreed with me and no further treatment was carried out. The management of the condition was planned appropriately and it would take place at a date when all of the post trauma oedema had resolved.

Analysis:
My attempt at discussing the clinical picture with the prescribing clinician, in addition to examining the urgency of the imperative to act immediately, was on all fours with the practice recommended by the BOA; that cast technicians exercise good clinical judgement. I determined that I could potentially harm the patient if I had followed the instruction to remove a perfectly adequate posterior slab from an unstable injury and exchange it for a full above elbow cast. Given that the injury was still relatively fresh at three days old and there was a lot of swelling around the injury, a full cast was going to become ill-fitting after a relatively short period of time had elapsed. 

In my view, there was no clinical advantage to be gained from subjecting the patient to needless pain and discomfort. It was not possible to bring about any significant change in the patient's clinical position. In short, there was no pressing need to make any change in the clinical management of the patient's injuries. The radiographic images below show the severity of the trauma sustained. The curve of the soft tissue swelling present on the anterior aspect of lateral view underlines the severity of the injury.

Elbow Joint - Lateral View

Elbow Joint - Lateral View

What can be clearly seen on the lateral view is a disordered elbow joint. The derangement is total and the joint is non-functional. These images are not of diagnostic quality but the ulna and radius can be seen to have translated posteriorly under the influence of the triceps muscle. The distal humerus has sustained a comminuted fracture and the fragments are displaced. The capitulum is neither located at the radial head nor is it in the space usually described as the humeroulnar joint; which is formed by the coronoid process and the olecranon. 

Elbow Joint AP View

Elbow Joint AP View

The capitulum is fractured and displaced anteriorly and it appears superiorly to the radial head. The medial and lateral humeral epicondyles have fractured and displaced posteriorly; and moved towards their respective sides as can be seen on the AP image. There is a suggestion of an irregularity just distal to the radial head but the image is insufficiently detailed to make an assessment with any degree of confidence.
 
Conclusion:
Cast technicians are always acting on behalf of the patient. Advocating for the patient's best interest is integral to our role and this particular aspect of my work had caused me to question the prescribed treatment. It had appeared to me to be a very poor choice, especially as there would be no particular clinical advantage resulting from the new treatment prescription. I had asked why it was deemed necessary to change the slab to a full cast and I tried to understand why there was no clear clinical objective. 

Without a good reason to make a change to the treatment pathway, it was clear to me that the swopping of one splint for another splint of a similar type (the oedema would have mandated another posterior slab) without any clearly defined clinical need, made absolutely no medical, orthopaedic or biomechanical sense. I had no choice but to refuse to follow the prescription to change the above elbow posterior slab for an above elbow full cast. I had considered that the risk of making the clinical situation worse was both very high and completely unnecessary.

The result would have been the same if there had actually been any written instruction. I would still have contacted the prescribing clinician to understand what clinical objective I was being asked to facilitate. The lack of a written prescription and the inability of the trainee clinician to adequately justify a change in the treatment, given that there would be no resulting change or advantage to the whole clinical picture, suggested that the situation was outside of the specific clinician's experience and competence.  

The A&E department posterior slab was not applied in an expert manner. It had been applied at the time of the A&E attendance by staff without training in cast application. Nevertheless, it was adequately preventing any elbow movement and thus it had reduced the patient's pain and the risk of further damage to the bony fragments, the joint, the surrounding soft tissues and the neurovascular structures present at the injury site.

Cast technicians should not find themselves following orders blindly. If we cannot see sense in the prescription, we must ask the clinician why they have ordered it. If the clinician (usually a trainee) makes no sense, we must refer to the treating consultant and obtain a definitive view on the treatment to be applied. As an advocate for our patients, we must talk for them when they have insufficient knowledge to speak up for themselves. 

Focussed Rigidity Casting

Infection Under A Cast