Locum work will often leave orthopaedic practitioners in situations which require more resources than are readily available to them. I was recently working on my own in a fracture and orthopaedic clinic. It was a weekday but the plaster room was only staffed by me and I was working as a newly contracted short-term locum appointment.
I was asked to remove a cast from a patient who was under 18 years of age and who had sustained a fractured tibia. The cast was an above knee cast and the patient was unable to get out of the wheelchair in which they had attended the plaster room.
The patient presented with a serious co-morbidity in that they were suffering with a genetic, progressive degenerative condition. The condition is sometimes known as peroneal muscular atrophy (PMA) or hereditary motor and sensory neuropathy (HMSN). More commonly it is known as Charcot Marie Tooth disease. (CMT)
I had removed the patient's cast and noticed that there was a grade one pressure ulcer on the calcaneal tuberosity of the heel. The cast had been worn for a period of four weeks. There was non-blanching erythema present over the tuberosity and clearly defined pain on gentle palpation of the area.
The heel had been painful under the cast for 10 days. I documented my findings on the reverse of the cast room treatment request sheet and asked one of the clinic nursing staff to ensure that a clinician would be notified. I wanted the clinician to examine the pressure ulcer and then prescribe an effective treatment regime.
Some hours later, the patient was sent to the cast room to have another above knee cast applied for a further four weeks. I checked with the relative of the patient as to what the clinician's response had been to the pressure ulcer. I was surprised to discover that the patient's relative had been told by the clinician that "sore heels were normal" for the cast type prescribed.
The clinics had formally closed and the prescribing clinician was no longer available to me by 'bleep', personal pager or mobile telephone by the time I came to apply a new cast to the patient's fractured limb. With no treatment having been prescribed for the pressure ulcer, I was reluctant to apply a cast and thereby become the facilitating mechanism by which the pressure ulcer would deteriorate; with the inevitable and serious consequences for the patient.
Without the availability of a prescribing orthopaedic clinician and the reluctance of junior (FY1/2) orthopaedic 'on-call' staff to advise me, I had to look elsewhere for a solution. I contacted the tissue viability service and discussed the case with them. I was prohibited from making a formal referral to the tissue viability service without a clinician's prescription. The circular discussion ended with me applying a cast which was very well padded at the heel and explaining the essentials of cast care (for patients with neuropathic conditions) to the relative.
I gave the patient's relative the consultant clinician's personal phone number and requested that the relative contact the consultant clinician to make an early appointment and schedule a regular (weekly) check on the state of the heel, despite the four week appointment which was made in the fracture clinic. With unbroken skin it was unwise to apply any sort of dressing under the cast.
I am not inclined to make windows in casts because they are frequently too small to permit an adequate size of sterile field to be created when dressing a wound. Where cast windows are large enough to permit a good sized sterile field to be created around the wound to be dressed, they are usually large enough to impair the structural integrity of the cast. They also allow the protrusion of labile soft tissues. I prefer the application of a posterior slab cast splint which can be removed whenever required; to permit easy and complete access to a wound which needs constant aseptic wound care.
I had written a comprehensive record of the treatment and advice in the patient's clinical care record so that other healthcare professionals in the orthopaedic care team would be aware of the treatment I had applied and the advice I had given to both the patient and their relative. The patient was going to find it difficult to be aware of every change in their own foot and heel because of the neuropathy. The dead weight of their leg was going to make it difficult to wear a cast without a constant pressure on their anatomical prominences through gravity.
The patient was unable to care for themselves and as the disease process progresses, they are going to become prone to many of the issues seen in patients with diseases such as Duchenne's muscular dystrophy. CMT is a specific form of neuropathic condition which was once considered to be a sub-type of muscular dystrophy.
Developing a pressure ulcer is a risk for a number of healthcare populations. Patients who are immobile or wearing a cast have an increased risk of developing pressure ulcers. Immobility combined with neuropathic conditions such as CMT are additional factors for increasing the opportunity for the development of pressure ulcers.
The wheelchair bound patient would be wearing a cast for another four week period and had very little sensation of the lower limbs. The pain at the heel which was felt by the patient must have been very severe to have registered on a sensory system which had been functionally affected to a substantial degree and weakened by the depredations of CMT.
Giving the relative an additional contact point for the treating consultant, outside of the usual clinic procedures, was a strategy designed to involve senior clinical input at the first sign of a complication; which could potentially affect the whole of the treatment process. It was an unusual step to take but in lieu of any other pathway with which I could assist the patient, I had to adapt the normal clinic visit process to the specific clinical needs of the patient.
The involvement of the tissue viability service at an early stage of treatment would have been beneficial and possibly would have prevented the patient from developing a pressure ulcer. Now the issue is out in the open and the principle caring relative is aware of what has to be done in the event of any issues being raised by wearing the cast.
The clinician who had stated that it was normal for a patient to develop sore heels while wearing a cast had mislead the patient by giving them wrong information. Pressure ulceration is an unwanted complication which must never be considered to be a normal finding, especially while the patient is wearing a cast.