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. 

Advanced Working

Fracture Reduction

The work of a cast technician covers a large area of knowledge and requires many different skills. It is frequently the case that excellent cast technician work can enhance the prescribed treatments and potentially improve the outcomes for the patients. What is less clear are the grey areas which impinge on technician competence, knowledge, skill and ethics. 

For example, it could be argued that a blanket ban on technicians 'moulding' a cast would lead to a consistent approach to the work while potentially leading to less effective casts. Whether moulding a cast during its application constitutes a reduction of a fracture or not; is really a matter to be decided upon by a formal ethics committee.

As a general rule, I would prefer not to see cast technicians attempting to reduce fractures by closed methods, without a very specific training to do so. The type of comprehensive training programmes which are provided by AOTrauma, such as those provided as non-operative fracture treatment courses for limited income countries, are an excellent and ideal starting point.

It is an inseparable and integral part of the cast technician role to facilitate the treatment prescribed by the clinician. The treatment is facilitated by the cast technician applying the cast so that it can exert its effect in the most clinically useful manner possible. 

This also implies that the cast technician must not subject the patient to any further harm while applying the cast to achieve its maximum therapeutic benefit. Should this facilitative aspect of cast technician work include fracture reduction via close moulding of the cast?

The close fit of a cast is an essential attribute if it is to be an effective cast. The legal position of the cast technician in the UK (before applying the cast) is that there is no formal requirement to reduce any fracture requiring a cast. Any fracture reduction completed at the time of cast application is expected to be carried out by the formally trained prescribing clinician.

When might it be acceptable for the cast technician to closely mould a cast? It is always expected that the cast technician will apply a well-fitted cast. I suggest that the cast technician is obligated to apply the best fitted cast that they know how to produce. 

What about the question of reducing a fracture by deliberate intent? This question is more difficult to answer but it should be clear that the reduction of a close fracture should only be attempted if the process has been formally taught and the technician has been judged competent.

The attached radiographs illustrate that the treatment outcome can be changed by the intelligent application of deformation forces while casting an injured limb. The patient had sustained a fracture classified as a Danis-Weber B fracture of the fibula. The patient was prepared for the corrective surgery procedure of open reduction and internal fixation (ORIF). 

In the 'before' radiographic image, the fracture is demonstrated in a true mortice view. It is oblique and begins at the level of the tibial metaphysis on the medial aspect of the fibula. It starts at about two centimetres above the level of the tibial plafond. The fracture line concludes on the lateral aspect of the fibula at about two centimetres above the distal point of the fracture. There is an obvious diastasis at the level of the distal tibiotalar joint between the fibula and the tibia. 

The disruption of the distal syndesmosis implies injury to any of the four ligaments which comprise this syndesmotic joint. The ligaments which are at risk of injury in this case are the distal anterior tibiofibular ligament, the distal posterior tibiofibular ligament, the transverse ligament and the interosseous ligament.

The 'after' radiographic image is also a mortice view and it shows the same injured limb encased in a closely fitting lightweight cast. The distal tibiofibular syndesmosis diastasis has closed and ORIF was now not the only treatment option. In the event, the patient preferred not to have surgery and because they were pain free after casting, they had opted to continue with the non operative treatment.

The injured limb was cast with care taken to keep the padding minimal as is demonstrated by the thin dark line between the cast and the outer aspect of the soft tissues. The application of pressure at the level of the tibial plafond and the fibula above the fracture line, while the opposite hand compressed the medial malleolus had resulted in an improved clinical and radiological picture. 

The pressure was sustained to compress the soft tissue oedema before the cast had set. The casting tape had been activated so that it would set relatively slowly. This permitted the most control for the operator when setting the cast. 

The improved radiological picture does not obscure the fact that this fracture had been reduced while the cast was being applied. I was the operator and I have attended the AO non operative fracture treatment course. In conjunction with my experience and skills, I was able to make a positive difference to the treatment options which were available for this patient.

Theatre time demand, the need for outpatient follow-up, clinical resources and the inherent risks of surgery have been reduced. It would be difficult to argue that this type of approach does not reduce the net demand on the limited resources of the NHS.

Apart from AOTrauma, there is no recognised body offering to teach the skills required to cast technicians. Given the disparate backgrounds from which cast technician candidates are being drawn for the five week taught course; Theory and Practice of Musculoskeletal Casting and Splinting, this is a significant omission in our training.

How should UK trained cast technicians proceed? Unless you have received specific training in fracture reduction, you should not reduce fractures on behalf of clinicians. The legal minefield is easy to discern... you have no formal qualification in closed fracture reduction and therefore must be considered to be unqualified to undertake fracture reduction.

Continue to apply casts in the most well fitted manner that you can but be aware that any push, pull, twist or tweak is tantamount to carrying out a fracture reduction. That is to say any act which you perform, that is designed to improve the alignment or apposition of the fracture fragments, must be regarded as fracture reduction.

You can acquire the necessary skills to continue to work with mobile fracture fragments but it is an advanced skill and you should attend a recognised course of instruction on the theories and methods for working at an advanced level.

The biomechanics of each injury should be studied and assimilated and the distal radial fracture example linked gives an indication as to the depth of knowledge required before the operator undertakes the closed manipulation of a fracture. 

Before reduction

Before reduction

After reduction

After reduction

Help Or Harm?

Reasonable Workloads