Deviation in the Standard of Orthopedic Care When Applying a Cast

Evaluate breaches in the standard of care with the assistance of the following questions and answers to determine whether or not there has been a Deviation in the Standard of Orthopedic Care When Applying a Cast

Answer the following questions to find out if the standard of care was followed for your case.

  • Was casting indicated?
    Yes
    No
    Answer unknown
    Why is this important?
    Casting is the standard treatment for many closed, non-displaced, or reduced fractures.
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  • What type of cast was applied initially? Why is this important?
    Answer this question
    
The choice of which casting material to use is largely dependent on the individual clinical situation.

    (2008) 39 ESINJR 12 1467-1473 



  • Was the cast correctly sized for the injury? Why is this important?
    Answer this question
    
The application of casts is an integral part of orthopedic and trauma surgery practice.

    (2002) 6 EJORTN 3 170-173 



  • Was a molding technique employed during cast application? Why is this important?
    Answer this question
    
The goal of molding is to maintain alignment of an unstable fracture. An oval or elliptical shaped cast is better suited for maintaining fracture alignment than a perfectly cylindrical cast. 

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  • Were the pressure points involved in the cast adequately padded? Why is this important?
    Answer this question
    
Extra padding is often needed over bony prominences that are susceptible to pressure and skin breakdown that may be caused by the cast.

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  • Did the patient complain of skin irritation at the edges of the cast? Why is this important?
    Answer this question
    
To avoid pressure on the skin and over bony prominences, stockinette and layers of cotton sheet wadding (Webril) need to be snugly applied first.

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  • Was a window created on the cast in case of an open wound? Why is this important?
    Answer this question
    
A window may be placed in the cast, and the cutout area may be used as access to skin wounds that require care during immobilization.

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  • Was the cast inspected after its application? Why is this important?
    Answer this question
    
After the initial cast is applied and fracture alignment is confirmed, the next essential step is to ensure adequate and timely follow-up. The interval between visits depends on the nature of the fracture, the type of cast, and any concerns there may be about patient compliance.

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  • Did the patient experience a burning sensation after cast application? Why is this important?
    Answer this question
    
Immersing the plaster in water for too short a time or squeezing too much water out, also leads to generation of excess heat.

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  • Were post-reduction radiographs obtained? Why is this important?
    Answer this question
    
Changes in fracture position can occur during cast application despite an optimal reduction and excellent casting technique with proper molding.

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  • Was patient education provided prior to discharge? Why is this important?
    Answer this question
    
The clinician must provide clear instructions about signs and symptoms of skin breakdown, vascular compromise and nerve injury to the patient prior to discharge from the health care facility. 

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  • Was deep vein thrombosis prophylaxis initiated? Why is this important?
    Answer this question
    
Lower extremity fractures frequently result in long periods of immobilization and the potential need for anti-coagulation therapy.

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  • With which of the following symptoms did the patient present? (Choose all that apply) Why is this important?
    Answer this question
    
Compartment syndrome is a serious, acute emergency complication that should be considered whenever pain and paresthesias occur in an extremity after a fracture has been treated with a cast.

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  • Was the cast assessed once the patient complained of swelling and pain? Why is this important?
    Answer this question
    
The first step in the management of compartment syndrome involves bi-valving the cast and splitting the underlying padding to aid in reducing the pressure.

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  • Was the compartment pressure measured? Why is this important?
    Answer this question
    
If the history and examination suggest compartment syndrome, compartment pressures should be measured.

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  • Were the patient’s complaints of numbness and tingling below the cast treated? Why is this important?
    Answer this question
    
Casts that are applied too tightly or that become too tight due to soft tissue swelling, can cause vascular compromise.

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  • Was a follow-up visit after cast application advised? Why is this important?
    Answer this question
    
A cast applied to an already swollen extremity may become loose as swelling subsides, providing inadequate support and immobilization.

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  • Was cellulitis, abscess or necrotizing fasciitis treated? Why is this important?
    Answer this question
    
Casts obscure wound infections, sources of sepsis and even the source of tetanus. 

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  • Was the patient taught peripheral joint exercises? Why is this important?
    Answer this question
    
Follow-up visits are ideal venues for teaching appropriate rehabilitative exercises and ensuring compliance with activity restrictions.

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