Neuromuscular Patients Are 40% More Likely to Get a Cast Injury

Abstract

Background: Cast injuries can occur during application, throughout immobilization, and during removal, with common morbidities being pressure ulcers and cast saw burns. The incidence rate of cast injuries in generalized and diagnosis specific pediatric populations is not known. The goal of this study is to accurately quantify the rate of incidence of cast injuries at a large pediatric orthopaedic practice and identify potentially modifiable risk factors to guide quality of care improvement. Methods: A retrospective review was performed at our institution between July 2019 and October 2020. Inclusion criteria was all pediatric patients (below 21 y old) with an orthopaedic diagnosis that was treated with casting. The child's diagnosis, specific type of cast, and training level of the person applying the cast was recorded. Patient injuries were identified through cast technicians' documentation regarding cast removal. The primary outcome was the incidence of casting injuries from July 2019 through October 2020. Additional outcomes included the association between diagnosis of neuromuscular disease and training level of individual applying the cast with casting injuries. χ 2 tests were used to compare categorical variables and post hoc comparisons using Bonferroni correction. Injury incidence rates were calculated as number of injuries per 1000 casts. Results: There were 2239 casts placed on children at this institution between July 2019 and October 2020 and a total of 28 injuries for an incidence rate of 12.5 per 1000. Of the 28 total injuries reported, there were 5 cast saw burns (2.2 per 1000) and 23 pressure ulcers (10.3 per 1000). Incidence of cast injury was not significantly correlated with timing of application during the academic year or training level of the individual applying the cast (P = 0.21 and 0.86). Notably, there was a significantly higher incidence of cast injuries in individuals with a diagnosis of a neuromuscular disorder (37.4 per 1000) than those without (7.5 per 1000) (P < 0.01). Conclusion:The incidence of cast injuries is 12.5 per 1000 children at our level I trauma tertiary referral pediatric clinic. Training level of the individual applying the cast or timing during the academic year did not correlate with cast injuries. Patients with neuromuscular disorders are at significantly higher risk for experiencing cast injuries. Level of Evidence: Level III.

Determining Incidence and Risk Factors of Pressure Injury After Orthopaedic Surgery in Children and Adolescents With Neuromuscular Complex Chronic Conditions

“…The majority of device-related pressure injuries were of the heel (58%) and were primarily owing to casts, while those of the knee or calf (33%) were primarily owing to knee immobilizers. A recent study found that pediatrics patients with a neuromuscular diagnosis had a significantly higher incidence of cast-related injuries (pressure injuries and saw burns) compared with those without 19. Therefore, it is important to have increased suspicion of heel pain in postoperative neuromuscular patients with lower extremity casts and establish routine skin checks and protective padding over bony prominences for those children wearing postoperative knee immobilizers.…”

“…A recent study found that pediatrics patients with a neuromuscular diagnosis had a significantly higher incidence of cast-related injuries (pressure injuries and saw burns) compared with those without. 19 Therefore, it is important to have increased suspicion of heel pain in postoperative neuromuscular patients with lower extremity casts and establish routine skin checks and protective padding over bony prominences for those children wearing postoperative knee immobilizers. Furthermore, preventive measures such as educating health care providers to provide heel padding in lower leg casts particularly in the immediate postoperative period when edema is present, have been shown to decrease rates of cast-associated skin injuries.…”

What's New in Orthopaedic Management in Neuromuscular Disorders

“…Cast problems in children with neuromuscular conditions were presented at the 2022 American Academy of Orthopaedic Surgery (AAOS) Annual Meeting. 18 They found 14/28 cast injuries were in children with a neuromuscular diagnosis and all were pressure ulcers. There was no difference in who placed the cast (attending surgeon, resident, or cast tech) or where the cast was placed (operating room, clinic, or emergency room).…”

Children’s orthopaedics

“…Researchers from Los Angeles (California, USA) therefore reviewed all their paediatric patients treated with a plaster cast over a 15-month period, recording the underlying diagnosis, the type of cast, and the level of training of the plaster technician. 4 Injuries were identified from contemporaneous records made at the time of cast removal. Overall, 2,239 casts were placed on children over this period with a total of 28 injuries recorded, giving an incidence rate of 12.5 per thousand.…”