This Signal relates to delayed recognition of pressure ulcers under plaster casts leading to harm (including amputation) and the need to identify patients at risk.
Good casting techniques and monitoring should prevent complications such as pressure ulcers in most cases. Severe pressure ulcers can lead to pain, prolonged hospitalisation and substantial morbidity (including amputation).
Healthcare staff should be aware of the possibility of pressure ulcers under plaster casts. They need to inform patients of warning signs and who to contact if complications develop. This is particularly important for high-risk patients, for example those with significant vascular disease, including patients with neuropathy (most commonly with diabetes) or conditions like stroke with sensory deficit, who will feel little or no pain, increasing risks of delayed recognition.
A typical incident report reads:
“Plaster of paris to left leg for fracture. Pressure caused grade 4 pressure ulcer to right shin. Patient already prone to pressure damage due to arterial disease.”
A search of two years of incident data held by the National Reporting and Learning Service (NRLS) revealed 84 cases where pressure ulcers developed under plaster casts. These included 26 grade 4 reports (deep necrotic or exposing bone ulcers) and 19 grade 3 (cavity wound) reports. Since only a sample of data was reviewed, we might expect to see around 20 more grade 3 or 4 ulcers if all data over two years had been reviewed.
Concerns raised by incident data include:
- the amount of padding or poor alignment of plaster
- reports of pain and/or symptoms (e.g. exudate) by patient not acted on by staff either in the hospital or the community
- patients with known vascular disease and multiple sores where staff appear not to be aware of heightened risk
The British Orthopaedic Association has been working with the Society of Orthopaedic and Trauma Nursing (Royal College of Nursing) and the Association of Orthopaedic Technicians/Practitioners to raise standards in casting skills.
Casting may be done by a range of staff and in a variety of settings, including emergency departments, minor injury units and operating theatres, as well as casting rooms. Review and investigation of local incidents may identify skills gaps in staff. Further information is available on accredited training.
Other useful resources for staff include a model patient information leaflet for patients and carers with possible signs of complication and contact numbers (as well as exercises and care of cast). See British Orthopaedic Association website.
Note that national guidelines recommend that organisations carry out local investigations of pressure ulcers of grade 2 and over.
Have you had any grade 2 or above pressure ulcers under plaster casts at your trust? Have any of these prompted local investigations which you could send to us (anonymised)? firstname.lastname@example.org
Relevant to: surgery, general medicine (especially elderly and those confined to bed)
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