Driving with a forearm plaster cast: patients' perspective

On the Road Again: Return to Driving Following Minor Hand Surgery

BACKGROUND

Patient return-to-driving following minor hand surgery is unknown. Through daily text message surveys, we sought to determine return-to-driving after minor hand surgery and the factors that influence return-to-driving.

METHODS

One hundred five subjects undergoing minor hand surgery received daily text messaging surveys postoperatively to assess: (1) if they drove the day before and if so; (2) whether they wore a cast, sling, or splint. Additional patient-, procedure-, and driving-related data were collected.

RESULTS

More than half of subjects, 54 out of 105, returned to driving by the end of postoperative day #1. While patient-related factors had no effect on return-to-driving, significant differences were seen in anesthesia type, procedure laterality, driving assistance, and distance. Return-to-driving was significantly later for subjects who had general anesthetic compared to wide awake local anesthetic with no tourniquet (4 ± 4 days vs 1 ± 3 days, P = 0.020), as well as for bilateral procedures versus unilateral procedures (5 ± 5 days vs 1 ± 3 days, P = 0.046). Lack of another driver and driving on highways led to earlier return-to-driving (P = 0.040 and, P = 0.005, respectively).

CONCLUSIONS

Most patients rapidly return to driving after minor hand surgery. Use of general anesthetic and bilateral procedures may delay return-to-driving. Confidential real-time text-based surveys can provide valuable information on postoperative return-to-driving and other patient behaviors.

Return to driving following surgery to the upper limb: a scoping review protocol

INTRODUCTION

Upper limb surgery is a common burden on the active and ageing population, often resulting in a transient state of functional impairment. Many activities of daily living can be affected, including ability to drive. Currently there are no guidelines regarding safe return to driving following upper limb surgery. This scoping review aims to systematically review the current literature on the topic of driving following surgery to the upper limb.

METHODS AND ANALYSIS

Informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review extension guidelines, this protocol details the scoping review's methodological and analytical approaches. The review will consider all primary and secondary source articles that examine return to driving following surgery to the upper limb, including the impact of orthoses on functional ability to drive. All studies will be included regardless of methodology and text and opinion pieces will also be considered. Studies conducted in any geographical location or setting will be included in the review. Systematic searches of scientific databases such as OVID (MEDLINE, EMBASE and Cochrane), NCBI (PubMed), Scopus, PsycINFO, EBSCOhost (CINAHL), Web of Science, Google Scholar and ProQuest will be conducted. In addition, relevant organisational websites, dissertations, theses from university repositories and grey literature will be included. Further articles will be identified by searching references of relevant studies. Studies conducted in English in any year will be included. Two independent reviewers will screen identified literature sources based on predetermined inclusion/exclusion criteria. Discrepancies will be resolved through discussion, therefore, negating the need for a third reviewer. Article data will be presented in tabular or graphical format along with a narrative summary.

ETHICS AND DISSEMINATION

Ethics approval is not required. Findings will be disseminated through professional networks, peer-reviewed publications and conference presentations.

Modeled Wide-Awake, Local-Anesthetic, No-Tourniquet Surgical Procedures Do Not Impair Driving Fitness: An Experimental On-Road Noninferiority Study

BACKGROUND

The use of wide-awake, local-anesthetic, no-tourniquet (WALANT) surgical techniques is increasingly common, and patients commonly ask whether they may drive home following these procedures. The impact of a numb hand and bulky dressing on driving fitness is unknown, and there is no literature to guide surgeons when counseling these patients. Thus, the primary objective of the present study was to determine driving fitness following a modeled-WALANT procedure.

METHODS

Twelve right-handed individuals (6 male and 6 female) with an average age of 50 years (range, 38 to 64 years) were enrolled. An instrumented vehicle was used to obtain driving kinematic and behavioral data, thus allowing for a multidimensional assessment of driving fitness. Participants first performed a drive to establish baseline kinematic metrics. The route included both public streets and a closed course. Several driving tasks were assessed, including reverse parking, parallel parking, and perpendicular parking. The total course length was 18 miles (29 kilometers) and took 45 to 55 minutes to complete. After the first drive, 10 mL of 1% lidocaine was injected in the volar aspect of the right wrist and another 10 mL was injected into the right carpal tunnel to model the anesthetic used for a WALANT carpal tunnel release, and a bulky soft dressing was applied. The modeled-WALANT drive included an identical route and tasks, in addition to a surprise event to evaluate emergency responsiveness. Driving metrics were analyzed for noninferiority of the modeled-WALANT state to baseline driving.

RESULTS

The modeled-WALANT state showed noninferiority to baseline driving on all 11 analyzed dimensions of driving behavior compared with the control drives. In the modeled-WALANT state, participants drove more conservatively, braked harder, and steered more smoothly. All participants safely performed the 3 parking tasks and emergency response maneuver. Driving fitness in the modeled-WALANT state was noninferior to driving fitness in the preoperative drive.

CONCLUSIONS

A modeled-WALANT state has no clinically relevant negative impact on driving fitness, and thus surgeons should not discourage patients from driving home after unilateral WALANT surgical hand procedures.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Upper Extremity Immobilization and Driving: Limitations and Liability

Orthopaedic injuries of the upper extremity remain common, often requiring prolonged immobilization after surgical or nonsurgical management. Upper extremity immobilization often has a profound effect on a patient's daily life, including one's ability to safely operate a motor vehicle. Current literature on the safety of driving while immobilized is varied, although above-elbow immobilization of the upper extremity is generally thought to present a particular hazard to safe driving. Unfortunately, as common as this situation is, currently little to no guidance exists for patients, physicians, or lawmakers with regard to deciding whether a patient is safe to return to driving with upper extremity immobilization. Similar discord exists with the issue of patient and physician liability in such cases. In this review, we seek to present both historical precedent and a contemporary update of this complex, though a frequently encountered situation.

Development of a System for Real-Time Monitoring of Pressure, Temperature, and Humidity in Casts

Cast fixation is a general clinical skill used for the treatment of fractures. However, it may cause many complications due to careless treatment procedures. Currently, swathing a cast for a patient can only be determined by a doctors' experience; however, this cannot be determined by the value of pressure, temperature, or humidity with objective and reliable equipment. When swathing a cast for a patient, the end result is often too tight or too loose. Hence, in this paper we developed a sensor for detecting pressure, temperature, and humidity, respectively. This could provide reliable reference cast data to help physicians to understand the tightness of cast swathing and to adjust the tightness of cast swathing instantly to alleviate a patient's complications caused by excessive pressure or overheating. In this paper, six pressure sensors and one temperature-humidity sensor are used to detect the pressure, temperature, and humidity in an arm swathed with a cast to confirm whether the tightness of the cast is fixing the fracture efficiently, while avoiding causing any damage by using excessive pressure. Currently, the variation in temperature and humidity can be detected by the inflammation of the wound, displaying secretions, and fever in the cast. Based on the experiments, the voltage and power conversion coefficients of the developed sensors could be compensated for by the nonlinear error of the sensor. The experimental results could be instantly displayed on a human interface, such as a smart mobile device. The average skin pressure in a swathed cast was 12.14 g and ranged from 5.0 g to 17.5 g. A few casts exceeded 37.50 g. The abnormal pressure of wrinkles produced during swathing a cast often ranged from 22.50 g to 38.75 g. This shows that cast wrinkles cause pressure on the skin. The pressure caused by cast wrinkles on bone protrusions ranged from 56.5 g to 84.4 g. Compared to other parts that lacked soft skin cushioning, the pressure of cast wrinkles that occurred in the ulna near the protrusion of the wrist bone increased averagely. The pressure error value was less than 2%, the temperature error was less than 1%, and the humidity error was less than 5%. Therefore, they were all in line with the specifications of commercially available products. The six pressure detection points and one temperature and humidity detection point in our newly designed system can accurately measure the pressure, temperature, and humidity inside the cast, and instantly display the corresponding information by mobile APP. Doctors receive reliable reference data and are instantly able to understand the tightness of the swathed cast and adjust it at any time to avoid complications caused by pressure or overheating due to excessive pressure.

Driving with a short arm cast in a simulator

PURPOSE

To test the ability to steer in a driving simulator in subjects with a short arm cast.

METHODS

17 men and 13 women aged 23 to 67 (mean, 37) years who had a valid driver's licence were randomised to the cast-first group (n=16; 7 had the cast on the dominant arm) or the cast-second group (n=14; 8 had the cast on the dominant arm) and drove in a simulator. A short arm plaster-of-Paris cast was applied in a neutral position, allowing free movement of the metacarpophalangeal joints, thumb, and elbow joint. Outcome measures included the number of driving off track instances, the number of crashes, the lap time, and the effect of hand dominance on these parameters. Subjects were asked whether the cast had impeded their steering ability.

RESULTS

Subjects with or without a cast were comparable in terms of the number of driving off track instances, number of crashes, and lap time. Compared with no cast, the odds ratio (OR) of a subject in a cast driving off the track was 1.02 (p=0.921) and having a crash was 0.79 (p=0.047). All subjects were 1.23 times more likely to drive off the track in their first lap (OR=2.66, p=0.019). The mean lap time decreased for each consecutive lap from the 2nd to 5th laps. Subjects driving with a cast on the dominant or non-dominant arm were comparable. 26 out of the 30 participants considered that the plaster cast impeded their steering ability.

CONCLUSION

Compared with no cast, driving with a short arm cast did not significantly decrease steering ability in a driving simulator.

When can I drive? Return to driving following a wrist fracture: A critical review

Introduction

The primary aim of this review was to identify literature that examined factors which influence driving performance following a wrist fracture. Given the known scarcity of research in this area, secondary aims were to detail current practices including the driving habits of patients following a wrist fracture and health professionals’ opinions on safe return to driving.

Methods

We performed a search in April 2015 using three electronic databases to obtain relevant literature in the English language. Relevant studies including clinical trials, surveys and case reports were reviewed.

Results

The search identified 12 relevant studies. Five of these were clinical studies with a crossover design that investigated the driving ability of uninjured individuals with the wrist immobilised in a cast. The remaining were survey-based studies. The clinical trials showed that the presence of a wrist cast reduced driving performance in uninjured individuals. No studies investigated driving performance in individuals with a wrist fracture. The surveys showed that this patient group returns to driving despite perceived safety risks. Inconsistency in expert opinions on whether individuals with a wrist fracture are safe to drive was highlighted.

Conclusions

There is evidence to suggest that driving performance is reduced in uninjured individuals when wearing a cast immobilising the wrist; however, the influence of wrist fracture is unknown. This, along with safety implications resulting from current driving behaviours and inconsistent information provided to patients regarding return to driving, highlights the need for further studies to ascertain which factors influence driving performance following wrist fracture.

Driving with upper extremity immobilization: a comprehensive review

Driving with upper extremity immobilization can be potentially dangerous. The aim of this article is to review current medical literature, state laws, and guidelines on driving with upper extremity immobilization and appraise the available evidence. A literature search was conducted to identify citations related to driving with upper extremity immobilization and included a law literature search. Each state's Department of Motor Vehicle handbook was reviewed. Fourteen studies were reviewed and 5 provided subjective and/or objective assessments of upper limb immobilization. Of 2 studies that evaluated only below-elbow immobilization, 1 found driving in a wrist splint had no perceptible effect on driving ability, and the other supported safe driving under normal conditions. The studies that evaluated both below- and above-elbow immobilization recommended against driving with left arm above-elbow immobilization. Two of them found a trend toward worse driving performance in both below- and above-elbow splints. The following organizations' policies on driving are (1) The American Medical Association and National Highway Traffic Association have a joint recommendation for older drivers recommending referral to a rehabilitation specialist, (2) the U.S. Public Health Service recommends normal motor function and adequate mobility of both upper extremities and a performance examination when impaired, and (3) the U.S. Department of Transportation recommends a performance evaluation to determine fitness of commercial motor vehicle drivers. There are no state statutes or multijurisdictional surveys on the topic. This review finds that driving is hindered in some splints, there are substantial variations in physician practice patterns, there are no formal guidelines for physicians and patients to consider, and there is a paucity of published literature on this topic in the United States. Both physicians and patients would benefit from evidence-based recommendations or practice guidelines.

Driving after orthopaedic surgery

The decision to drive after orthopaedic injury or surgery is fraught with legal and safety issues. Although driving is an important part of most patients' lives, there are no well-established guidelines for determining when it is safe to drive after injury or treatment. Typically, impairment in driving ability is measured by changes in the time needed to perform an emergency stop. Braking function returns to normal 4 weeks after knee arthroscopy, 9 weeks after surgical management of ankle fracture, and 6 weeks after the initiation of weight bearing following major lower extremity fracture. Patients may safely drive 4 to 6 weeks after right total hip arthroplasty or total knee arthroplasty. Patients should not drive with a cast or brace on the right leg. Upper extremity immobilization may cause significant impairment if the elbow is immobilized; however, simple forearm casts may be permissible.

An objective assessment of safety to drive in an upper limb cast

Patients managed with upper limb cast immobilization often seek advice about driving. There is very little published data to assist in decision making, and advice given varies between healthcare professionals. There are no specific guidelines available from the UK Drivers and Vehicles Licensing Agency, police, or insurance companies. Evidence-based guidelines would enable clinicians to standardize the advice given to patients. Six individuals (three male, three female; mean age 36 years, range 27-43 years) were assessed by a mobility occupational therapist and driving standards agency examiner while completing a formal driving test in six different types of upper limb casts (above-elbow, below-elbow neutral, and below-elbow cast incorporating the thumb [Bennett's cast]) on both left and right sides. Of the 36 tests, participants passed 31 tests, suggesting that most people were able to safely drive with upper limb cast immobilization. However, driving in a left above-elbow cast was considered unsafe.