Assessment of Emergency Department Casting Errors and Cast-Related Complications in Children

Abstract

Background: Fractures account for 10-15% of injuries sustained in childhood. Many children undergo fracture immobilization in the emergency department (ED). Literature suggests that cast quality impacts fracture healing, however, quality of casting in the pediatric ED has not been well studied. Further, there is little literature on the association between cast quality and subsequent soft tissue complications in children. Objectives: The primary aim of this study was to describe common casting errors and complications following casting of pediatric fractures in the ED. The secondary aim of this study was to determine whether there was an association between casting errors and soft tissue and fracture site complications. Methods: This was a prospective case-control study of children aged 0-17 years, who sustained a traumatic fracture of an extremity requiring casting in the ED and orthopedic follow up. Patients were excluded if they had a pathologic fracture or if their cast had been changed or split prior to orthopedic follow up. A clinical cast assessment tool was utilized to assess casting errors and complications. The cast assessments were made at both the initial orthopedics visit and at the time of cast removal. Assessments for complications occurred at each orthopedic clinic visit. Patients were classified as cases if they sustained any soft tissue complication or worsening displacement/angulationre at the fracture site. Results: 85 patients were enrolled in the study. The majority were between 6-12 years (53%) and had fractures involving the radius and ulna (62%). 53% of children had at least 1 casting error identified. Common errors included: poor molding (25%), excess padding (16%), cast too tight/ loose (15%), improper limb position (15%), cast too short (15%), cast covering fingers/toes (14%). The presence of a soft tissue or fracture site complication was seen in 28% of patients. Common complications included: pressure sores (7%), worsening displacement/angulation (14%). A significant association was found between patients with a complication and the presence of at least 1 casting error (OR 7.2, CI 2.2-23.6). Conclusions: Casting errors are common in the pediatric population. There is an association between poor cast application and both soft tissue and fracture site complications. Knowledge of common casting errors may assist emergency physicians in providing optimal care to pediatric fracture patients.