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Incidence and Etiology of Unplanned Cast Changes for Fractures in the Pediatric Population

DiPaola, Matthew J. MD*; Abzug, Joshua M. MD; Pizzutillo, Peter D. MD; Herman, Martin J. MD

Journal of Pediatric Orthopaedics: September 2014 - Volume 34 - Issue 6 - p 643–646
doi: 10.1097/BPO.0000000000000191

Background: The majority of pediatric fractures are treated in casts due to the child’s ability to heal rapidly and remodel. Unplanned cast changes are a time and economic burden with potentially adverse effects on fracture management. The purpose of this study is to document the incidence, etiology, and complications related to unplanned cast changes.

Methods: A prospective study was conducted over a 6-month period to determine the incidence of unplanned cast changes. All casts applied were nonwaterproof. Data collected include the reason for cast placement, type of cast placed, duration of wear before the unplanned change, reason for the unplanned change, experience level of the original cast applicator, and cast-related complications.

Results: A total of 1135 casts were placed with 58% placed by a resident, 38% by a cast technician, 2% by a physician’s assistant, and 2% by an attending physician. Sixty casts (5.3%) required an unplanned change including 19 short-arm casts, 18 short-leg casts, 17 long-arm casts, 4 thumb spica casts, and 2 long-leg casts. The average duration from cast application until the unplanned change was 13 days. Twenty-eight (47%) were changed for wetness, 20 (33%) for wear/breakage, 2 (3%) for skin irritation, and 10 (17%) for other reasons including objects in the cast and patient self-removal. Two patients had superficial skin infections requiring oral antibiotics. No fracture reductions were lost secondary to an unplanned cast change. The need for an unplanned cast change did not correlate with the level of experience of the applicator.

Conclusions: Most unplanned cast changes were the result of patient nonadherence to instructions and not related to cast application technique. Improved patient and family education regarding cast care may reduce the frequency of unplanned cast changes, thus reducing an economic and time burden on the health care system.

Level of Evidence: Level II—prognostic study.

*Department of Orthopaedic, Wright State University School of Medicine, Dayton, OH

Department of Orthopaedic, University of Maryland School of Medicine, Baltimore, MD

St. Christopher’s Hospital for Children, Philadelphia, PA

The authors declare no conflicts of interest.

Reprints: Martin J. Herman, MD, Department of Orthopaedic Surgery, St. Christopher’s Hospital for Children, 3601 A Street, Philadelphia, PA 19134-1095. E-mail:

© 2014 by Lippincott Williams & Wilkins