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Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Litigation related to casting in OrthopaedicsAn analysis of claims

against the National Health Service in England
Jamie ACourta , Rak Yassaa , Charalambos P. Charalambousa,b,*
a
Department of Orthopaedics, Blackpool Victoria Hospital, Blackpool, UK
b
School of Medicine, University of Central Lancashire, Preston, UK

A R T I C L E I N F O A B S T R A C T

Article history:
Accepted 17 April 2017 Orthopaedic casts have been used to treat musculoskeletal conditions for hundreds of years and are still a
fundamental component of treating a variety of disorders. As surgical techniques have advanced the
Keywords: frequency of use of orthopaedic casts has declined. With Orthopaedics being is one of the most litigious
Litigation specialties in medicine we sough to evaluate how this related to casting in Orthopaedics and how we
Casts could learn from past mistakes.
Plaster We analysed litigation claims related to Orthopaedic casts from 1995 to 2010 in which the claims were
Negligence closed. 43 cases were related to orthopaedic casts. The total costs of these claims were over 2.3 million
with an average total cost of 48,500 per claim. The most common cause for claim was harm caused when
a cast was applied too tight and secondly from removing the cast. This is the rst study to evaluate
litigation claims related to Orthopaedic casts and highlights potential complications that if avoided will
certainly improve the care of the patients and avoid unnecessary litigation.
2017 Elsevier Ltd. All rights reserved.

Introduction concern as it is increasing at a faster rate than litigation as a whole

Cast application is a fundamental technique in Orthopaedics,
with casts used for temporary splinting or denitive treatment in a
variety of soft tissue and bony injuries. Appropriate use of this non-
surgical technique is essential to help promote healing and ensure
patient satisfaction [1]. With the advancement of surgical
techniques and the increase use of operative treatment of
fractures, the mastering of plastering techniques may be in decline
[2]. Inadequate casting techniques could lead to cast related
complications, with potentially resultant negligence claims.
Two types of negligence maybe described 1. clinical/medical
negligence dened as injury or death occurring as a result of direct
or indirect breach of a duty of care, and 2. malpractice, dened as
injury or death caused by deviation from an accepted standard of
practice in the medical community [3]. The National Health System
(NHS) is liable for negligence and omissions of is employees.
Over the last 20 years there has been a rise in negligence claims
throughout the NHS with the surgical specialties facing the
majority of them. Litigation in Orthopaedics is of particular
* Corresponding author at: Department of Orthopaedics, Blackpool Victoria
Hospital, Blackpool, UK.
E-mail address: mr.charalambous@bfwhospitals.nhs.uk (C.P. Charalambous).
in the NHS [4,5]. Orthopaedic claims in the United Kingdom (UK)
for 20082013 were found to be the second highest of any specialty
[6], with the average settlement for an orthopaedic claim being
over 60,000 [7]. One study from the United States reports that
approximately 30% of settlements are in excess of over $100,000
[8] for Orthopaedic cast injuries.
There has been no published data evaluating the clinical
negligence claims related to plaster cast care in the NHS in England.
Analysis of such claims can help identify patterns, provide learning
points, and improve awareness amongst clinicians to help prevent
future claims.
Methods
The NHS is liable for negligence and omissions of is employees.
The National Health Service Litigation Authority (NHSLA) was
established in 1995 to organise the management for NHS litigation
indemnity claims. Claims against the NHS are reported to the
NHSLA in order to assist the organisation promote patient safety.
Between 1995 and 2002 NHSLA dealt with claims with large costs
only. From 2002 and onwards, this has been extended to include
claims of any cost [9].
A request was submitted to the NHSLA to acquire data under the
Freedom of Information Act (2000) [10]. The raw data obtained

http://dx.doi.org/10.1016/j.injury.2017.04.037
0020-1383/ 2017 Elsevier Ltd. All rights reserved.

Please cite this article in press as: J. ACourt, et al., Litigation related to casting in OrthopaedicsAn analysis of claims against the National
Health Service in England, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.04.037
G Model
JINJ 7202 No. of Pages 3
2 J. ACourt et al. / Injury, Int. J. Care Injured xxx (2017) xxxxxx
from the NHSLA included all legal claims of negligence against NHS
trusts, which involved orthopaedic departments between 1995
and 2010.
The raw data obtained from the NHSLA contained information
on details of the events and location of the case leading to claim,
the cause of the claim, status of case (open or closed) and total
costs paid (cost covering defence costs, claimants legal fees and
damages). The raw data was studied by the rst two authors to
identify any claim that resulted from orthopaedic cast use between
1995 and 2010. Claims that were still open were excluded. All costs
are quoted to the nearest 100 pounds Sterling ().
Results
Between 1995 and 2010, 9800 claims were made to NHSLA.
These were evaluated, and 43 (0.43%) of these cases were
considered to be related to orthopaedic casts. The total cost of
these claims for defence and compensation was 2,306,925. The
costs ranged from 600-375,900, with an average of 48,500
(median 53,600).
Claims were divided into 5 categories assigned by the authors
according to the cause of the claim (Table 1). For a claim to be
categorised as cast applied too tight, the claim had to directly
related to damage caused by pressure from the cast. Incorrect
application of the cast applied to situations such as below elbow
casts used instead of above elbow, incorrect position of the cast
leading to worsening alignment of the fracture and issues such as
ankles placed in equinus rather than neutral. Cast applied too tight
was the most frequent reason for claim (n = 17), followed by injury
caused when removing the cast (n = 15). Cast applied too tight or
any other incorrect application of cast accounted for most of the
settlement costs of these claims (56%).
The most common location (48.8%) of the casting action leading
to these claims was the outpatient department (plaster room),
followed by the operating theatre (30.2%) (Table 2). The median
cases of litigation per year over the 5 years was 4 (range 19).
Discussion
The NHSLA payments for clinical negligence claims has doubled
over the last two years [11]. Clinical/medical negligence claims
affect patients, health care professionals, and hospitals worldwide.
Despite increased awareness with regards to patient safety within
the UK healthcare system, following major enquires in recent
years, the trend of claims for Orthopaedics induced patient
damages have been steadily increasing [7]. Despite being
highlighted as a potential issue, it is difcult to draw comparisons
from other countries with developed health systems with regards
to Orthopaedic cast litigation as there is very little data available.
This study has shown that the vast majority of cast related
claims in the NHS (more than 90%) were due to the technical aspect
of the procedure (cast being applied too tight, incorrect cast
application and harm when removing the cast), therefore attention
to detail is these components of casting is paramount. From a
Table 1
Reasons for claim.
Reason for claim Number of cases (%) Total defence and compensation cost (-nearest 100)
Cast applied too tight 17 (40) 736,700
Injury caused when removing cast 15 (35) 427,000
Incorrect application of cast 8 (19) 436,900
Failure to provide follow up 2 (5) 387,900
Cast removed too early 1 (2) 97,900
Please cite this article in press as: J. ACourt, et al., Litigation related to casting in OrthopaedicsAn analysis of claims against the National
Health Service in England, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.04.037
Table 2
Locations of reported cast related claims.
Location of incident No. of claims (%)
Accident & Emergency 3 (7.0)
Ward 6 (14.0)
Operating theatre 13 (30.2)
Orthopaedic outpatient clinic 21 (48.8)
Total 43
nancial perspective this related to a total cost in claims and
defence of 1.6 million.
Casts can cause damage to the limb from excessive pressure [8].
This can lead to pressure sores and tissue necrosis. In extreme
conditions it can result in compartment syndrome, which can be a
devastating consequence for the patient. Skin surface pressure is
dependant on the type of material used with breglass cats
exhibiting greater pressure on the skin than traditional plaster
[12]. Technique is another factor, with application of breglass
casts using a stretch and relax technique accommodating more
swelling under the cast, to minimise pressure injuries, as opposed
to the traditional wrap technique [13]. Any suspicion of a pressure
injury should warrant prompt cast removal and appropriate
assessment.
There is limited information in the literature regarding the
epidemiology of harm sustained during orthopaedic cast removal.
One study evaluating cast saw injuries in a busy paediatric
orthopaedic department in the UK reported a rate of 1.23 per 1000
patients and found that injuries were mostly related to user
inexperience and poor cast saw blade condition [14]. Another
study from a single institution in the UK found an incidence of
0.72% of cast saw injuries over a 2 year period and again attributed
this mainly to user inexperience [15]. Injuries from cast saws can
either be direct physical trauma causing abrasions or thermal
injuries. Skin burns when removing the cast have also been
reported in the litigation claims. The potential mechanism for this
has been evaluated in cadaveric studies [16] and concluded that
higher skin temperatures maybe a result of poor technique, with
the saw blade never leaving the cast when cutting. Fibreglass cast
material and thinner cast padding have also been shown to
increase skin temperature and could result in burns at the time of
removal [17].
Thermal injuries at the time of application are recognised
complications of casting but there is little reported in the
literature. Thermal injuries to the skin can occur when the cells
are subjected to heat of over 49  C for 23 min which can lead to 1st
degree burns. It can develop into 3rd degree burns if the exposure
lasts for more than 8 min [18]. Thermal injuries are more likely to
be encountered when warm dip water (over 24  C) is used, the cast
and padding material applied is excessively thick and when the
cast is left to set on a pillow [19,20]. Applying moulded casts can
result in higher temperatures that are potentially damaging to the
underlying skin [21].
Recently the British Orthopaedic Association has released
dedicated casting standards [22] that allows local monitoring
% of total cost related to cast claims
35
20
21
19
5
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and audit of casting practice. This BOA guidance also aims at
ensuring that quality control and constant improvement are
fundamental to the practice of casting. These standards recom-
mend that practitioners applying casts should hold a British
casting certicate and be committed to continued professional
development, that casts should be functional and applied/removed
safely with appropriate documentation of such interventions, and
that patients are given appropriate verbal and written advice with
regards their cast.
There is currently little focus on achieving a measured degree of
competency in casting in Orthopaedic training in the UK. For T&O
specialty training applications, a casting course directed speci-
cally to Orthopaedic surgeons is seen as a desirable but not
essential qualication. The T&O training curriculum includes
principles of casting as a general objective for Trauma training
[23] and the Hand section of the curriculum includes an objective
to be procient in a range of casts for the treatment of hand
fractures, but it is the only section to have this objective. Similarly
the Joint Committee of Higher Surgical Training (JCST) does not
include competency in cast application and removal as an
indicative procedure along other indicative procedures [24].
In addition, the vast majority of technical and procedural skills
focus on surgical techniques and are assessed by a trainer
throughout the surgical component of the operation. Casting in
theatre is usually the last part of an operation and trainees may
nd themselves performing this on their own. Given a perception
that casting is not as technically demanding as other components
of the procedure, trainees may feel reluctant to ask for assistance if
its not a skill they are familiar with, whereas trainers may assume
trainees are competent to perform casting unsupervised [25].
Orthopaedic casting is commonly performed by nursing staff in
the Emergency Department (ED), and by non-medical cast
practitioners in Orthopaedic clinics, limiting the training oppor-
tunities of ED and Orthopaedic doctors in this important skill.
Improved training may help reduce adverse events and legal
claims related to casting. In particular, there is an argument for a
structured casting course becoming a formal and essential
criterion of training in those who want to pursue a career in
Orthopaedics or other specialties dealing with musculoskeletal
injuries. Moreover, a range of dedicated workplace assessments
should be implemented within the Core Surgical and the Higher
Surgical Orthopaedic training aiming at achieving a high level of
competency in cast care. This has been recently recognised by the
British Orthopaedic Association (BOA) and incorporated into the
Intercollegiate surgical curriculum programme for T&O in 2016
[26].
There are several limitations of this study. The NHSLA does not
cover work performed in Scotland, Wales, Northern Ireland, or in
the private sector, hence the results are related to the England NHS
rather than the whole of United Kingdom practise. In addition, the
NHSLA database was designed for the purpose of managing the
Clinical Negligence Scheme for Trusts (CNST) rather than for the
research purposes. This database is therefore, run by non-medical/
clinical trained personnel. As a result some of the details in the
database were unclear or ambiguous, and hence were excluded
from analysis. It also meant that the exact mechanism to which a
patient came to harm was not specically identied in every case.
Furthermore, patients who experienced an adverse event related
to Orthopaedic casting but not pursuing a legal claim, and claims
settled out of court are not included in the NHSLA database and
therefore our results are an underestimate of the number of
patients who have suffered adverse events in relation to cast care
and an underestimate of the nancial burden to the NHS [27].
Nevertheless, despite its limitations this study highlights an
issue that not only damages reputations of institutions and has
substantial nancial burdens but also causes serious harm to
Please cite this article in press as: J. ACourt, et al., Litigation related to casting in OrthopaedicsAn analysis of claims against the National
Health Service in England, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.04.037
3
patients. To our knowledge, this is the rst study to solely evaluate
cast litigation in England. Vigilance towards cast care and
complications is of an utmost importance in avoiding a number
of preventable complications and consequently lawsuits. Struc-
tured targeted training towards achieving competency in provid-
ing cast care should be implemented in any training program for
health care professionals involved in applying and removing casts.
Conicts of interests
No conict of interests.
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