COVID-19 AND CASTING - CAN WE DO BETTER?

Scott J. Tarantino, MD, FAAOS

Although the coronavirus pandemic may have slowed us all down, orthopedic surgeons worldwide are still treating patients with broken bones using casting techniques.  Unfortunately, traditional casts with cotton padding do not allow for thorough handwashing for fear of getting the cast wet and needing it removed.  I think we’re all familiar with that horribly “smelly cast” or the dirty hands and feet we see at follow-up visits.  But now with Covid-19 around, should traditional casting techniques still be the norm if there are other options that may allow for better hygiene?

Waterproof cast padding and materials have been available for use for nearly 30 years, but there has been hesitation from some orthopedic surgeons in adopting this technology for various reasons.  Is it truly safe to get water under the cast?  Will it irritate the skin?  Are the casts well-tolerated by patients?  Are they less comfortable?  Will the fracture stay in proper alignment?  These are all good questions. Many of us physicians have used our own “tried and true” methodologies in caring for patients for decades and have a healthy concern about change and the risks it may present to the patients who count on us to make the right treatment decisions for them on a daily basis.  The barriers to change are certainly understandable.

However, given the incredible importance of handwashing to limit the spread of the Covid-19 coronavirus, now may be a good time to consider a change to the use of waterproof casting methodologies.  Orthopedic surgeons may not be on the front lines battling this virus in the ER or the ICU, but if we can help to contain the caseload of Covid-19 and in turn, help lower the burden on our colleagues, as well as provide patients the ability to wash their hands while recovering from a fracture, we should at least consider it.  None of us wants our pediatric wrist fracture patient to give Covid to his mother or grandmother because he/she can’t wash their hands.  For orthopedic surgeons who have been successfully using traditional cast padding for their entire career, this may still be a difficult or uncomfortable transition.  

Beginning in the early 1990s with the Gore Procel cast liner, the concept of waterproof cast technologies took off.  Many comparative studies have been done over the years to look at the safety, reliability, and outcomes with the use of waterproof cast liners to treat fractures.  A selection of these studies can be reviewed here:     
    1.  A waterproof cast liner earns high marks
    2.  Waterproof casts for immobilization of children’s fractures and sprains
    3.  Waterproof versus cotton cast liners: a randomized, prospective comparison
Although other waterproof cast options were and have been available, the “Gore-Tex” cast liner became the worldwide leader in a very short time, but its lifespan was limited as the company decided to stop production earlier this past decade for strategic reasons.  In 2013,  AquaCast created essentially the next-generation, “upgraded” cast liner model of the Gore Procel product.  

A waterproof cast liner is designed to take the place of the cotton padding traditionally used under fiberglass casts.  It is a non-absorptive, breathable padding that allows for water to run out from underneath the cast via channels created by small “pillows” built into the material.  Any residual perspiration or water caught between the liner and the skin will evaporate directly through the liner from the patient’s body heat.  It allows for patients to shower, swim, or bathe safely and without concern.  It allows for soap and water to be used for hand and arm hygiene.  

In the current days of the Covid-19 pandemic, hand hygiene is of paramount importance.  Never before have we as a people been so keenly aware of the impact of doing something so simple as washing our hands.  Watch this webinar by orthopedic surgeon and clinical assistant professor, Dr Kali Tileston, from Stanford University discussing “Modern Casting Techniques in a Covid-19 World” to get her view on the use of waterproof cast liners during the pandemic.  

We, as orthopedic surgeons, may not feel like we can directly impact the coronavirus pandemic, but maybe we can. If you have ever considered the use of waterproof cast materials in your practice, now may just be the right time to move forward to help out your patients, our frontline healthcare workers, and families all over the world by facilitating hand hygiene for those recovering from fractures requiring casting.