Removal of a below knee plaster cast worn for 28 months: a case report
© Ingoe et al; licensee BioMed Central Ltd. 2011
Received: 30 June 2010
Accepted: 22 February 2011
Published: 22 February 2011
An unusual situation in which a below knee cast was removed after 28 months is reported. To the best of our knowledge no similar cases have been reported in the literature.
The cast was removed from the leg of a 45-year-old Caucasian woman. Significant muscle atrophy and dense skin scales were present but the underlying skin surface was relatively healthy with only small pitted 1-2 mm ulcers. No pathogenic organisms were cultured from this environment.
It seems likely that skin can tolerate cast immobilization for prolonged duration.
Extremity casts are frequently applied for routine immobilization for many acute fractures. The period of immobilization varies according to the patient and the fracture. For example, a non-operatively treated tibial fracture is rarely immobilized for longer than six months. Total contact casting has been used in the treatment of Charcot's neuropathy for periods of up to one year . We report a case of a below knee cast removal after 28 months.
When she was 40 years old, a Caucasian woman underwent bunion surgery for pain whilst ambulating. The wounds healed without complication but she went on to develop mechanical allodynia, intermittent swelling and a bluish discoloration of the foot, consistent with a diagnosis of type 1 complex regional pain syndrome. She received many different treatments for continued pain over the subsequent years. Drug therapies using pregabalin, strong opiates and epidural analgesia were not fully successful and she was offered a below knee cast as a temporizing measure. There was no pre-existing psychiatric diagnosis but the patient developed a psychological dependence upon this cast. She was reluctant to have it removed, believing that her pain remained inadequately treated. She failed to attend several appointments at the pain clinic. When she did return, the anesthetists asked for orthopaedic assistance to remove her cast. By this point she was 45 years old and had spent the previous 28 months in the same below knee cast. She was no longer taking regular analgesia but was unable to tolerate anyone touching her leg and therefore received a general anesthetic to facilitate the cast removal.
She was later reviewed in the pain clinic. Her skin was healthy but her allodynia remained symptomatic. At this stage she was reluctant to pursue any further treatment.
Cast immobilization is a routine orthopedic treatment which is administered for short periods of time in order to limit its complications. Total contact casts are used for longer time periods but are changed quite often in order to monitor for complications . A patient found to have been wearing the same cast for 28 months is extremely rare and there have been no previous cases reported in the literature. Patients who are known to be wear casts occasionally fail to attend for cast removal. In this scenario an awareness of the extent of potential complications is useful for this less compliant patient group.
Halanski and Noonan  reviewing plaster cast complications describe joint stiffness, muscle atrophy, cartilage degradation, ligament weakening and disuse osteoporosis. Joint stiffness was present in this case but was relatively insubstantial with only 10° of relative reduction in passive plantar flexion. This finding suggests that any stiffness observed after cast removal may be attributable to capsular stretch pain.
Muscle atrophy as a consequence of cast immobilization has been described  and was observed in this case where the leg circumference was substantially reduced. Research has attributed this change to an increase in both the resting inorganic phosphate concentration in skeletal muscle  and a change in the neural command of muscle contraction  with immobilization.
Skin complications have been described following plaster cast immobilization. Ulceration occurs where there is insufficient padding over bony protuberances and excoriation is known to occur particularly in casts worn by children which have become soiled . One case describes skin atrophy and hyperpigmentation thought to be a variant of stasis dermatitis . In this case the skin under the dense scales was relatively healthy. The small and regularly distributed pitted ulcers occurred where each individual skin pore had become blocked. The tissue at the base of these pits was healthy.
Prolonged cast immobilization is extremely rare and occurs in non compliant patients. This case demonstrates muscle atrophy which was anticipated. The stiffness of the ankle joint was not marked. Skin changes were minor with no substantial areas of ulceration or stasis dermatitis. Where patients choose to remain in their cast for prolonged duration the complications may only be minor.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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