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An objective assessment of safety to drive in an upper limb cast

Authors:
Helene Lenore Stevenson at Aintree University Hospital NHS Foundation Trust
Helene Lenore Stevenson
Nicholas D Peterson
Nicholas D Peterson
Joseph C Talbot at Harrogate and District NHS Foundation Trust
Joseph C Talbot
S Dalal
S Dalal
S Dalal
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Patients managed with upper limb cast immobilization often seek advice about driving. There is very little published data to assist in decision making, and advice given varies between healthcare professionals. There are no specific guidelines available from the UK Drivers and Vehicles Licensing Agency, police, or insurance companies. Evidence-based guidelines would enable clinicians to standardize the advice given to patients. Six individuals (three male, three female; mean age 36 years, range 27-43 years) were assessed by a mobility occupational therapist and driving standards agency examiner while completing a formal driving test in six different types of upper limb casts (above-elbow, below-elbow neutral, and below-elbow cast incorporating the thumb [Bennett's cast]) on both left and right sides. Of the 36 tests, participants passed 31 tests, suggesting that most people were able to safely drive with upper limb cast immobilization. However, driving in a left above-elbow cast was considered unsafe.
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The Journal of Hand Surgery
(European Volume)
38E(3) 321 –324
© The Author(s) 2012
Reprints and permissions:
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DOI: 10.1177/1753193412451385
jhs.sagepub.com
JHS(E)
Introduction
The use of cast immobilization in orthopaedic and
trauma patients is commonplace, whether for con-
servative treatment of fractures, after open reduction
and internal fixation (ORIF), or after an orthopaedic
intervention. The question of whether the patient is
able to drive while this immobilization is in place is
frequently asked, often by patients who are self-
employed or are dependent on driving to get to or
carry out their job. Advice given varies between
healthcare professionals, and there are no specific
guidelines available from the UK Drivers and Vehicles
Licensing Agency (DVLA) or insurance companies
(Blair et al., 2002; Edwards et al., 2009; Von Arx et al.,
2004). Current law only dictates that it is the driver’s
responsibility to ensure that they are fit to drive
(Edwards et al., 2009; Von Arx et al., 2004), and that
notifying the DVLA of a disability that is likely to last
less than 3 months is not required (Drivers Medical
Group, 2005).
In the absence of guidelines, doctors often err on
the side of caution and advise the patient not to drive
(Von Arx et al., 2004), a decision that may affect not
just the finances of the individual, but also the wider
economy. There is little published information to
assist in decision making.
This prospective randomized study aimed to assess
driving safety while wearing a variety of upper limb
casts in an objective way and to aid the development
An objective assessment of safety
to drive in an upper limb cast
H. L. Stevenson
Wrightington Hospital, Wigan, Lancashire, UK
N. Peterson
St Helens & Knowsley NHS Trust, Merseyside, UK
C. Talbot, S. Dalal, A. C. Watts and I. A. Trail
Wrightington Hospital, Wigan, Lancashire, UK
Abstract
Patients managed with upper limb cast immobilization often seek advice about driving. There is very little
published data to assist in decision making, and advice given varies between healthcare professionals.
There are no specific guidelines available from the UK Drivers and Vehicles Licensing Agency, police, or
insurance companies. Evidence-based guidelines would enable clinicians to standardize the advice given to
patients. Six individuals (three male, three female; mean age 36 years, range 27–43 years) were assessed by
a mobility occupational therapist and driving standards agency examiner while completing a formal driving
test in six different types of upper limb casts (above-elbow, below-elbow neutral, and below-elbow cast
incorporating the thumb [Bennett’s cast]) on both left and right sides. Of the 36 tests, participants passed 31
tests, suggesting that most people were able to safely drive with upper limb cast immobilization. However,
driving in a left above-elbow cast was considered unsafe.
Keywords
Upper limb cast, immobilization, driving, driving safety, plaster cast, cast
Date received: 19th March 2012; revised: 2nd May 2012; accepted: 21st May 21 2012
Corresponding author:
HL Stevenson,#Wrightington Hospital, Hall Lane, Appley Bridge,
Wigan, Lancashire, WN6 9EP, UK
Email: hlemstevenson@aol.com
451385JHS38310.1177/1753193412451385Stevenson et al.Journal of Hand Surgery (European Volume)
2012
Full length article
at UNIV OF GEORGIA LIBRARIES on May 27, 2015jhs.sagepub.comDownloaded from
322 The Journal of Hand Surgery (Eur) 38(3)
of guidelines for patients and doctors when faced with
this situation.
Methods
Six individuals (three female, three male) with a
mean age of 36 (range 27–43) years underwent a
formal driving test, in accordance with the UK
Driving Standards Agency (DSA), carried out by a
DSA examiner. Each examinee wore six different
upper limb casts, which were randomly assigned,
applied, and checked by independent medically
qualified personnel, for a total of 36 tests. Both left
and right casts were used for each type, and the
casts examined were above-elbow neutral, below-
elbow neutral, and a below-elbow cast incorporating
the thumb (Bennett’s cast). These were lightweight
medical fibreglass casts made by BeneCare Medical
(Manchester, UK). All six participants were in
possession of a full UK driving licence.
Assessment of driving safety was through the cur-
rent official UK driving test, featuring all the required
standard manoeuvres. This was carried out over a 13
mile circuit on public roads in one car equipped with a
manual gearbox and dual controls. One qualified
DSA-approved examiner assessed the six individuals
for all 36 tests. A pass/fail result was determined by
the examiner according to the standards applied in
the official UK driving test and recorded for each test.
In addition, a mobility occupational therapist (OT)
was also present for all 36 tests and made an assess-
ment for each test that focused on overall control of
the vehicle. Individual driving tasks, such as gear
changes, indication, steering, and negotiation of
roundabouts, were assessed separately and given a
score of 1 to 4 by the OT, with 1 indicating safe control
and 4 being deemed unsafe. The scores from individ-
ual components were then combined to give a quanti-
tative assessment of driving safety in each type of cast.
Scores were compared using analysis of variance
(ANOVA) statistical testing, with significance set at 5%.
Results
Of the 36 driving tests, the DSA examiner recorded
a fail in only five cases. Four of these were during
testing in the left above-elbow cast, with the
remaining failure occurring while a participant was
wearing a left Bennett’s cast. All 18 tests taken
wearing right-sided casts were passed. During all
tests it was noted by both the drivers and assessors
that instinctive adaptations were made by the driver
(such as moving the seat closer to the steering
wheel or using the index finger rather than the
thumb to release the handbrake) to improve the
driver’s ability to control the car.
Scores from the mobility specialist OT were com-
bined for each of the six casts, and a mean score for
each cast was produced (Table 1). A lower score indi-
cated that the participant performed driving tasks
more safely. The OT assessment scores showed a sig-
nificant difference between the left above-elbow cast
and all the other casts, suggesting that it was less
safe. There was no statistically significant difference
between the other casts.
Discussion
For many patients the prospect of not driving
for several weeks is likely to cause significant
inconvenience. This issue has been recognized but
not resolved, and there remains a need for evidence-
based guidelines to assist patients and doctors
faced with this scenario.
Advice on driving while suffering from a musculo-
skeletal injury is not currently provided by the DVLA
to patients or medical professionals (Drivers Medical
Group, 2005). Furthermore, section 94 of the Road
Traffic Act 1988 suggests that a driver is “not required
to notify” the DVLA of any condition that “will not
extend beyond the period of 3 months” (Department
of Transport, Road Traffic Act, 1988). The DVLA
advice on driving after surgery can be applied to this
situation, however, and so the “distracting effect of
pain, impairment due to analgesia and any physical
restrictions” should certainly be considered by both
patient and doctor (Blair et al., 2002).
In our study, we aimed to reproduce the situation 2
to 3 weeks after the initial fracture, when the patient
has stopped requiring strong analgesia and has had a
lightweight resin cast applied. At this time, patients
would seem to be within the law if they assessed
Table 1. Driving assessment results by mobility occupational therapist. For explanation of scores see text
Below elbow
neutral (right arm)
Below elbow
neutral (left arm)
Bennett’s (right
arm)
Bennett’s (left arm) Above elbow (right
arm)
Above elbow (left
arm)
125 123 125 128 129 175*
*Significantly different (p = 0.023) from all other scores.
at UNIV OF GEORGIA LIBRARIES on May 27, 2015jhs.sagepub.comDownloaded from
Stevenson et al. 323
themselves as fit to drive, in accordance with “rule 79
of the Highway Code which clearly states that it is
the driver’s own responsibility to ensure they are fit to
drive at all times” (Von Arx et al., 2004).
Previous studies have sought the opinion of patients,
police officers, the DVLA, insurers, and orthopaedic
surgeons. Blair et al. (2002) contacted the DVLA and
five insurance companies. The Drivers Medical Unit
of the DVLA advised that it is the responsibility of the
driver to be in control of the vehicle at all times and to
be able to demonstrate this if stopped by police. Of
five insurance companies, one did not advise, two
advised against driving, and three permitted driving if
it was considered safe by a doctor.
This confusing picture was confirmed by Von Arx
et al. (2004), who received only one response after
surveying 28 insurance companies, which advised
that patients should follow the advice of their doc-
tors regarding safety to drive. They also summarized
the responses of 62 orthopaedic surgeons, finding
that they “offer varied and non-standardized advice
that is not evidence-based.” Surgeons often advised
patients to take the advice of their insurance compa-
nies, a position echoed by the police who suggested
referring patients to the Highway Code or their
insurance companies “should any patient be in
doubt.” It would seem very likely that patients will
be in doubt if, as suggested by published evidence,
they are told by their doctors to refer to their insur-
ance companies for advice and vice versa (Blair et al.,
2002; Von Arx et al., 2004).
Edwards et al. (2009) demonstrated that patients
remained “in doubt” in their survey of adult patients
recently treated for forearm or wrist fractures, with
13% feeling it was safe to drive a car and 4% a motor-
bike, but 98% of respondents saying they “would value
written guidelines.” They concluded that emergency
and orthopaedic practitioners should advise patients
not to drive. This response does seem representative
of current practice; however, it is far from evidence
based and may unnecessarily prevent patients from
driving.
Attempts to formally assess the ability of drivers
in cast immobilization have been made previously.
Blair et al. (2002) used a self-assessed single-
driver evaluation of driving safety while wearing
different below-elbow casts. They concluded that
scaphoid and Bennett’s casts have significant
effects on driving control, but that a below-elbow
neutral cast is unlikely to affect it. The applicability
of this advice is obviously limited by the subjective
study design. Kalamaras et al. (2006) used a single-
driver assessment by a driving instructor and OT
while wearing a variety of casts. They reported that
a short arm cast was better than a long arm cast, but
all driving tests were failed despite passing the OT
assessment while wearing a short arm cast. This
contradictory result seems to add to the confusion
around this issue rather than resolve it. A US study
analyzed the driving performance on a course
marked out by cones of 30 military personnel while
wearing six different types of cast (Chong et al.,
2010). For each cone knocked over, time was added
to the total time taken to complete the course.
Interestingly, the above-elbow left-sided cast had the
worst effect on driving times, and was perceived by
examinees to be the least safe and most difficult,
despite the car being an automatic with left-hand
drive. Interpretation of these findings is complicated
because the tests were not carried out in a “real-life”
scenario and were of driving performance measured
by time, not driving safety, in a group of drivers with
unusually high driving skills.
After analyzing the results of the current study, the
authors contacted the Crown Prosecution Service
(CPS), the organization responsible for the prosecu-
tion of most criminal cases after investigation by
police in the UK. After informing them of our findings,
we asked their advice on how driving in upper limb
immobilization would influence prosecution. Their
response was that they “are unable to comment on
general studies conducted as each case prosecuted
by the CPS must be considered on its own set of facts
and circumstances.”
The authors also discussed the findings of this
study with Neil Greig, Director of Policy and Research
at the Institute of Advanced Motorists (IAM) in the UK,
who responded with the following statement: “The
IAM welcomes this study and supports its findings
that advice and information for drivers with upper
limb casts must be improved. The IAM would like to
see this information converted into guidelines for GPs
and other medical practitioners to allow them to give
more detailed advice to their patients. In the long
term the IAM believe that more research is need into
a wider range of medical interventions and their
impact on driving. This study suggests a simple and
consistent method that could be adopted for such
research.”
The senior medical adviser at the Drivers Medical
Group of the DVLA has also reviewed the results of
this study and will consider them when the At a Glance
Guide to the Medical Standards of Fitness to Drive is
next updated.
The present study is representative of a common
situation 2 to 3 weeks after injury or surgical inter-
vention, when patients have very little residual pain.
The objective assessment by a DSA examiner and
at UNIV OF GEORGIA LIBRARIES on May 27, 2015jhs.sagepub.comDownloaded from
324 The Journal of Hand Surgery (Eur) 38(3)
mobility OT of six individuals over 36 tests is the
largest study of its kind, and the results suggest
that the current practice of advising against driv-
ing in cast immobilization may be incorrect. Indeed
no further changes in the usual driving position
were needed for below-elbow neutral casts. Simple
adaptive procedures such as releasing the hand-
brake with the index finger instead of the thumb in
a Bennett’s cast and moving the seat closer to the
wheel in a right above-elbow cast made both safe
to drive in.
The current evidence on driving in cast immobili-
zation is confusing and contradictory. The present
study suggests that it is safe to drive in below-elbow
neutral casts. It is also safe to drive with Bennett’s
type casts on either arm and in right above-elbow
casts with the simple adaptive measures mentioned
above. We consider it unsafe to drive in left-sided
above-elbow casts.
Acknowledgments
We extend our grateful thanks to Mr Barry Clift, the mobility
occupational therapist, and Mr D Hughes, the DSA examiner,
for giving up their free time to participate in this study.
Conflict of interests
None declared.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
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... Immobilization studies have revealed the only casts that are definitively safe to drive in are short arm casts that preserve grip strength (Gregory et al., 2009;Mansour et al., 2015). Relatively strong and otherwise healthy patients may also drive in short arm casts that affect grip, but this has not been assessed in hazardous scenarios (Blair et al., 2002;Kalamaras et al., 2006;Stevenson et al., 2013). Stevenson's objective driving assessment used an occupational therapist derived scoring system and revealed driving in above elbow casts to be safe, provided that the only role of the arm is to steer, and grip strength is preserved (Stevenson et al., 2013). ...
... Relatively strong and otherwise healthy patients may also drive in short arm casts that affect grip, but this has not been assessed in hazardous scenarios (Blair et al., 2002;Kalamaras et al., 2006;Stevenson et al., 2013). Stevenson's objective driving assessment used an occupational therapist derived scoring system and revealed driving in above elbow casts to be safe, provided that the only role of the arm is to steer, and grip strength is preserved (Stevenson et al., 2013). Slings immobilizing the dominant arm have been shown to have a detrimental effect on driving ability (Hasan et al., 2015). ...
... that would turn the steering wheel in the appropriate direction. This finding could support Stevenson's claim that above elbow casts inhibiting elbow motion may be safe to drive in (Stevenson et al., 2013). Forearm rotation was the most extensive motion in the total driving scenario (Fig. 5). ...
Defining the upper extremity range of motion for safe automobile driving
Article
  • Mar 2018
  • CLIN BIOMECH
Background: There are no guidelines for return to driving following upper extremity injury. A greater comprehension of the role of the upper extremity in driving is required to assist clinicians in their fitness-to-drive assessments. This research aims to assist clinicians by analyzing the motion at the upper extremity in safe automobile driving. Methods: Thirty-six participants were recruited to the Monash University Accident Research Centre's driving simulator. They were tested in a realistic driving simulation using highway scenarios and traffic hazards. An OptiTrack™ motion tracking system recorded participants' upper limb movements. Findings: The following ranges of motion were recorded (left and right arm mean whole numbers): The shoulder flexed from 14 to 54°, abducted to 18°and adducted to 9°. Shoulder rotation ranged from 6° external to 32° internal rotation. Elbow flexion ranged from 35° to 72°. Pronation reached 77° and supination to 24°. Wrist flexion reached 34° and extension reached 23°. The wrist deviated to 17°radially and 38° ulnar. To avoid simulated hazards, the steering wheel revolved 57.2° (SD 19.2). The key movements in hazard avoidance are shoulder flexion, shoulder rotation, forearm rotation and wrist deviation. Interpretation: Shoulder flexion, internal rotation and forearm rotation have been shown to be key upper extremity movements in safe driving. Clinicians can refer to the ranges of motion recorded in this investigation, or the driving task at hand in their fitness-to-drive assessments. The ability to revolve the steering wheel 100° exceeds the 95th percentile of the steering wheel revolution angle required to avoid simulated traffic hazards.
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... Distal radius fractures are one of the most common upper limb fractures treated by Orthopaedic and Hand surgeons [2,3]. While many studies have evaluated the effect of immobilization of upper limb injuries on driving [5e7, 9,10], few have studied driving post distal radius fixation [2,11]. ...
... However, there is suggestion that successful driving evaluation may take place earlier. Prior literature has judged evaluating patients 2 to 4-weeks post-surgery to be appropriate [2,10,13]. Jones et al. [15] studied a group of 23 patients who underwent volar plating for a distal radius fracture. Patients had begun driving independently an average of 13 days post-surgery, with 70% successfully passing the driving examination an average of 18.4 days post-surgery. ...
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Introduction: After surgical fixation of distal radius fractures, many patients are keen to return to driving. There are however limited guidelines assisting surgeons. The aims of this study were to determine when patients could return to driving safely after distal radius fracture fixation and determine the clinical parameters (range of motion and grip strength) that patients needed to achieve before return to safe driving could be advised. Materials and methods: A prospective grant-funded clinical study was conducted. Patients above the age of 21 years who underwent surgical fixation with a volar plate, possessed a class 3 standard motorcar license, and were regular drivers were recruited in a single institution from 2017 to 2019. A hand surgeon and an occupational therapist who sees routine hand therapy cases, assessed the patients at regular intervals from 2 to 12-weeks post-surgery. Clinical parameters of pain, wrist range of motion and grip strength were measured. Patients underwent off and on-road driving assessments. Results: A total of 26 patients were recruited, with 21 successfully completing the driving assessment. Median time post-surgery to passing the driving test was 6 and 8-weeks for off and on-road assessments respectively. Pain score was observed to decrease over time, with a significant decrease from week 2 to week 4. Range of motion improved over time, with maximal improvement between 2 to 4-weeks post-surgery. When compared with the unaffected wrist, the difference in pronation, supination and radial deviation in the affected hand was consistently no longer statistically significant 4 to 6-weeks post-surgery. Conclusion: Patients with isolated surgically treated distal radius fractures can be recommended for a driving assessment as early as 4-6 weeks post-surgery if pain control is adequate, and clinical parameters for pronation and supination are met.
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... In total, 68 studies were identified meeting our study aims and inclusion criteria for both upper and lower extremity procedures (Fig. 1, Table 1, Supplementary Tables 1 and 2) (1,14,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86). There was a wide variation in procedures performed and sample size, the study methodology, and measurements obtained. ...
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Patients undergoing planned or unplanned orthopaedic procedures involving their upper or lower extremity can prevent them from safe and timely return to driving, where they commonly ask, ‘Doctor, when can I drive?’ Driving recommendations after such procedures are varied. The current evidence available is based on a heterogenous data set with varying degrees of sample size and markedly differing study designs. This instructional review article provides a scoping overview of studies looking at return to driving after upper or lower extremity surgery in both trauma and elective settings and, where possible, to provide clinical recommendations for return to driving. Medline, EMBASE, SCOPUS, and Web of Science databases were searched according to a defined search protocol to elicit eligible studies. Articles were included if they reviewed adult drivers who underwent upper or lower extremity orthopaedic procedures, were written in English, and offered recommendations about driving. A total of 68 articles were included in the analysis, with 36 assessing the lower extremity and 37 reviewing the upper extremity. The evidence available from the studies reviewed was of poor methodological quality. There was a lack of adequately powered, high quality, randomised controlled trials (RCTs) with large sample sizes to assess safe return to driving for differing subset of injuries. Many articles provide generic guidelines on return to driving when patients feel safe to perform an emergency stop procedure with adequate steering wheel control. In future, RCTs should be performed to develop definitive return to driving protocols in patients undergoing upper and lower extremity procedures.
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... Most of the published research on driving fitness following an orthopaedic procedure has focused on the lower extremities 5 . A recent review of the literature on driving with the upper extremity immobilized showed that there are few studies to provide guidance for patients or physicians 6 and that those studies were limited, typically only examining driving ability with the upper arm immobilized in a cast or splint [7][8][9] . Among those studies involving the upper extremity, we were able to identify only 2 that focused on the hand, and both studies investigated invasive procedures with wound-healing and stiffness that impaired driving ability 10,11 . ...
Modeled Wide-Awake, Local-Anesthetic, No-Tourniquet Surgical Procedures Do Not Impair Driving Fitness: An Experimental On-Road Noninferiority Study
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Background: The use of wide-awake, local-anesthetic, no-tourniquet (WALANT) surgical techniques is increasingly common, and patients commonly ask whether they may drive home following these procedures. The impact of a numb hand and bulky dressing on driving fitness is unknown, and there is no literature to guide surgeons when counseling these patients. Thus, the primary objective of the present study was to determine driving fitness following a modeled-WALANT procedure. Methods: Twelve right-handed individuals (6 male and 6 female) with an average age of 50 years (range, 38 to 64 years) were enrolled. An instrumented vehicle was used to obtain driving kinematic and behavioral data, thus allowing for a multidimensional assessment of driving fitness. Participants first performed a drive to establish baseline kinematic metrics. The route included both public streets and a closed course. Several driving tasks were assessed, including reverse parking, parallel parking, and perpendicular parking. The total course length was 18 miles (29 kilometers) and took 45 to 55 minutes to complete. After the first drive, 10 mL of 1% lidocaine was injected in the volar aspect of the right wrist and another 10 mL was injected into the right carpal tunnel to model the anesthetic used for a WALANT carpal tunnel release, and a bulky soft dressing was applied. The modeled-WALANT drive included an identical route and tasks, in addition to a surprise event to evaluate emergency responsiveness. Driving metrics were analyzed for noninferiority of the modeled-WALANT state to baseline driving. Results: The modeled-WALANT state showed noninferiority to baseline driving on all 11 analyzed dimensions of driving behavior compared with the control drives. In the modeled-WALANT state, participants drove more conservatively, braked harder, and steered more smoothly. All participants safely performed the 3 parking tasks and emergency response maneuver. Driving fitness in the modeled-WALANT state was noninferior to driving fitness in the preoperative drive. Conclusions: A modeled-WALANT state has no clinically relevant negative impact on driving fitness, and thus surgeons should not discourage patients from driving home after unilateral WALANT surgical hand procedures. Level of evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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... 14 Most studies investigating potential impacts of DRF on fitness to drive have been performed on healthy participants using immobilisation orthoses, but not on actual patients. 10,12,13,15,16 These provide low level evidence that driving when the wrist is immobilised results in worsened driving performance in healthy participants, 9 but potential confounding factors relating to DRF pathology remain poorly understood. There is only one other known study which assessed driving performance in participants with DRF. 17 Jones et al. 17 assessed the driving performance of 23 individuals with DRF managed with ORIF, using an on-road, closed course driving examination. ...
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Introduction Driving performance, as assessed using a driving simulator, after distal radius fracture has not been previously studied. Our aims were to undertake a pilot study to assess feasibility via: (i) acceptability of driving simulation for this assessment purpose, (ii) recruitment and retention, (iii) sample size calculation. Preliminary evaluations of differences in driving performance between individuals recovering from distal radius fracture and controls were conducted to confirm if the methodology provided meaningful results to aid in justification for future studies. Methods Driving performance of 22 current drivers (aged 21–81 years), recruited by convenience sampling, was assessed using a driving simulator. The fracture group included those recovering from distal radius fracture managed with open reduction and internal fixation using a volar plate. The control group were uninjured individuals. Assessment was performed approximately five weeks post-surgery and follow-up assessment two weeks later. Acceptability outcome measures included pain and simulator sickness scores, feasibility measures included retention rates and measures of driving performance included time spent speeding, time spent out of the lane, standard deviation of lateral position and hazard reactions. Results The assessment was completed by 91% of participants; two participants dropped out secondary to simulator sickness. Retention rates were 83%. Preliminary results suggest those with distal radius fracture spent more time out of the lane and less time speeding. Conclusion This method was sensitive, acceptable and feasible according to the parameters of this pilot study. The results from this small sample suggest that between-group differences in driving performance are measurable using driving simulation five weeks following distal radius fracture. Keywords Distal radius fracture, driving performance, driving simulator, orthopaedics, wrist fracture
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Doctor, when can I drive?—the range of elbow motion while driving a car
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Full-text available
  • Dec 2018
Orthopedic procedures can affect patients’ ability to perform activities of daily living, such as driving automobiles or other vehicles that require coordinated use of the upper and lower extremities. Many variables affect the time needed before a patient can drive competently after undergoing orthopedic surgery to the extremities. These variables include whether the patient underwent upper- or lower-extremity surgery; the country in which the patient resides; whether the right or left lower extremity is involved; whether the dominant arm is involved; whether the extremity is in a cast or brace; whether the patient has adequate strength to control the steering wheel; and whether the patient is taking pain medication. The type and complexity of the procedure also influence the speed of return of driving ability. Few studies provide definitive data on driving ability after upper- or lower-extremity surgery. Patients should be counseled not to drive until they can control the steering wheel and the pedals competently and can drive well enough to prevent further harm to themselves or to others. This review discusses the limited recommendations in the literature regarding driving motorized vehicles after upper- or lower- extremity orthopedic surgery.
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Upper Extremity Immobilization and Driving: Limitations and Liability
Article
  • Nov 2018
Orthopaedic injuries of the upper extremity remain common, often requiring prolonged immobilization after surgical or nonsurgical management. Upper extremity immobilization often has a profound effect on a patient's daily life, including one's ability to safely operate a motor vehicle. Current literature on the safety of driving while immobilized is varied, although above-elbow immobilization of the upper extremity is generally thought to present a particular hazard to safe driving. Unfortunately, as common as this situation is, currently little to no guidance exists for patients, physicians, or lawmakers with regard to deciding whether a patient is safe to return to driving with upper extremity immobilization. Similar discord exists with the issue of patient and physician liability in such cases. In this review, we seek to present both historical precedent and a contemporary update of this complex, though a frequently encountered situation.
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Empfehlungen zur Fahrtauglichkeit bei Erkrankungen des Bewegungs- und Stützapparates: Ein systematisches Review
Article
  • Oct 2018
Objective Driving a motor vehicle is one of the most important aspects of personal mobility in our society. However, there is a lack of evidence regarding driving fitness after orthopedic or trauma surgery-related diseases. Aim of this systematic review was to support the treating physician to determine the individual driving fitness in patients with musculosceletal disorders. Material and methods A systematic analysis was performed using the PubMed database. Following a predefined algorithm, all relevant articles published from 2013 to 2018 were included. Results The results were categorized according to the affected part of the body into I. lower extremity and II. upper extremity. Also, results were subcategorized into movement restrictions caused by external joint-braces, musculoskeletal diseases, and postoperative conditions. Conclusion This article supports the treating physician to individually determine the driving fitness in patients with musculoskeletal disorders. However, only a few standardized tests exist to individually determine the driving fitness in patients with musculoskeletal disorders. A particular shortcoming was observed for impairments of the upper extremity.
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Doctor, when can I drive Die Beweglichkeit des Handgelenks beim Autofahren
Article
  • Aug 2017
Background The range of joint motion which is necessary to drive a car has not been sufficiently characterized yet. In this study, we tried to define the characteristic pattern and range of motion of the wrist while driving a car. Materials and methods A 3D motion analysis of the right wrist of 20 healthy subjects was performed while driving a car. To define the characteristic range of motion, the results were compared with the individual maximum active range of motion of the wrist. In addition, the area of wrist movement was calculated. In order to define the characteristic pattern of motion while driving a car, the wrist positions were subdivided according to their location probability in five levels (25%, 50%, 75%, 90%, 99%). Results There were no significant differences of the range of motion in the main axes between driving a car and the individual maximum active range of motion. However, a significantly smaller area of wrist movement was observed. Remarkably, extension was not significantly smaller until level 5 and ulnar abduction until level 4. Conclusion Maximum active range of motion of the wrist is used in the main axes while driving a car. The significantly smaller area of wrist movement suggests that not all possible wrist movements are used while driving a car but certain maximum movements in the main axes are regularly found. Furthermore, the results indicate that extension and ulnar abduction are used significantly more often and beyond active range of motion while driving a car.
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Driving with an Arm Immobilized in a Splint: A Randomized Higher-Order Crossover Trial
Article
  • Oct 2010
  • J BONE JOINT SURG AM
The aim of this study was to determine whether immobilization of an arm has detrimental effects on driving performance. Thirty-six healthy officers-in-training were assigned a sequence of fiberglass splints (left and right-sided above-the-elbow thumb spica and below-the-elbow splints) with use of a randomized higher-order crossover design. Runs were scored on a cone-marked driving course used for officer certification with predetermined passing requirements. Driving time, the number of cones hit per course section, and the cone-adjusted total time (a five-second penalty per hit cone) were recorded. A linear mixed-effect model with random environmental and learning effects for cone-adjusted time analysis was used. Participants rated perceived driving difficulty and safety with each splint, and ratings were compared with the Wilcoxon signed-rank test. Thirty participants completed the entire set of runs. Analysis of total cone-adjusted time revealed a significant performance decrease with the left arm in an above-the-elbow thumb spica splint (average, 22.2 seconds; p < 0.001) and with the left arm in a below-the-elbow splint (average, 16.2; p = 0.007). Analysis of forward-only course sections revealed poorer performance trends with all splints, with the worst performance with the left arm in an above-the-elbow thumb spica splint. Driving with the left arm in an above-the-elbow thumb spica splint had the highest perceived difficulty (median, 8.0) and lowest perceived safety (median, 3.0). Driving performance as measured with a standardized track and scoring system was significantly degraded with splint immobilization of the left arm. Further studies are required to determine the effect of arm immobilization on normal driving conditions.
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Driving with a forearm plaster cast: Patients' perspective
Article
  • Jul 2009
  • EMERG MED J
Forearm plaster casts are commonly used in orthopaedic practice for the treatment of fractures of the wrist and carpal bones. A common question put by patients seeks to clarify suitability to drive a motor vehicle. DVLA guidelines do not specifically comment about temporary immobilisation in a cast. A questionnaire was sent to 248 adult patients who had recently been treated in Colles' or scaphoid-type casts to determine the driving habits of the patients and their attitudes to the legality and safety of driving with a cast. Of those who responded, 87% considered it unsafe to drive a car with a plaster cast. 79% thought it should be illegal. Only 9% of patients reported driving while immobilised, and these tended to be young men who did not inform any authority. Previous literature is confusing and there appears to be little consensus among orthopaedic surgeons about letting these patients drive. Clarification is reported from the Medical Advisory Group at the DVLA and the Head of Road Policing Business Area for the Association of Chief Police Officers. It is recommended that all medical professionals advise their patients that they should not drive while immobilised in an upper limb plaster cast.
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Doctor, can I drive with this plaster? An evidence based response
Article
  • Feb 2002
  • INJURY
The purpose of this study is to assess the effect of the commonly used below elbow plaster casts on driving ability. The position of the Driver and Vehicle Licensing Agency and five motor insurance companies is established. The study aims to help doctors decide whether or not a patient is fit to drive with a plaster cast. Three types of cast were tested using one driver. A score was given for several driving abilities. The right Colles cast was found to have no effect on ability to drive. Scaphoid and Bennett's casts were found to have significant affects on driving ability. The DVLA has no specific guidelines regarding driving with a plaster cast and the position of insurance companies is variable, but will usually depend upon medical advice.
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Driving whilst plastered: is it safe, is it legal?
Article
  • Oct 2004
  • INJURY
Many patients, immobilised in a plaster cast after a fracture of the upper or lower limb, wish to drive. They frequently ask permission to do so from the treating surgeon. Insurance companies are apparently willing to insure these patients to drive if they obtain their doctors permission. The DVLA guidelines are unhelpful in these circumstances. We therefore established current practice within the south west region by canvassing 126 consultant orthopaedic surgeons, 27 insurance companies and the 6 regional police constabularies, sending them specific clinical scenarios and asking how they would advise these patients regarding safety to drive. The results were as follows: sixty-seven (53%) of surgeons responded of which 97% gave specific advice regarding safety to drive. The insurance companies were generally unwilling to respond and a national response was received from the Association of Chief Constables, which specifically stated that safety to drive was for the individual patient to decide and the doctor should not give advice. We consider this to be unsatisfactory for all parties and suggest how this situation could be improved for both the patient and other road users welfare.
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Driving plastered: Who does it, is it safe and what to tell patients
Article
  • Jul 2006
The number and safety of patients who drive in an upper limb fracture cast has been largely untested. This study investigates the proportion of persons who drive in their casts and the capability of a casted persons driving is also assessed. The stance of government and insurance bodies is reviewed. The aim is to provide a guide for when a doctor should advise a patient not to drive while wearing an upper limb fracture cast. Patients attending fracture clinic in upper limb casts were anonymously surveyed and asked (along with demographics) if they drove while in a cast and if they believed it illegal or covered by insurance to drive. Driving tests of the author wearing upper limb fracture casts were undertaken. The Queensland police traffic branch, the Queensland Department of Transport and the RACQ insurance company were contacted to review the legal and insurance issues involved. Two-thirds of male and one-third of female patients (half overall) were found to drive while in an upper limb cast. The author failed driving instructor tests in all casts and occupational therapist driving assessments while wearing long arm casts. The author passed occupational therapy driving assessments in left and right short arm casts. According to these results, a doctor's advice should be to patients not to drive in a long arm upper limb fracture cast and to consider concomitant patient factors when advising patients in short arm casts. Although we do not suggest that patients drive while wearing any cast, we have found a large proportion do. Our limited study has found that a young, fit and pain-free person may be able to drive well enough to pass a driving test while wearing a short arm cast.
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  • May 1988
  • Department Of Transport
Department of Transport. Road Traffic Act 1988. http:// www.legislation.gov.uk/ukpga/1988/52/part/III/crossheading/physical-fitness (accessed 25th May 2012).
For medical practitioners: at a glance guide to the current medical standards of fitness to drive
  • Jan 2005
  • Swansea Dvla
Drivers Medical Group, DVLA, Swansea. For medical practitioners: at a glance guide to the current medical standards of fitness to drive. DVLA Publication, 2005.
Driving whilst plastered: is it safe, is it legal? A survey of advice to patients given by orthopaedic surgeons, insurance companies and the police
  • Jan 2004
  • INJURY
  • 883-887
  • Von Arx
  • O A Langdown
  • A J Brooks
  • R A Woods
Von Arx OA, Langdown AJ, Brooks RA, Woods DA. Driving whilst plastered: is it safe, is it legal? A survey of advice to patients given by orthopaedic surgeons, insurance companies and the police. Injury. 2004, 35: 883-7.