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The Journal of Hand Surgery
(European Volume)
38E(3) 321 –324
© The Author(s) 2012
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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
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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.
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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
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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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