Pressure Ulcer on Wrist Post Synthetic Fracture Cast: A Case Report

Abstract

With evolution of technology and materials, new synthetic substances like fiberglass are now available and used for the casting of fractures. Though these offer advantages for both patient and physician, the possibility of developing a pressure ulcer needs to be kept in mind, which should be treated timely and effectively. The family physician can play an important role in imparting such awareness, as well as in treating, and regularly monitoring such cases, with the support of telephonic and video digital health platforms.

Full text

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*Corresponding author: E-mail: info@drvarsha.com;
Asian Journal of Case Reports in Medicine and Health
4(1): 22-25, 2020; Article no.AJCRMH.62117
Pressure Ulcer on Wrist Post Synthetic Fracture
Cast: A Case Report
Varsha Narayanan
1*
1
Family Medicine and Holistic Health, Dr. Varsha’s Health Solutions, Andheri west, Mumbai, India.
Author’s contribution
The sole author designed, analysed, interpreted and prepared the manuscript.
Article Information
Editor(s):
(1)
Dr. Hab. Mariusz Cycon, Medical University of Silesia, Poland.
Reviewers:
(1) Luigi maria Lapalorcia, Italy.
(2)
Prosper, Obunikem Adogu, Nnamdi Azikiwe University, Nigeria.
Complete Peer review History:
http://www.sdiarticle4.com/review-history/62117
Received 10 August 2020
Accepted 15 October 2020
Published 31 October 2020
ABSTRACT
With evolution of technology and materials, new synthetic substances like fiberglass are now
available and used for the casting of fractures. Though these offer advantages for both patient and
physician, the possibility of developing a pressure ulcer needs to be kept in mind, which should be
treated timely and effectively. The family physician can play an important role in imparting such
awareness, as well as in treating, and regularly monitoring such cases, with the support of
telephonic and video digital health platforms.
Keywords: Pressure ulcer; synthetic cast; digital health; wound healing.
1. INTRODUCTION
The presentation of this case aims to stimulate
awareness on two important points of clinical
practice. Firstly, the development of pressure
ulcers is a possibility in any patient undergoing
bandaging or casting, even if no predisposing
factors or pointing symptoms exist. Secondly,
prompt intervention along with meticulous
monitoring and documentation through the use of
digital visualization health platforms can lead to
effective management of such cases.
2. PRESENTATION OF CASE
2.1 History
A 30-year old male presented with pain,
tenderness and swelling on the extensor side of
his right hand, through digital video consultation.
Case Reports

He gave history of banging his right hand hard
against the wall some days prior, and having
applied ice on it therea
fter a few times. However,
the pain and swelling continued to be present.
An X Ray (anteroposterior and lateral view) of
the right hand and wrist was ordered, which
revealed a shaft fracture of the right 5
metacarpal. He was sent for an orthopedic
refer
ral, and a synthetic fiberglass cast was
applied for 14 days from below the elbow
enclosing 4 fingers, excluding thumb (see Fig
Patient was also started on an anti
and analgesic medication (Etoricoxib 90
a week, and a multivitamin-
mineral supplement
with calcium and vitamin D3 for a month. The
patient had no medical co-
morbidities.
The patient reported reduction in pain, and
improved overall comfort on telephonic follow
He complained of a slight feeling of itching in the
right
lower forearm, but was not unduly disturbed
by it. His cast was removed after 2 weeks, and a
skin ulcer was seen on the ulnar side of the
extensor surface of the wrist. The ulcer was
circular, measured approximately in diameter,
and was shallow with a red-
pink base. Its
margins were well defined, and the surrounding
skin showed a reddish-
blue discolouration. There
was minimal serosanguinous discharge, no
slough present, and the ulcer did not appear
infected. Patient did not complain of any pain, but
Fig. 1. Initial patient presentation
metacarpal fracture. c) Synthetic fiberglass cast
Narayanan;
AJCRMH, 4(1): 22-25, 2020
; Article no.
23
He gave history of banging his right hand hard
against the wall some days prior, and having
fter a few times. However,
the pain and swelling continued to be present.
An X Ray (anteroposterior and lateral view) of
the right hand and wrist was ordered, which
revealed a shaft fracture of the right 5
th
metacarpal. He was sent for an orthopedic
ral, and a synthetic fiberglass cast was
applied for 14 days from below the elbow
enclosing 4 fingers, excluding thumb (see Fig
. 1).
Patient was also started on an anti
-inflammatory
and analgesic medication (Etoricoxib 90
mg) for
mineral supplement
with calcium and vitamin D3 for a month. The
morbidities.
The patient reported reduction in pain, and
improved overall comfort on telephonic follow
-up.
He complained of a slight feeling of itching in the
lower forearm, but was not unduly disturbed
by it. His cast was removed after 2 weeks, and a
skin ulcer was seen on the ulnar side of the
extensor surface of the wrist. The ulcer was
circular, measured approximately in diameter,
pink base. Its
margins were well defined, and the surrounding
blue discolouration. There
was minimal serosanguinous discharge, no
slough present, and the ulcer did not appear
infected. Patient did not complain of any pain, but
only m
ild irritation. A diagnosis of a stage II
pressure ulcer was made [1].
2.2 Management
The patient was managed and monitored by
video calling. This was done in accordance with
ethical principles and guidelines of the
Health and Family Welfare
(Government of India)
Telemedicine Practice Guidelines on using
Tele/Video/Online platforms for patient diagnosis,
prescribing medicines, monitoring and
documentation (released on March 25, 2020).[2]
Patient was advised daily dressing with povidone
iodine
10% ointment, gauze and bandage. He
was also advised guided arm raising and gentle
wrist exercises. He was monitored daily for the
first week through video calling, for healing and
improvement, and was instructed to avoid
wetting the dressing. The ulcer sh
healing and reduction in size. After a week, the
povidone iodine and gauze dressing were
discontinued, and the patient was asked to apply
a gel formulation containing amorphous hydrogel
(Propylene glycerol IP 4.96% w/w and Carbomer
IP 0.76% w/w
) and colloidal silver (32 ppm), once
a day. He was also simultaneously started on
physiotherapy for hand and wrist. The ulcer
showed complete healing at the end 12 days.
(see Fig. 2)
Fig. 1. Initial patient presentation
– a) Swel
ling on first consultation. b) Arrow shows 5
metacarpal fracture. c) Synthetic fiberglass cast
; Article no.
AJCRMH.62117
ild irritation. A diagnosis of a stage II
The patient was managed and monitored by
video calling. This was done in accordance with
ethical principles and guidelines of the
Ministry of
(Government of India)
Telemedicine Practice Guidelines on using
Tele/Video/Online platforms for patient diagnosis,
prescribing medicines, monitoring and
documentation (released on March 25, 2020).[2]
Patient was advised daily dressing with povidone
10% ointment, gauze and bandage. He
was also advised guided arm raising and gentle
wrist exercises. He was monitored daily for the
first week through video calling, for healing and
improvement, and was instructed to avoid
wetting the dressing. The ulcer sh
owed steady
healing and reduction in size. After a week, the
povidone iodine and gauze dressing were
discontinued, and the patient was asked to apply
a gel formulation containing amorphous hydrogel
(Propylene glycerol IP 4.96% w/w and Carbomer
) and colloidal silver (32 ppm), once
a day. He was also simultaneously started on
physiotherapy for hand and wrist. The ulcer
showed complete healing at the end 12 days.
ling on first consultation. b) Arrow shows 5
th

Fig. 2. Progressive healing of pressure ulcer
3. DISCUSSION
During the period of the COVID pandemic,
digital/online or teleconsultations
have played a
big role in the care and management of patients,
limiting the number of clinical visits, preventing
possible risk of exposure, and also facilitating
more meticulous monitoring and documentation
[3,4].
In this patient, a synthetic fiberglass
was chosen for immobilization and expedited
healing of the metatarsal fracture, instead of a
conventional plaster of Paris (POP) cast.
Synthetic fiber glass casts have the advantage of
weighing less and being
more porous than POP
casts, making them ‘
breathable’ and more
comfortable to wear [5,6].
Such casts are also
supposed to make the underlying skin less
vulnerable to irritation and sweating. Taking
effective X rays is also facilitated with such casts
on.
However, in any kind of skin bandaging, in
synthetic casts, pressure ulcers represent a
possible risk [7].
In this case the patient was
largely comfortable, and did not proactively
complain of bandage tightness, or pain.
Therefore, the possibility of a pressure ulcer
should be considered in
patients when synthetic
fiberglass casts are used, even if any suggestive
symptoms, or predisposing risk factors (like
immobility, malnutrition, and comorbidities
affecting vascular, nerve or skin function), do not
exist. Even though pressure ulcers have
reported in leg casts especially at the heel, such
ulcers in the upper limb are rare
wrinkles, uneven ridges or focused pressure on a
specific small area, can cause even pressure
distribution throughout the casting area
Patients should be instructed to report any sense
Narayanan;
AJCRMH, 4(1): 22-25, 2020
; Article no.
24
Fig. 2. Progressive healing of pressure ulcer
During the period of the COVID pandemic,
have played a
big role in the care and management of patients,
limiting the number of clinical visits, preventing
possible risk of exposure, and also facilitating
more meticulous monitoring and documentation
In this patient, a synthetic fiberglass
cast
was chosen for immobilization and expedited
healing of the metatarsal fracture, instead of a
conventional plaster of Paris (POP) cast.
Synthetic fiber glass casts have the advantage of
more porous than POP
breathable’ and more
Such casts are also
supposed to make the underlying skin less
vulnerable to irritation and sweating. Taking
effective X rays is also facilitated with such casts
However, in any kind of skin bandaging, in
cluding
synthetic casts, pressure ulcers represent a
In this case the patient was
largely comfortable, and did not proactively
complain of bandage tightness, or pain.
Therefore, the possibility of a pressure ulcer
patients when synthetic
fiberglass casts are used, even if any suggestive
symptoms, or predisposing risk factors (like
immobility, malnutrition, and comorbidities
affecting vascular, nerve or skin function), do not
exist. Even though pressure ulcers have
been
reported in leg casts especially at the heel, such
[8]. Avoiding
wrinkles, uneven ridges or focused pressure on a
specific small area, can cause even pressure
distribution throughout the casting area
[9].
Patients should be instructed to report any sense
of pressure, irritation, itching or feeling of
wetness anytime during wearing of the cast.
Povidone iodine is an effective antiseptic agent
and the one of choice due to its bactericidal
activity against both gram-
positive and gram
negative organisms as well as spores and
biofilms, with a lack of bacterial resistance. It also
does not impede wound healing, and has both
therapeutic and prophylactic effectiveness in all
kinds of acute and chronic wounds inclu
pressure sores [10,11].
Thereafter when healing
was progressing satisfactorily, patient was
switched to amorphous hydrogel with added
colloidal silver, for patient convenience and to
begin physiotherapy. The hydrogel facilitates
wound protection from
water and environmental
agents, at the same time helping in moisture
retention and effective healing, while the colloidal
silver imparts antimicrobial action
[
4. CONCLUSION
Pressure ulcers should be kept in mind while
using synthetic fiberglass c
asts for fractures. An
intermediate clinical visit may be recommended
with opening and appropriate re
cast if even mild irritation or tightness is reported.
Any resulting pressure ulcer should be managed
with povidone iodine gauze dressings.
to antimicrobial hydrogels to maintain effective
healing without additional dressing can be
considered for patient convenience and
commencing appropriately physical activity.
Digital online consultation, which has evolved
due to the current COVID-
19 (Coronavirus
disease), can be well utilized for more regular
and effective clinical inspection, monitoring and
documentation of patients developing pressure
ulcers.
; Article no.
AJCRMH.62117
of pressure, irritation, itching or feeling of
wetness anytime during wearing of the cast.
Povidone iodine is an effective antiseptic agent
and the one of choice due to its bactericidal
positive and gram
-
negative organisms as well as spores and
biofilms, with a lack of bacterial resistance. It also
does not impede wound healing, and has both
therapeutic and prophylactic effectiveness in all
kinds of acute and chronic wounds inclu
ding
Thereafter when healing
was progressing satisfactorily, patient was
switched to amorphous hydrogel with added
colloidal silver, for patient convenience and to
begin physiotherapy. The hydrogel facilitates
water and environmental
agents, at the same time helping in moisture
retention and effective healing, while the colloidal
[
12,13].
Pressure ulcers should be kept in mind while
asts for fractures. An
intermediate clinical visit may be recommended
with opening and appropriate re
-application of
cast if even mild irritation or tightness is reported.
Any resulting pressure ulcer should be managed
with povidone iodine gauze dressings.
Switching
to antimicrobial hydrogels to maintain effective
healing without additional dressing can be
considered for patient convenience and
commencing appropriately physical activity.
Digital online consultation, which has evolved
19 (Coronavirus
disease), can be well utilized for more regular
and effective clinical inspection, monitoring and
documentation of patients developing pressure

Narayanan;
AJCRMH, 4(1): 22-25, 2020; Article no.AJCRMH.62117
25
CONSENT
As per international standard, informed consent
was obtained for the publication of this report
ETHICAL APPROVAL
The patient was managed and monitored by
video calling. This was done in accordance with
ethical principles and guidelines of the Ministry of
Health and Family Welfare (Government of India)
Telemedicine Practice Guidelines on using
Tele/Video/Online platforms for patient diagnosis,
prescribing medicines, monitoring and
documentation (released on March 25, 2020).2
COMPETING INTERESTS
Author has declared that no competing interests
exist.
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© 2020 Narayanan; This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
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