Dumb question... Casts?

[Campy Lobacter]

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Do physiatrists ever put on casts? I can think of nothing more MSK and functionally oriented than this... So do you ever do it?

 

[lobelsteve]

No, this is the purview of Ortho.
I would not like to think of the defense in court after a PMR doc casts somebody and they develop compartment syndrome.

 

[DOctorJay]

while the physiatrist may not apply the cast, i have rotated and seen physiatrists order casts for spasticity, venous stasis, and foot ulcers - typically the PT/OT will apply the cast.

i agree with lobelsteve that fracture management belongs to the orthopods but there may be other types of casting you will apply or be exposed to in pm&r (unna boot, pressure relief, spasticity management).

 

[PMR 4 MSK]

I've done some serial casting with nerve blocks and/or Botox for spasticity. I've also had a couple patients casted for fractures that I found, until they could get into one of our orthos and I've also casted a couple of severe ankle sprains, but mostly after curbsiding one of the orthos.

 

[agdoc04]

Why can't physiatrists be able to tell if a fracture is an operable/inoperable event, and then treat as needed. If its operable, get ortho in on the deal. I would think (with my very limited experience) that a fracture is something that should be considered a key area of PM&R MSK. In other words, why don't we refer to ortho, instead of depending on ortho to refer to us.

A concern with the field that I have is that we allow ourselves to fall into a area of "another doctor could better treat that".

Thanks for any/all replies.

 

[SSdoc33]

you make a good point. some physiatrists do manage fracture care. Heidi Prather's fellowship in St. Louis spends a considerable amount of time working with acute-care orthopedics, and stuart willick from utah just gave a lecture about fracture management and casting at this year's aapmr in boston. there really is no reason why a physiatrist cant manage non-operative fractures. family practice docs (especially the sports-trained ones) do this semi-routinely, and get reimbursed quite well for it as well. i think its a matter of training and comfort. most of us havent had the training to do it, so we wouldnt want to mess it up, but its definitely an area that COULD fall under our jurisdiction. i think that there would be some turf issues with the orthopods, though, because it does pay well from what ive heard.....

 

[ampaphb]

you make a good point. some physiatrists do manage fracture care. Heidi Prather's fellowship in St. Louis spends a considerable amount of time working with acute-care orthopedics, and stuart willick from utah just gave a lecture about fracture management and casting at this year's aapmr in boston. there really is no reason why a physiatrist cant manage non-operative fractures. family practice docs (especially the sports-trained ones) do this semi-routinely, and get reimbursed quite well for it as well. i think its a matter of training and comfort. most of us havent had the training to do it, so we wouldnt want to mess it up, but its definitely an area that COULD fall under our jurisdiction. i think that there would be some turf issues with the orthopods, though, because it does pay well from what ive heard.....

are you speaking of casting a fracture in situ? Or reducing displaced fracture fragments?

 

[bedrock]

It's simply a matter of exposure. PM&R residencies don't provide it. And you can count on one hand the fellowships that do, Utah being one of the best for this.
As far as reimbursement and scope of practice, orthopedists are only interested in surgery and surgical fractures. If they know a physiatrist they trust to manage a non-surgical fracture, they are happy to let the physiatrist do it. It reimburses much less than surgical procedures so they are happy to let it go.
However it takes a lot of time for a physiatrist to be ready to evaluate and treat anything that comes in the door, (i.e. beyond ankle fractures)

 

[lobelsteve]

Manage them all you want, but call your malpractice carrier first and ask them if you should be doing it.😀

I'm going to stick with this being a bad idea, unless you have the fellowship credentials from Prather and an Ortho willing to bail you out if things don't go as planned. I can think of a few dozen Orthos willing to testify against you if you mess up.

 

[SSdoc33]

amphaphbabhamphad, i was talking about "fracture management". example: seeing a kid with a broken wrist in clinic after he gets sent home from the ER with a makeshift cast. im supposing "in situ" means handling fractures at a sporting event, or if someone happens to fall walking out of the office. like anything in medicine, there ideally would be a triage process. i dont think reducing comminuted fractures should be done by anyone except an orthopedic surgeon. but managing a mid-shaft fibula fracture or buddy-taping a non-displaced finger fracture? why not?

i personally dont feel qualified to manage all different types of fractures, and to be honest, im not all that interested in it either, but give me one good reason that a physiatrist with proper training should not be able to do it if a PA in an orthopod's office can.

i understand the legal component, getting sued, etc. thats really what would be preventing any movement in this area.

 

[bedrock]

I have to respectfully disagree on the malpractice issue.
If it's such a legal risk for any non-orthopedic surgeon to touch a closed fracture then why do FP's take care of thousands of non-surgical fractures every year without legal complications?
It's simply a matter of appropriate training and knowing when to refer, just as with the rest of MSK medicine.

 

[savealife]

Why do so many posts on the PM&R forums degenerate into "What is the role of a Physiatrist for ___________?" Nobody ever asks what the role of an Anesthesiologist during a surgical procedure is. 🙂

Just an observation. 🙂

 

[ampaphb]

amphaphbabhamphad, i was talking about "fracture management". example: seeing a kid with a broken wrist in clinic after he gets sent home from the ER with a makeshift cast. im supposing "in situ" means handling fractures at a sporting event, or if someone happens to fall walking out of the office. like anything in medicine, there ideally would be a triage process. i dont think reducing comminuted fractures should be done by anyone except an orthopedic surgeon. but managing a mid-shaft fibula fracture or buddy-taping a non-displaced finger fracture? why not?

i personally dont feel qualified to manage all different types of fractures, and to be honest, im not all that interested in it either, but give me one good reason that a physiatrist with proper training should not be able to do it if a PA in an orthopod's office can.

i understand the legal component, getting sued, etc. thats really what would be preventing any movement in this area.

Casting a fracture "in-situ" means leaving the fragments untouched, in the alignment you find them, and just casting them as they lie. If the alignment provides a reasonable biomechanical construct, or in kids is likely to remodel, that can be acceptable. But that is not the end of the story - you have to know which fractures are likely to fall apart, or lose alignment over time.

Typically, the single most common fracture you will be called for in the ER is a displaced Colles fracture - if you can't reduce that (ie. put it back in anatomic alignment) AND cast it, what good are you?

Could physiatrists be trained to do this work in residency? Sure. Do you really want to take ER call, trauma call, etc, and likely not get paid for the vast majority of what you do? I'm not sure why you'd want to.

 

[drusso]

Why do so many posts on the PM&R forums degenerate into "What is the role of a Physiatrist for ___________?" Nobody ever asks what the role of an Anesthesiologist during a surgical procedure is. 🙂

Just an observation. 🙂

Welcome to the fray...

 

[rehab_sports_dr]

There was a great talk at AAPM+R with Stu Willick from Utah and Jonathon Finoff from Mayo talking about the role of physiatry in fracture management. There are definitely some physiatrists who are involved in acute fracture management.