What to do if a patient with a potential fracture or other condition requiring immobilization removes their own Soft Protective Cast (SPC) or immobilization device on their own?

Immediate Reapplication of Immobilization Device

If a patient removes their soft protective cast (SPC) on their own, immediately reapply a non-removable knee-high immobilization device to prevent progressive deformity, delayed healing, and potential complications. 1

Assessment of Current Status

Upon discovering the patient has self-removed their immobilization device, evaluate:

• Skin integrity: Check for new wounds, blisters, or pressure areas that developed under the cast 1
• Fracture stability: Assess for increased pain, swelling, or deformity suggesting displacement 1
• Neurovascular status: Confirm intact sensation, motor function, and perfusion 1
• Time without immobilization: Document how long the extremity has been unprotected 1

Reimmobilization Strategy

First Choice: Non-Removable Device

Apply a non-removable knee-high offloading device as the primary treatment to prevent patient non-adherence. 1 The evidence strongly demonstrates that removable devices lead to poor compliance and delayed healing, with median time to remission being three months longer compared to non-removable devices. 1

Options include:

• Total contact cast (TCC): Made of plaster of Paris or fiberglass in close contact with the entire foot and lower limb 1
• Non-removable walker: Prefabricated knee-high walker rendered irremovable by circumferentially wrapping with fiberglass cast material or tie wraps 1

Second Choice: Enhanced Removable Device (Only if Non-Removable Contraindicated)

If a non-removable device is contraindicated or not tolerated, use a removable knee-high device with intensive patient education about the consequences of removal. 1 However, recognize this carries substantial risk of repeat non-compliance. 1

Patient Education and Counseling

Provide explicit counseling about the severe consequences of premature device removal:

• Progressive deformity: Mechanical stress perpetuates the inflammatory process, causing bone destruction, fracture progression, and joint dislocation 1
• Delayed healing: Inadequate immobilization extends time to remission by months 1
• Skin ulceration: Unprotected weight-bearing on compromised tissue leads to breakdown 1
• Permanent disability: Malalignment and non-union may require surgical correction 1

Despite the absence of pain (due to neuropathy in many cases), continued mechanical stress causes ongoing damage. 1

Critical Pitfalls to Avoid

Do not simply reapply the same removable device without addressing the underlying non-compliance. 1 Studies demonstrate that patients with removable devices frequently remove them despite education, leading to treatment failure. 1

Do not use below-ankle devices (surgical shoes, postoperative sandals, custom molded shoes) as these provide inadequate immobilization of diseased bones and joints. 1

Do not delay reimmobilization while waiting for additional imaging or specialist consultation—immediate protection is essential to prevent progressive deformity. 1

Monitoring After Reapplication

• Serial radiographic monitoring during the first 3 weeks to confirm maintained alignment 2
• Frequent skin checks (every 1-2 weeks) to detect cast-associated blisters or ulcers, which occur in approximately 14% of patients 1
• Assistive devices (crutches, wheelchair) to reduce weight-bearing on the affected limb 1

Special Considerations

For pediatric patients with stable fractures (buckle fractures, nondisplaced fractures), soft cast materials may be appropriate as they demonstrate equivalent outcomes with higher patient satisfaction. 3, 4 However, for potentially unstable fractures or conditions requiring strict immobilization, non-removable devices remain essential. 1, 5

The key principle: mechanical stress perpetuates injury and prevents healing—immobilization must be maintained until clinical remission is achieved. 1, 2