A common question put to emergency care and orthopaedic physicians in the emergency department is: “Can I drive with this plaster cast?”. The answer to this simple question is fraught with safety and medicolegal aspects. The Driver and Vehicle Licensing Authority (DVLA)’s guidelines do not cover driving after injury or while immobilised in a plaster cast; surprisingly, their at-a-glance guide does not contain a section on musculoskeletal disorders.1 A recent paper by Von Arx et al sought the advice of the Association of Chief Police Officers on this issue.2 Police Officer Bailey suggested that “rule 79 of the Highway Code clearly states that it is the driver’s responsibility to make sure you are fit to drive” and recommended that the only advice given to such patients should direct them to the Highway Code.

The current literature has reviewed the position of the law, sought opinions from orthopaedic surgeons about the advice they give and which patients should be allowed to drive, and gained the opinions of insurance companies. To our knowledge the opinions of patients recently treated has not yet been ascertained.

METHODS

A postal questionnaire was sent in two rounds to 248 patients who had been treated in a forearm cast for a fracture in the preceding 6 months. The patients were defined from fracture clinic records and were limited to those aged 18–65 years. Only patients with below-elbow Colles’ and scaphoid-type casts were included. The questionnaire was confidential in nature. Questions were asked on demographic characteristics, type of cast and limb treated. Patients’ opinion on whether it was safe to drive motor cars or motor cycles was sought, as was their opinion about legality. Their driving habits while immobilised were ascertained as well as the advice they were given.

RESULTS

Questionnaires were sent to 248 patients in two mailings (second mailing to primary non-responders) and responses were received from 144 (response rate 58%). The respondents comprised 82 women and 62 men of mean age 43.9 years, although there was a bimodal distribution; 102/144 (71%) had been treated in a Colles’-type cast and the remaining 42 (29%) in a scaphoid cast.

In response to the question “Do you think it is safe to drive motor cars/motor cycles with a plaster cast?”, 87% (125/144) thought it was unsafe to drive a car and 96% (136/144) a motor bike; 78% (112/144) thought it should be illegal to drive any motorised vehicle while immobilised in a plaster cast.

With respect to the advice received, 36% (52/144) of the respondents received advice from the fracture clinic doctor. The advice was either to avoid driving or to seek advice from the insurance companies. Four patients were referred to the Highway Code. Forty-six respondents (32%) received advice from the plaster technician, 21 of whom were advised not to drive, 23 were advised it was “up to them” and 1 remembered getting advice but could not recall its contents; 98% would welcome written advice from the fracture clinic.

Only 12 patients drove a motor car and one a motor bike (9% of respondents). Of those who drove, 11 were men. The mean age of those who drove was 32.2 years. Seven of the 13 were immobilised in scaphoid-type casts. Three patients stopped driving during the period of immobilisation due to advice given at follow-up appointments (from the fracture clinic and a physiotherapist), and one stopped driving after the insurance company told him he was uninsured. Of these 13 patients, only one informed the DVLA, two informed their insurance company and none informed the police. Ten informed no-one of their intention to drive. Three of the 13 patients who drove thought it should be illegal.

Of the 104 non-responders, the demographic characteristics did not differ significantly from those who replied, with a mean age of 41.2 years, 76% male and 81% being treated in a Colles’ cast.

DISCUSSION

The previous literature on this subject is confusing.3 5 The DVLA does not currently provide adequate guidance about fitness to drive, and interpretation of section 92 of the Road Traffic Act 1998 seems to indicate that, for those with a duration of disability of <3 months, there is no need to inform the DVLA.4 Dr A Sheppard, Medical Advisor to the Drivers Medical Group of the DVLA recommends: “we do not at the DVLA wish to be notified of conditions that will probably not affect the driver for more than three months. We offer the general advice that drivers wishing to drive with such self limiting conditions should establish with their own practitioners when it is safe to resume driving.” Dr Sheppard goes on to state: “With regard to driving with an upper limb plaster, I am aware that the extent and type of plaster used does affect the limb mobility to a greater or lesser extent. I would suggest it is important to advise patients that it is the responsibility of the driver to ensure that he or she is in control of the vehicle at all times and to be able to demonstrate that this is so if stopped by the police” (personal communication, 4 November 2005).

In the study only 36% of patients received advice from the treating doctor. Von Arx concluded that orthopaedic surgeons offer varied and non-standardised responses that are not evidence-based.2 Depending on the type of cast, 8–26% of doctors said that driving with an upper limb cast was suitable. In the same study the response from insurance companies was poor; only one valid response was received from 27 questionnaires. The single response suggested that advice should be sought from the treating doctor.

Chief Constable Meredydd Hughes is the UK’s most senior traffic police officer and Head of Road Policing Business Area for the Association of Chief Police Officers (ACPO). In a personal communication he states: “Regulation 71(4) c Motor Vehicle (Driving Licence) Regulations 1999 does state that loss of the use of the limb also includes a reference of deficiency of limb movement or power … advice from a Medical Practitioner that a person should not drive with a plaster cast should be based upon their assessment with regard to movement and power” (personal communication, 15 November 2005). As plaster casts are designed to restrict joint movement (and are likely to significantly affect power), it would follow that medical practitioners should take this into account when advising patients.

With this study we have sought the opinion of 248 patients who have recently been treated with an upper limb cast. The results suggest that the uncertainty and confusion felt by the profession is mirrored by the patients. Very few patients appear to drive while immobilised in a Colles’ or scaphoid cast (9%). Of those few who drive, the majority are young men who have a scaphoid cast. These patients do not appear to inform the DVLA, insurance company or police. The vast majority of all patients questioned would value written guidelines (98%).

The authors advise that caution should be taken when advising suitability for driving with an upper limb cast. The DVLA do not offer any specific advice other than it being the responsibility of patients as to whether or not they are fit to drive. From a legal viewpoint, an assessment of power and movement must be made prior to any decision. Any advice suggesting the patient is fit to drive would put the doctor/hospital in a position that may attract vicarious liability.2

Of patients recently immobilised in an upper limb cast, 87% thought it was unwise to drive a car while in a cast. Between 74% and 92% of orthopaedic consultant surgeons would advise their patients they are not “fit to drive” with a below-elbow upper limb cast. We therefore conclude that emergency care and orthopaedic practitioners should advise patients with below-elbow upper limb casts not to drive while immobilised.