When can I drive? Return to driving following a wrist fracture: A critical review

Abstract

Introduction

The primary aim of this review was to identify literature that examined factors which influence driving performance following a wrist fracture. Given the known scarcity of research in this area, secondary aims were to detail current practices including the driving habits of patients following a wrist fracture and health professionals’ opinions on safe return to driving.

Methods

We performed a search in April 2015 using three electronic databases to obtain relevant literature in the English language. Relevant studies including clinical trials, surveys and case reports were reviewed.

Results

The search identified 12 relevant studies. Five of these were clinical studies with a crossover design that investigated the driving ability of uninjured individuals with the wrist immobilised in a cast. The remaining were survey-based studies. The clinical trials showed that the presence of a wrist cast reduced driving performance in uninjured individuals. No studies investigated driving performance in individuals with a wrist fracture. The surveys showed that this patient group returns to driving despite perceived safety risks. Inconsistency in expert opinions on whether individuals with a wrist fracture are safe to drive was highlighted.

Conclusions

There is evidence to suggest that driving performance is reduced in uninjured individuals when wearing a cast immobilising the wrist; however, the influence of wrist fracture is unknown. This, along with safety implications resulting from current driving behaviours and inconsistent information provided to patients regarding return to driving, highlights the need for further studies to ascertain which factors influence driving performance following wrist fracture.

Keywords

Wrist wrist injuries fracture automobile driving

Introduction

Health practitioners are commonly asked by patients at what point ‘it is safe’ to return to driving following a wrist fracture. There is a poor understanding of the clinical factors that may influence the driving capacity in individuals with a wrist fracture. As a result, health professionals may base their responses on radiographic and clinical factors of fracture healing rather than on evidence-based measures of the individuals’ physical capacity to drive safely.

Driving a motor vehicle is a complex task requiring a combination of cognitive and physical performance. Drivers need to be able to use the ignition, grip and turn the steering wheel, operate the indicators, gear lever and hand brake consistently,¹ and to be able to do these tasks quickly and accurately in case of an unexpected event. Driving with restricted ability poses obvious risks to the driver and to other road users.

Inaccurate advice on driving capacity given to individuals following a wrist fracture could result in people returning to driving before they are safe to do so. If the individual was involved in a motor vehicle accident, negative medico-legal consequences could arise. Conversely, unnecessarily delaying the return to driving may lead to loss of independence and time away from daily activities, including work.

Fractures to the wrist occur more frequently than in any other area of the body.² The incidence is highest in older females; however, wrist fractures occur in all age groups. The wrist is one of the most common fracture sites in the under 55-year-old age groups.^3,4 It follows that a high number of individuals who sustain a wrist fracture are current motor vehicle drivers.

Wrist fractures result in a significant reduction in wrist range of motion and grip strength.⁵ These impairments contribute to a significant limitation in activities of daily living, especially in the first 3 months following fracture.⁵ Given the resultant limitation in other activities of daily living, it is likely that driving performance in individuals recovering from a wrist fracture will be reduced.

Formal driving assessment of people with disabilities is a specialised field. Some national guidelines⁶ require people with some permanent disabilities to have a driving assessment by a specialised driving occupational therapist prior to resumption of driving. With non-permanent impairments including most fractures, these assessments are usually neither feasible nor routinely recommended due to their financial expense and time consuming nature.¹ The use of objective tests in a clinical setting to guide recommendations has the potential to be both cost effective and result in increased safety among this group.

The primary purpose of this critical review was to investigate the effect of wrist fracture on driving performance. The secondary aims were to describe the current driving habits of patients following a wrist fracture and health professionals’ opinions on when it is safe to return to driving.

Method

In this review, we sought to examine all studies in the English language investigating any element of driving a motor vehicle following a wrist fracture. The EMBASE, CINAHL and PubMed databases were searched for relevant studies from the inception of each database to April 2015. The search strategy used the following key words: (‘driving’ OR ‘drive’ AND ‘fracture,’ ‘injury,’ ‘upper limb,’ ‘wrist’ OR ‘arm’). Given the known paucity of clinical trials in this field, the search terms used were deliberately broad to capture any related research in this area. The types of studies included were limited to clinical trials, observational studies and survey studies, while review articles were excluded.

Following removal of duplicate articles, one author (SS) performed a title and abstract screen to obtain published and completed studies of relevance. We completed a manual reference check of the retrieved articles to identify additional articles not captured by the original search. A qualitative analysis of the data was then performed. As the method of assessing driving performance and outcome measures differed between studies, the results could not be pooled and a meta-analysis could not be performed.

Results

The initial search identified 958 articles. The search process is described in Figure 1. Following article exclusion using the selection method detailed, 12 articles were included. Out of the 12 eligible articles, 5 were clinical trials and 7 included surveys (one article included both a clinical trial and a survey).

Figure 1.

Search strategy.

There were no studies that investigated the driving performance of individuals with a wrist fracture. All of the clinical trials investigated the driving performance of uninjured individuals when wearing a wrist cast. The surveys outlined driving behaviours of patients following a wrist fracture and health practitioners’ opinions regarding return to driving in this patient group.

Driving performance whilst immobilised in a wrist cast or splint

The five clinical studies investigated the driving ability of uninjured people whilst wearing a cast or splint. Details of each study are detailed in Table 1. The sample size varied from one to 30 healthy participants. Each of these studies used a crossover study design where each participant had their driving performance assessed in a number of different cast types. Statistical analysis of significance was only performed in three studies.^7–9 Subsequently, the results need to be interpreted with caution, especially when considering the small sample sizes.

Table 1.

Details of clinical studies investigating driving in a cast.

Author	Study type	Method of driving assessment	Study group	Type of casts worn by participants in driving assessment	Groups with reduced driving ability	Place of study
Blair (2003)	Crossover trial	On road test using a points system	1 healthy participant assessed using each type of cast	Colles cast Scaphoid cast Bennett’s cast	Left Colles cast Left Scaphoid cast Right Scaphoid cast Left Bennett’s cast Right Bennett’s cast	UK
Chong (2010)	Randomised crossover trial	Driving course with cone markings. Time was recorded and cones knocked down were counted, giving a cone-adjusted time.	30 healthy police officers assessed using each type of splint	Short arm splint Long arm splint Control (no splint)	Significant time reduction in left hand splint groups All groups with splints trend towards worse performance	USA
Gregory (2009)	Randomised crossover trial	Driving simulator test recording indices of driving performance	8 healthy participants each assessed with/without the cast	Short arm cast Control (no cast)	Cast group deterioration in performance when responding to hazards. More pronounced in right sided casts.	UK
Kalamaras (2006)	Crossover trial	On road driving test, assessed by specialised OT and driving instructor (pass/fail)	1 healthy participant (the author) assessed using each type of cast	Short arm cast Long arm cast Control (no cast)	All casts groups failed test	Australia
Stevenson (2013)	Randomised crossover trial	On road driving test, assessed by a driving instructor (pass/fail)	6 healthy participants assessed using each type of cast	Short arm cast Long arm cast Bennett’s cast	5 individuals in long arm cast failed test 1 individual with Bennett’s cast failed test	UK

Colles cast: a short arm cast, with the wrist immobilised in slight flexion.

Scaphoid cast: a below elbow cast, with the thumb immobilised up to the interphalangeal joint.

Bennett’s cast: a below elbow cast, with the thumb immobilised in extension.

A variety of elbow, wrist and thumb casts were used. Each study included trials for both left and right hand casts. All of the studies used a group with a short arm cast. Two studies also used short arm casts that included the thumb.^9,10 Three studies used long arm casts.^7,9,11

The method of driving assessment varied among studies with on-road driving tests used by the majority.^9–11 Kalamaras¹¹ and Stevenson⁹ used a formal driving test. Blair¹⁰ used an informal on-road test which assessed performance where points were given for components of the driving task including gear changing, steering, reversing, hand brake control, indicator/horn control and on-road performance. Other studies used off-road tests. Chong⁷ used an off-road driving course with cone markings and recorded the time taken to complete the course and the number of cones knocked down. Gregory⁸ assessed performance in a driving simulator equipped with STISIM™ software to record aggregate indices relating to speed and lateral control of the vehicle as well as the number of collisions.

These studies were performed in different countries including the United Kingdom,^8–10 the United States⁷ and Australia,¹¹ with resultant differences in left- or right-hand drive cars used in the driving assessments. Right-hand drive cars are used in the United Kingdom and Australia while left-hand drive cars are used in the United States.

Wearing a wrist-only cast showed a trend towards altered driving performance in four studies.^7,8,10,11 The impairment in driving performance was reported as increased time taken to complete the assessment,⁷ poorer response to hazards,⁸ failing the on-road driving test¹¹ and loss of points in an on-road driving test.¹⁰ The size of this effect varied among these studies, with a significant reduction in performance only in one study.⁷ Gregory⁸ showed that wrist immobilisation also led to more cautious driving, with less adjustment of speed and lateral road position than when unrestricted.

Above-elbow casts showed some trends towards reduced driving performance in all relevant studies.^7,9,11 Chong⁷ showed that those with both left and right above elbow casts took longer to complete an off-road driving course, but this was only significant in the left hand above elbow cast groups. Studies by Stevenson⁹ and Kalamaras¹¹ also highlighted impaired performance where the single participant failed the driving assessment when using both the left and right above elbow cast¹¹ and four out of six individuals failed the driving assessments when using the left above elbow cast, with significantly worse driving assessment scores when compared to the other groups.⁹

Casts including the thumb had varying effects on driving performance.^9,10 All cast groups including the thumb in the study by Blair and colleagues failed the driving assessment.¹⁰ One out of the six participants using a left sided cast including the thumb failed the driving test by Stevenson.⁹

There were some reported differences in driving performance depending on the side of the immobilised arm.^7–9 Two of these studies were completed in right-hand drive cars,^8,9 and found driving performance was worse in left arm cast groups in one study,⁹ but the other showed worse driving performance when responding to hazards in right arm cast groups.⁸ The third study was completed in a left-hand drive car⁷ and found significantly reduced driving performance in left arm cast groups.

Current driving behaviour reported by individuals with a wrist fracture

Five of the surveys questioned individuals with wrist fractures about current driving behaviours whilst in a wrist cast or splint.^11–15 The proportion of individuals who reported driving in the cast varied greatly among the studies; 12 out of 144 (9%) of individuals in the United Kingdom reported driving whilst in a Colles plaster cast,¹³ 18 out of 118 (15%) of individuals in Ireland reported driving in a wrist cast,¹⁵ and 84 out of 168 (50%) of individuals in Australia¹¹ with an arm cast reported driving at least once.

Not all individuals sought professional advice before returning to driving following a fracture. In the United Kingdom, only 52 out of 144 individuals (36%) in a Colles or scaphoid cast reported consulting their doctor, and 46 out of 144 individuals (32%) consulted the plaster technician before driving.¹³ In the United States, 64% of the 70 survey respondents reported consulting their doctor before driving following their musculoskeletal injury.¹² In Ireland, 4 out of 18 (22%) of individuals sought advice from their doctor prior to returning to driving whilst in a wrist cast, and 2 out of 18 individuals (11%) asked their insurance company.¹⁵

There are safety concerns related to driving whilst in a wrist cast which are reported or perceived as potential issues by survey respondents. Two of the survey studies questioned patients about perceived driving ability when using a variety of wrist casts and thermoplastic splints. Over 85% (125 out of 144) of patients thought that driving in a wrist splint or cast would be unsafe¹³ and 19% reported feeling unsafe while driving.¹² Despite known safety implications, many of those surveyed also began driving while on narcotic pain medications or returned to driving despite advice to the contrary from their doctor, family or friends.¹²

The inconvenience and loss of independence associated with not being able to drive is significant. One survey reported that 42% of the 70 respondents found not being able to drive following a fracture was a major difficulty and 26% found there was associated major financial hardship.¹²

The influence of legal implications and potential loss of insurance coverage also did not seem to deter patients from driving following a wrist fracture. The majority (83% of 168 respondents) of people surveyed thought they might be breaking the law or were not sure if they were breaking the law by driving when using a wrist cast.¹¹ Most of these individuals (98% of 168 respondents) also thought they were either not covered by their insurance company, or were unsure if they would be insured if they drove.

Reported advice to patients by clinicians

Health practitioners were questioned about their opinions on driving following a wrist fracture. Five surveys were sent to surgeons,^12,16,17 plaster technicians¹⁸ and general practitioners (GPs)⁹ including a variety of questions regarding the driving ability of patients following a wrist fracture or when the wrist was immobilised.

The opinions from health practitioners on driving ability following a wrist fracture were variable. Surgeons’ opinions regarding whether patients were safe or not safe to drive whilst immobilised in a wrist cast varied by up to 50%.^16,17 The timeframes suggested by surgeons after which patients could return to driving following a wrist fracture varied from zero to 12 weeks following the injury.¹² The majority of GPs gave advice that was more conservative than the surgeons’ advice for driving whilst using a wrist cast: more than 20 out of 24 GP’s survey respondents (over 80%) were of the opinion that patients using varying upper limb splints would not be safe to drive. There was less clarity about the safety of driving whilst wearing soft wrist supports. The consensus from plaster technicians regarding return to driving following a wrist fracture was to seek further advice from their car insurance company (166 out of 188 respondents) the local driving authority (22 out of 188 respondents), their doctor (20 out of 188 respondents) or the police (11 out of 188 respondents).¹⁸

Some studies^14,17,18 reported that doctors advise patients to seek advice from their insurance company as a guide on return to driving. In contrast, the advice from insurance companies was for patients to follow the advice of their doctor.^11,15–18

Discussion

There is some evidence to suggest that uninjured individuals’ driving performance is worse when wearing a wrist cast.^7–11 The size of this effect varied among studies. Casts that immobilise the thumb and elbow had a larger effect on driving ability than casts that only immobilised the wrist. These studies used a variety of test methods and outcome measures, recruited small sample sizes and not all studies performed significance analysis, making grouped comparison of results impossible.

The sample size of all of the studies was small, though being a crossover study design, two of the studies used only one participant. One study had 30 participants, and this approached the sample size requirements for the Central Theorem Limit sample size guidelines. It is likely that all other studies were too underpowered to infer clinical significance. Further, the largest trial with 30 participants recruited police officers in training, affecting the generalisability of the results. Consequently, none of the studies included provided evidence to support strong conclusions.

This review found no studies which investigated the effect of wrist immobilisation on the driving ability of patients with wrist fracture, as all studies were performed on uninjured participants. Extrapolating from the findings of studies on healthy people, it is reasonable to assume that driving performance will also be impaired in patients with wrist fracture and immobilisation, but the extent of this effect is unknown.

In individuals with wrist fractures, the effect of wrist immobilisation is compounded by medication use, pain and arm weakness. Impairments including reduced movement and weakness are often still present following removal of the cast or splint, especially in the first three months following fracture.⁵ Studies are needed to quantify the effect of these impairments and identify criterion-based or time milestones that are associated with safe return to driving in this population. While the investigation of individuals with a wrist fracture may be limited due to ethical considerations of on-road driving safety, the risk of disrupting fracture healing, or provoking pain in the injured limb, it remains an important area to study.

The surveys on driving practices of patients with a wrist fracture show that a proportion of these individuals report returning to driving prior to gaining medical clearance, despite the perceived safety, legal and insurance-related risks of this behaviour. This review was not able to detail the risk of this behaviour, as we located no studies detailing the driving performance of individuals with a wrist fracture. The surveys also highlighted the inconsistent information health practitioners provide in regards to driving ability following a wrist fracture. Von Arx¹⁷ concluded that doctors may offer varied advice that is based on expert opinion rather than being guided by evidence based practice.

Three studies^11,13,15 revealed that individuals are likely to return to driving whilst in a wrist cast and not all individuals sought advice from their doctor before doing so.^12,13,15 It is perhaps substantial loss of independence of not being able to drive that prompts individuals with a wrist fracture to return to driving despite the perceived safety implications of this behaviour. However, it has been shown that drivers judge their own performance inaccurately and tend to overestimate their skills and underestimate impairment.¹⁹ It can be ethically argued that it is the role of the treating health practitioner to actively educate patients of any risks they take when driving with a wrist fracture. Research reporting on timeframes and explanations on guiding factors will assist the patient in making an informed decision on returning to driving following their wrist fracture.

The majority of the studies used on-road driving assessments to assess driving performance. The advantage of this method is the real life correlation as well as the option of using assessments parallel with those used for drivers licensing requirements. Conversely, off road tests have better potential to assess drivers’ reactions to hazards and more difficult vehicle control tasks such as those examined by Gregory⁸ and Chong.⁷

It could be argued that reduced driving performance in individuals with a wrist fracture may not be highlighted in routine driving scenarios where unplanned reactions are not required. In fact, some studies showed a more cautious, or arguably safer, driving behaviour in individuals when using a wrist cast⁸ with routine driving scenarios. A complete picture of driving performance is perhaps better reflected when also including the driver’s response and reaction to hazards and unplanned or more demanding tasks. Some studies may not have shown significant differences between groups if the driving assessment did not evaluate the performance in the more difficult components of driving such as hazard reactions.

The side of immobilisation had a varying impact on the results. As the studies varied between design in using left and right hand drive cars as well as using manual and automatic vehicles, it is unclear if it was the position of the arm in the car (i.e. the hand used on the gears), or if other factors such as hand dominance resulted in these differences.

There are no practice guidelines or policies that have been endorsed by an orthopaedic or speciality society, insurance company or the police that provide guidance about safe to return to driving following a musculoskeletal injury.¹² Guidelines that are endorsed by an orthopaedic professional society would be extremely valuable.

This review highlights the lack of published studies that investigated the driving performance of individuals who are recovering from wrist fracture. This evidence gap has been recognised by many authors in the field.^1,12,16,17 It is critical to note that the available research has been performed only on healthy individuals using a wrist immobilisation cast. This means that other factors such as the pain and other factors present in the injured population have not been examined. There are also no studies on driving performance in the wrist fracture population in the immediate period following removal of the cast when they still have impairments such as reduction in wrist range of motion and strength.

Conclusion

There is low-level evidence to suggest that the presence of a wrist cast or splint reduces driving performance in uninjured individuals. Considering the high prevalence of wrist fractures, the importance of driving in daily life and the risks associated with poor driving ability, it is essential for future research to assess performance in the wrist fracture population as it relates to driving safety.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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