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November 04, 2013

Is it Safe to Drive with My Arm in a Cast?

Frequently Asked Questions

Orthopaedic surgeon Geoffrey S. Marecek, MD answers frequently asked questions about driving after orthopaedic surgery.

 

Q: When should I talk to my orthopaedic surgeon about driving and potential limitations? How far in advance?
A: For most procedures you should discuss this when you are deciding to schedule surgery. This will help you make accommodations for your family’s transportation and your work well in advance. For more urgent surgeries, such as after a fracture, it is a good idea to discuss this before leaving the hospital or at your first postoperative visit.
   
Q: Are there guidelines on when to drive after a specific surgery or procedure?
A: There are a number of studies using driving simulators to determine when braking ability returns to normal after surgery. This provides a rough guideline for when a patient may begin to consider returning to drive. These have all been done for lower extremity or spine procedures. There are some upper extremity studies in the works, however.

The decision to resume driving should be individualized – each patient needs to speak with his or her surgeon about the results of these studies and how they apply to his or her own recovery process and level of driving skill.
   
Q: How soon will I be able to drive?
A: Patients with automatic transmission vehicles who had left leg surgery should be able to drive once they are off narcotic medications and pain free in most cases.

Patients who had a Total Hip Arthroplasty (THA) or Total Knee Arthroplasty (TKA) can think about driving around 4-6 weeks and 4 weeks postoperatively, respectively. For knee arthroscopy, braking function is normal after 4 weeks; with an Anterior Cruciate Ligament (ACL) reconstruction it becomes 6 weeks.

Patients who have an ankle fracture may consider driving around 9 weeks postoperatively, while for other major lower extremity fractures it takes about 6 weeks after beginning full weight bearing.
   
Q: What surgical sites or procedures are most likely to impair my ability to drive?
A: All injuries and procedures have the potential to alter one’s ability to drive. Braking and accelerating require coordinated activity at the hip, knee, and ankle while steering and shifting require use of the shoulder, elbow and wrist. Sitting upright and scanning the road will require good spine function—driving requires total body coordination!

Based on the available studies, major lower extremity fractures will delay driving the longest (a minimum of 18 weeks in some cases) but nearly all will cause some impairment.
   
Q: Are there any specific impairment that I should be aware of or sensitive to?
A: There is no function or activity that is critical or uniquely important with respect to driving. I would be particularly sensitive to any functional deficits such as a neurologic deficit before or after spine surgery. These would further impair one’s driving ability.
   
Q: What are some of the things to consider: range of motion, steering, checking the blind spot, sudden/quick movements, braking or hitting the clutch?
A: All of these things are important for safe driving, which underscores how necessary it is to return to driving only when one is truly ready.

Most studies have considered emergency braking to be the critical test that would allow a patient to return to driving without posing a risk to others. Other studies have shown that the addition of evasive maneuvers such as turning a steering wheel causes further delays in the braking time. In reality, driving is a much more complex task which is why some of the newer studies use full driving simulators to check all these parameters.

I advise my patients to think about the neighbor’s child running into the street; could you avoid an accident? If so, you may be ready to begin driving.
   
Q: What challenges are specific to leg or knee surgery?
A: Moving the foot from the gas to the brake pedal requires coordinated movement of the hip, knee, ankle, and foot. Surgery in each of these locations can impair braking function.

One critical concern is the ability to sit in a car safely after THA. Depending on the surgical approach used, many patients could be at risk for hip dislocation when sitting in a low car seat. Patients should check with their surgeon to see if they can drive while following their rehab protocol.
   
Q: What challenges are specific to arm, wrist, or hand surgery?
A: Much less is known about driving after upper extremity surgery—we have no studies documenting how a specific procedure impacts driving function, only how immobilization can impair driving. Any impairment in the shoulder, elbow, or wrist can affect the ability to shift and turn the steering wheel.
   
Q: Do splints, casts and slings help minimize risk?
A: No—in fact it’s quite the opposite. Any splint, cast, knee immobilizer, or walking boot on the lower extremity impairs braking function and driving should be avoided while wearing these. Similarly, slings and upper extremity splints impair driving ability. We know that even highly trained drivers like police officers do not drive well while wearing casts! There are conflicting reports about driving with removable wrist splints and patients should speak to their surgeon about their particular circumstance, though we generally advise against driving for our patients.
   
Q: Does it matter if I am driving a short or long distance?
A: No—it does not matter. Although fatigue and deficits in endurance may surface on longer trips, a drive of any duration can result in an accident and therefore patients must be fully prepared for any length trip.
   
Q: Are there are exercises or physical therapy I can perform that will help me accelerate the process of returning to drive?
A: There are no studies addressing specific rehabilitation protocols. In general, following one’s prescribed protocol should restore function and strength to an adequate level to allow driving. There are a few tests that can be done with one’s physical therapist to test readiness to drive such as the “step” or “stand” tests that have been described.
   
Q: Will my medication affect my driving?
A: While there is some evidence that chronic narcotic use under the supervision of a pain specialist may not affect braking ability, patients should avoid driving while taking any narcotics. Narcotics can impair cognitive function and reaction time and could be considered “driving under the influence.”
   
Q: What other considerations are there?
A: One of the most striking findings in our research for this paper was that insurance companies and law enforcement agencies consider the patient to be the only person responsible for determining when he or she is fit to drive. There is no “clearance” or “doctor’s note” that can help if one is in an accident or receives a ticket. With that said, one’s surgeon is uniquely equipped to provide guidance on this subject with the aid of the guidelines published in the literature. We would encourage all patients to discuss this with their physician before getting behind the wheel.




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