Journal Article Review, September 2017

“My distal radius fracture is plated. When can I resume driving?”

Jones CM et al: Safe return to driving after volar plating of distal radius fractures. J Hand Surg 2017, 42A:700-704

Many people equate freedom and independence with their ability to drive, which may be restricted following injury. Turkish investigators recently studied patients’ ability to drive safely following open reduction and internal fixation of distal radius fractures.

They studied 23 consecutive patients between ages 50 and 85 who had undergone volar plating of distal radius fractures and who agreed to participate in the study. The treatment was uniform. Patients received a thermoplastic orthosis and starting formal hand therapy one to two weeks following surgery.

The first driving evaluation was approximately two weeks after surgery with follow-up examinations at four and six weeks after surgery if the patient had failed an earlier evaluation. A certified driving rehabilitation specialist performed all of the evaluations, which were performed on a closed course using a four-door midsized sedan with automatic transmission.

The test included opening the door, starting the engine, shifting, signaling turns, turning right and left, and parking. Patients received grades for each function and were finally given a pass or fail score. Data collection included age, handedness, use of orthosis, strength, and ranges of motion. After the driving test, patients completed a questionnaire regarding their degree of comfort and safety, specific difficulties noted while driving, pain level on a visual analog scale (VAS), and use of pain medication.

RESEULTS: Sixteen of 23 patients passed the test on their first attempt, which was on average 18 days after surgery. Of the seven who failed, all related the failure to pain; six felt that they could manage the car in an emergency, but two noted that they would not feel safe with daily driving. Four of these seven, however, had returned to driving prior to the first evaluation. Of these seven who failed their first test, four passed on their second attempt, which was on average 31 days after surgery. The other three did not return for repeat evaluation because of scheduling conflicts.

Patients failing the exam relied too much on their non-injured hand, were not able to control the steering wheel with two hands, or had pain and felt insecure using the injured hand. Pain while driving averaged 1.3 on the 10-point VAS for those who passed compared to 2.4 for those who failed.

The investigators found no significant differences on pass/fail related to age, handedness, use of orthosis, strength, motion, or reported level of pain or level of confidence.

DISCUSSION: In the study, patients began driving on average 13 days after surgery, and 70% passed the driving examination 18 days after surgery. The investigators found no consistent component of the driving evaluation that was a barrier to passing the test. They concluded that driving performance is multifactorial and an in-office examination may not adequately determine a patient’s driving ability. A patient’s need to drive and their risk perception may greatly influence their determination to resume.

Individuals have a wide spectrum of baseline driving skills, and some may be abler than others to compensate and drive safely in face of pain, weakness, or stiffness. Others, especially elderly individuals, may have been marginally safe drivers pre-injury, and even small limitations after injury may severely impair their ability to drive safely.

Previous studies have evaluated driving skills in healthy individuals encumbered by various degrees of upper limb immobilization. These studies have shown that dominant limb immobilization, thumb immobilization, and elbow immobilization cause driving impairment. None of these studies, however, analyzed actual patients who could be experiencing pain or taking narcotic pain medication.

So what should we tell our patients? The US Public Health Service notes that safe driving requires normal motor function and adequate joint mobility in both upper limbs and in the right lower limb. Insurance companies and law enforcement organizations generally make the patient responsible to act sensibly in their own decision to resume driving.

As a general guideline, health care professionals can advise that many patients can safely return to driving three weeks after volar plating of a distal radius fracture. The authors caution, however, that an office evaluation cannot determine the ability to drive safely and that ultimately it is the patient’s decision about when to resume. An extensive hands-on evaluation by a certified driving rehabilitation specialist may prove helpful.

COMMENT: I found this article helpful even though it did not give a definite answer to the question, “When can drive?” Based on the information provided, I am going to say, “Many patients return to safe driving within three weeks, but it is highly variable. It ultimately depends on when you feel safe. If you are uncertain, let’s arrange for a hands-on evaluation.”