Abstract
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Patients undergoing planned or unplanned orthopaedic procedures involving their upper or lower extremity can prevent them from safe and timely return to driving, where they commonly ask, ‘Doctor, when can I drive?’ Driving recommendations after such procedures are varied. The current evidence available is based on a heterogenous data set with varying degrees of sample size and markedly differing study designs.
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This instructional review article provides a scoping overview of studies looking at return to driving after upper or lower extremity surgery in both trauma and elective settings and, where possible, to provide clinical recommendations for return to driving.
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Medline, EMBASE, SCOPUS, and Web of Science databases were searched according to a defined search protocol to elicit eligible studies. Articles were included if they reviewed adult drivers who underwent upper or lower extremity orthopaedic procedures, were written in English, and offered recommendations about driving.
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A total of 68 articles were included in the analysis, with 36 assessing the lower extremity and 37 reviewing the upper extremity. The evidence available from the studies reviewed was of poor methodological quality. There was a lack of adequately powered, high quality, randomised controlled trials (RCTs) with large sample sizes to assess safe return to driving for differing subset of injuries.
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Many articles provide generic guidelines on return to driving when patients feel safe to perform an emergency stop procedure with adequate steering wheel control.
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In future, RCTs should be performed to develop definitive return to driving protocols in patients undergoing upper and lower extremity procedures.
Introduction
There are a variety of upper and lower extremity procedures performed in the trauma and elective settings. For those undergoing these procedures, a commonly posed question is when they would be safe to return to driving. Patients perceive this to be an important marker of return to usual activities of daily living and subsequent stratification for return to work and planning of personal circumstances accordingly. This can pose significant legal and health ramifications if the advice provided is inaccurate (1). Despite this, driving insurance companies and national driving authorities fail to provide clear guidelines on when safe return to driving can be achieved (2, 3).
Medicolegally, surgeons cannot ‘clear’ patients as being safe to drive. While surgeons can advise patients if driving a vehicle is unsafe, they cannot make the legal determination that the patients’ driving is actionable under the law (4). The onus is on patients to drive safely, protecting themselves and others on the road. This contrasts other areas of medicine where clear legislation exists, for example post seizures or myocardial infarction (5).
Many measures can be used to assess safe return to driving, the most frequently reported being total brake reaction time (TBRT) (6). TBRT is the time interval between the activation of a signal to the beginning of force application to the brake pedal, commonly reported in milliseconds (ms). Numerous studies have assessed TBRT post hip/knee arthroplasty as well as lower extremity trauma (7, 8, 9). TBRT can be further broken down into reaction time (RT) which is the time to react to danger and release the accelerator pedal and the movement time (MT) which is the time to move from accelerator to apply pressure to the brake pedal (10).
The use of TBRT as a surrogate marker for safe return to driving poses a number of issues. First, these studies do not use a universal driving simulator therefore each definition of TBRT may vary. Furthermore, studies often assess TBRT replicating a ‘hazard’ on the simulator. Researchers have reported on the phenomenon of ‘hazard anticipation’ where study participants are in a state of hypervigilance whilst waiting for hazards to appear which can yield results different to real time driving (11). This may explain why globally there is no clear consensus on safe emergency braking time: 670 ms for the Transport Research Laboratory (UK), 750 ms for the Royal Automobile Club of Victoria (Australia), and 1500 ms for the German Transport Society (TÜV) (12, 13).
These parameters may not be as relevant for upper extremity trauma, as TBRT depends predominantly on the movement of the leg in response to a hazard (14). Return to driving following hip and knee arthroplasty procedures is well reported in the literature (8, 9, 15, 16). In contrast, there is a paucity in literature assessing the return to driving following non-arthroplasty lower extremity procedures and upper extremity surgical procedures in the trauma and elective setting.
Driving is a complex task involving visual, motor, and cognitive skills acting in tandem (17). This may be affected by the use of opioid medications in the post-operative recovery period as demonstrated by an increase in driving fatalities in patients using prescription opioids in a large case–control study performed in the United States (18). To our knowledge there have been no studies in the orthopaedic community attempting to assess all these parameters. In contrast, neurosurgical teams have attempted to determine fitness to drive post traumatic injury encompassing all the aforementioned factors (19).
This paper aims to provide a scoping overview of studies looking at the return to driving after any upper or lower extremity surgery (excluding hip/knee arthroplasty), in both trauma and elective settings and to provide clinical recommendations for return to driving where possible.
Methods
A Boolean search protocol for review was created to search multiple databases: Medline, EMBASE, SCOPUS and Web of Science (20). The search strategies are shown in Appendix 1 (see section on supplementary materials given at the end of this article).
Inclusion criteria were established following the PICO (Population Intervention Comparison Outcomes) approach (21):
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Population: adults (over 18) undergoing upper or lower extremity surgical procedures who were able to drive (in possession of a driver’s licence).
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Intervention: upper or lower extremity elective or trauma procedure.
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Comparator: pre-operative baseline or control cohort
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Outcomes: return to driving recommendations. If BRT was included for relevant studies this was also collated.
Only articles published in English were included. Results from the search strategy were reviewed by two independent investigators. All studies published between 1 April 1970 and 1 April 2023 were considered for eligibility. Titles and abstracts were screened for relevance prior to full inspection. Any discrepancies between the investigators (MK/VG) were referred to a third investigator for arbitration (BvD). Full texts of articles meeting the inclusion criteria were obtained. All studies related to limb amputation in the upper/lower extremity were removed as this study aimed to review procedures where the patient was expected to have an improvement in functionality or return to full functionality, excluding this subgroup of patients.
Data were extracted using a standardised data collection form, which was first tested using sample articles and optimised prior to final data collection. The following data were recorded: (a) demographics: population studied, age, gender, surgery, side, and indication; (b) study characteristics: study design, number of subjects, randomisation, blinding; (c) simulation design: type, automatic/manual, and measurements recorded; (d) outcomes: recommended return to driving (weeks/days), TBRT, RT, MT, and BF.
Results
In total, 68 studies were identified meeting our study aims and inclusion criteria for both upper and lower extremity procedures (Fig. 1, Table 1, Supplementary Tables 1 and 2) (1, 14, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86). There was a wide variation in procedures performed and sample size, the study methodology, and measurements obtained. A total of 23 papers utilised BRT as their primary outcome measure where sample sizes varied from 10 to 173 patients. A total of 16 studies utilised a driving assessment with parameters other than BRT as outcome measures: with eight simulators, six driving tests, and two driving courses. Sample sizes ranged from 1 to 30. A total of 11 articles utilised a questionnaire as their primary mode of assessment of safe return to driving, with sample sizes from 16 to 196.
PRISMA diagram showing search strategy.
Citation: EFORT Open Reviews 8, 12; 10.1530/EOR-23-0117
List of studies included in this review reporting on lower extremity procedures and upper extremity procedures (foot and ankle). Details of each of these studies are presented in Supplementary Tables 1 and 2.
| Procedures | References |
|---|---|
| Lower extremity procedures | |
| Elective procedures | Burnham et al. (22), Jeske et al. (23), Mcdonald et al. (24), McDonald et al. (25), Jennings et al. (26), Beck et al. (27), Reb et al. (28), Liebensteiner et al. (29), Sittapairoj et al. (30), Jeng et al. (31), Schwienbacher et al. (32), McDonald et al. (33), Dammerer et al. (34), Holt et al. (35), Talusan et al. (36) |
| Immobilisation devices | Hofmann et al. (37), Dammerer et al. (38), Orr et al. (39), Schick et al. (40), Von Arx et al. (42), Rees etal. (43), Nunn et al. (41), Tremblay et al. (45), Waton et al. (44), Murray et al. (46), Sansosti et al. (47) |
| Trauma procedures | Chen etal. (4), McKissack et al. (48), Kennedy et al. (49), Haverkamp et al. (50), Egol et al. (51), Kane et al. (52), Yousri et al. (53), Ho et al. (54), Shahid et al. (55), Nunez et al. (56) |
| Upper extremity procedures | |
| Elective procedures | DeBernardis et al. (57), Hasan et al. (61), Muh et al. (59), Littlewood etal. (58), Lawrence et al. (60), Hasan et al. (62), Badger et al. (63), McClelland et al. (64), Newington et al. (65), Hammert et al. (66), Acharya et al. (67), Murphy et al. (68), Frazier et al. (69) |
| Immobilisation devices, ROM studies, guidelines | Giddins et al. (1), Rawal et al. (14), Stock et al. (70), Latz et al. (71), Pandis et al. (72), Hasan et al. (73), Chong et al. (74), Jones et al. (75), Stevenson et al. (76), Blair et al. (77), Kalamaras et al. (78), Gregory et al. (79), Hobman et al. (80) |
| Trauma procedures | Chen et al. (4), Von Arx et al. (42), Rees et al. (43), Kennedy et al. (49), Nunez et al. (56), Musselwhite et al. (81), Tan et al. (82), Poiset et al. (83), Stinton et al. (84), Jones et al. (85), Edwards et al. (86) |
ROM, range of motion.
Due to the heterogeneity of studies, low samples per subset of injury, and variable study design, meta-analyses were not viable and so were not performed. Instead, simple statistical calculations are available per data subset. We stratified the data available by procedure for upper and lower extremity intervention, and sub-grouped further by elective or trauma procedure, or immobilisation device. Table 2 outlines the synthesised recommendations for safe return to driving.
Synthesis of recommendations from the literature.
| Procedure | Return to driving |
|---|---|
| Lower limb | |
| TAA | 6 weeks |
| Soft tissue foot and ankle injury | 2-7 weeks |
| Hallux valgus correction | 6-8 weeks |
| Ankle arthrodesis | 6-12 months |
| Treated ankle fractures | 2-6.6 weeks |
| Cast immobilisation | Conflicting evidence – avoid driving if right side casted versus no recommendations given |
| Upper limb | |
| Cast immobilisation of left arm | Avoid driving while casted |
| Splints, slings | Avoid driving while splinted or in a sling |
| Operatively managed wrist fractures | 2.14-7 weeks |
| Cast immobilised wrist fractures | Avoid driving while casted |
| Shoulder arthroplasty | 6 weeks or longer |
Foot and ankle
There were 36 lower extremity studies included in the review (4, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56) A total of 1021 patients were assessed, with 1006 having right-sided procedures and 15 left-sided procedures. The summary of these data is presented in Supplementary Table 1.
Elective procedures
Elective foot and ankle procedure
Burnham et al. surveyed patients on return to driving after miscellaneous elective foot and ankle procedures with some form of immobilisation post surgery (22). The average return to driving was between 6 and 9 weeks post procedure.
Ankle ligament injuries
One article by Jeske et al. advised upon return to driving post ankle ligament injury for grade 2 and 3 sprains (23). BRT was utilised as the primary outcome measure RT, FTT, and BTT were also assessed. The authors advised a safe return to driving at 4 weeks.
Total ankle arthroplasty
Two papers evaluated return to driving following total ankle arthroplasty: both utilising BRT as the primary outcome measure using specified brake simulators.(24, 25). Controls were used to establish the passing BRT. The mean return to driving across both studies was 6 weeks. McDonald et al. further advised that if pain and stiffness persisted to extend this to 9 weeks (25).
Achilles tendon repair
Three articles assessed return to driving following Achilles tendon rupture repair; two utilising BRT, with a passing time of <0.850 s; and the third utilising a survey (26, 27, 28). The mean return to driving across all articles was between 6–7 weeks.
Ankle arthroscopy
Two articles assessed BRT as the primary outcome measure for return to driving in patients who underwent ankle arthroscopy (29, 30). Both papers advised driving return at 2 weeks.
Ankle arthrodesis
Two papers utilised a driving simulator to assess BRT, TBRT, RT, MT, BF at 6–12 months post ankle arthrodesis (31, 32). Jeng et al. found that patients were able to brake safely at 1 year, with a mean BRT for controls as 0.33 ± 0.06 s and ankle fusion as 0.42 ± 0.14 s (P = 0.03) (31). They concluded this was safe as both groups were within safe BRT defined by the U.S. Federal Highway Administration (0.64–0.70 s). Schwienbacher et al. found that tibiotalar ankle arthrodesis’ (TTJA) were unsafe at 6 months (P = 0.026) with a slower overall TBRT whereas other foot ankle arthrodesis’ (OFJA) were not significantly different from controls (P = 1.0) (32). The mean TBRT in TTJA was 729.7 ms (s.d. 332.9), OFJA 596.2 ms (s.d. 141.4), and controls 475.7 ms (s.d. 63.5).
First metatarsal osteotomy
Three articles assessed BRT, TBRT, RT, BT following first metatarsal osteotomy with driving simulators (33, 34, 35). Patients achieved a passing BRT at 6–8 weeks post surgery. McDonald et al. advised a return at 8 weeks; however, if the VAS, driver readiness survey, and first metatarsal range of motion was satisfactory, patients may be able to return to driving at 6 weeks (33).
Foot and ankle injections
Talusan et al. performed a comparative study assessing BRT using a driving simulator following local anaesthetic and/or steroid injections for pain (36). The authors found that radiologically guided injections will not impair the patient’s ability to perform an emergency stop immediately after administration.
Lower extremity immobilisation
Ankle braces
Two articles assessed TBRT, RT, FTT, and BF in healthy participants wearing branded and non-branded ankle braces (37, 38). Hofmann et al. advised against driving while wearing an ankle brace; however, Dammerer et al. advised abstention from driving while wearing a boot type ankle brace (37, 38). Hofmann et al. found a mean BRT of 410 ms (s.d. 39) in controls, 429 ms (s.d. 45) for the Kallassy brace, 450 ms (s.d.307) in the CaligaLoc brace, 440 ms (s.d.43) for the Air-Stirrup brace, and 441ms (s.d. 49) for the ASO brace (P <0.001 between controls and all types of brace) (37). They advised that as all mean BRT measures were below 600 ms, the slight impairment of the brace was not enough to advise cessation of driving. Dammerer et al. found a mean BRT of 558.2 ms (s.d.123.1) for controls, 637.2 ms (s.d. 117.7) for ‘Maxtrax unrestricted’, 653.8 ms (s.d. 120.4) for ‘MaxTrax 1515’, 639 ms (s.d. 119) for ‘MaxTrax 1545’, and 577.3 ms (s.d. 119.8) for Procare surround (38). All braces apart from Procare surround had a significantly slower BRT than controls (P < 0.001).
Two articles assessed BRT, RT, BT, and TBT while patients wore a controlled ankle motion (CAM) brace, and both advised patients should not drive while wearing this device (39, 40). Orr et al. demonstrated a mean TBRT of 571 ms (s.d. 101) for controls and 675 (s.d. 136) for the CAM brace group, with a significantly slower TBRT in the CAM group (P < 0.05) (39). Schick et al. demonstrated a mean BRT of 713 ms for CAM boot usage and 593.86 ms while using the left foot to brake while wearing the CAM boot (40). CAM groups were significantly slower than the control of 1250 ms (P = 0.0001–0.0011).
Below-knee cast
Four studies assessed return to driving in patients immobilised in a below-knee cast (41, 42, 43, 44). One article utilised a standard driving manoeuvrability, advising that patients are not safe to drive unless they are wearing a left leg cast with automatic transmission (41).
Two surveyed orthopaedic surgeons, insurance companies, and police about return to driving guidance (42, 43). Over 90% of respondents in Von Arx et al. study advised patients were not safe to drive (42). Rees et al. looked at weight-bearing status (43). Hundred percent of participants were advised not to drive while PWB in the cast, 94% advised patients who are FWB in the cast not to drive, 39% advised that patients FWB with incomplete union and no cast were not to drive, and 61% advised patients who were FWB with complete union and no cast to drive.
Two studies utilised driving simulators assessing return to driving while in below-knee casts (39, 44). Waton et al. used a driving simulator on healthy participants in lower limb immobilisation to assess thinking time, MT, BTT, TBRT (44). Below-knee plaster resulted in a significantly longer TBRT than unrestricted trials (P < 0.001). They advised that legislation should be reconsidered on driving in a cast as currently there is no specific law against doing so, with the onus being on patient’s decision-making capabilities. Orr et al. assessed TBT, RT, and BT in participants wearing a below-knee cast, utilising a driving simulator (39). They advised to avoid driving while wearing a right-sided short leg cast. The mean BRT in the below-knee cast group (640 ± 144 ms) was significantly longer than the control (571 ± 101 ms) (P < 0.05).
Above-knee cast
Waton et al. also assessed driving in an above-knee cast, with the same advice as above (44). They found that TBRT in an above-knee plaster was significantly longer than unrestricted trials and all knee brace trials (P = 0.001 at 0 degrees and P < 0.001 for the rest).
Walking cast
Two studies looked at healthy volunteers wearing a walking cast to assess safety in driving (45, 46). Tremblay et al. assessed BRT, BF, and TBT using a driving simulator, giving no specific recommendation (45). Mean BRT was significantly longer in the walking cast group (0.625 s (s.d.0.057), 0.571 s (s.d. 0.051)) than the control group (0.602 s (s.d. 0.046), 0.548 s (s.d. 0.043)) with and without distractors respectively (45). Murray et al. looked at MT, BRT, and TBT in participants driving around a closed-circuit track and recommended against driving while immobilised (46). Median BRT in the walking cast group (0.474 s and 0.459 s) was significantly longer than that in controls (0.429 s and 0.399 s), with and without distractors, respectively (P < 0.017) (46).
Walking boot
Three studies looked at BRT, MT, TBT, and BF in participants wearing a walking boot and driving around a closed-circuit track, with the aid of driving simulators (45, 46, 47). No specific recommendations were given, aside from the advice from Murray et al. mentioned earlier (46). Tremblay et al. found a significantly longer mean BRT in the walking boot group (0.642 s (s.d. 0.053)) than both walking cast and control groups during the task with a distractor (45). Murray et al. found a significantly longer median BRT in the walking boot cohort (0.444 s) compared to controls in the task without a distractor (P < 0.017) (46). Sansosti et al. found the walking boot group to have a significantly slower mean BRT (0.736 s) than the control group (0.575 s) and the surgical shoe group (0.611 s) (P < 0.001) (47).
Surgical shoes
Two articles assessed driving while wearing a stiff surgical shoe utilising BRT as the primary outcome measure (40, 47). They advised slower braking times were found in this device, no specific recommendations were given by Sansosti et al.; however, Schick et al. advised that patients in any form of immobilisation device should not drive as they may fall outside of nationally recognised safe parameters (40, 47).
Trauma procedures
Right foot/ankle procedure
One article looked at unspecified foot and ankle procedures performed on the right side of the patient, utilising a survey and driving simulator as the outcomes (48). The authors found right-footed driving was associated with greater average Motor vehicle (MVC) collisions and instances of speeding, while left-footed driving was associated with prolonged throttle release and brake time in response to vehicular hazards. The article did not give any recommendations on return to driving.
Ankle fractures/open reduction internal fixation
Seven studies looked at the conservative and surgical management of ankle fractures to assess return to driving (49, 50, 51, 52, 53, 54).
Three of the articles surveyed surgeons, insurers, and patients on advice and return to driving (4, 49, 50). Kennedy et al. gave no specific recommendations on return to driving but found 18 out of 118 patients admitting to driving while immobilised (49). Insurance companies advised patients could drive if given medical clearance. Haverkamp et al. found that surgeons advised a return to driving of 6–9.7 weeks for operatively managed tibial fractures depending on weight-bearing status; 6 weeks for operatively treated ankle fractures; and 3.4 weeks for conservatively managed ankle fractures, out of cast (50). Chen et al. advised upon return to driving after right and left-sided ankle and pilon fractures after surveying advice given by orthopaedic surgeons to patients (4). For right-sided ankle fractures 7–7.8 weeks, left-sided ankle fractures 2.7–2.8 weeks, right-sided pilon fractures 11.3 weeks, and left-sided pilon fractures 4.8 weeks.
Three papers assess driving safety using driving simulators, with the final study utilising an off-road driving assessments (51, 52, 53, 54). The parameters assessed were TBT, BRT, BTT, DRT, RT, and BF across all studies. These studies advised a mean return to driving of 6.6 weeks (4-9) post fixation. One study also looked at conservatively managed fractures and advised a return to driving of 2 weeks post management (52).
Fifth metatarsal avulsion fracture
Shahid et al. looked at return to driving after avulsion fractures of the fifth metatarsal (55). The main parameter assessed was the Visual Analogue Scale – Foot and Ankle (VAS-FA). They assessed patients in a walking boot versus a short leg cast, with the former being advised a return to driving in 6 weeks and the latter 12 weeks. Participants were assessed at 3, 6, 9, and 12 weeks post injury with a preinjury score of 100. Patients wearing walking boots had VAS-FA scores of 93 at 6 weeks and those in short leg casts had VAS-FA scores of 93 at 12 weeks post injury.
Orthopaedic injuries
Nunez et al. assessed driving return after various orthopaedic injuries by surveying insurance companies, the BMA, the Royal College of Surgeons, and the BOA (56). The prevailing advice was that the patient is responsible for informing the DVLA if a permanent deformity persisted, and that insurers would refer to doctors in the first instance and the DVLA in the second.
Upper limb
There were 37 studies included for upper extremity procedures and guidelines (1, 4, 14, 42, 43, 49, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86). Some studies reported dominant versus non-dominant limb, while others reported handedness. Table 2 summarises this data.
Elective procedures
Shoulder arthroplasty
Five studies assessed driving return post shoulder arthroplasty; with four specifically assessing reverse shoulder arthroplasty (rTSA), three anatomic shoulder arthroplasty (aTSA), and one not specifying type (57, 58, 59, 60, 61).
DeBernardis et al. utilised questionnaires to assess driving return, finding aTSA returned to driving earlier than rTSA, with all patients eventually returning to driving after 6 weeks (57). Hasan et al. utilised a driving simulator assessing driving return looking at performance around a simulated course, advising patients of a 6–12 weeks gradual return to driving (61). Littlewood et al. assessed publicly available patient information sheets on driving returning and found a mean time of 7 weeks for aTSA and rTSA (58).
Two studies advised on time of return to driving after rTSA, with a range of 6–12 weeks (57, 61). The time increased depending on pain, advancing age, and reduced driving experience. A third paper assessed functional activity after rTSA with a patient survey, using return to driving as a parameter, and found that 60% of patients after rTSA drive (60). Muh et al. utilised a questionnaire to assess return to driving in patients with TSA (type not specified) and found that patients returned to driving after 6 months (59).
Arthroscopy
RCR
Two articles assessed rotator cuff repair: one using a driving simulator and the other a road driving assessment (62, 63). The parameters assessed were driving performance as specified by such measures as number of collisions, centre-line crossings, and off-road excursions. The mean advised return to driving was 7 weeks (2–12) across studies.
Subacromial decompression
McClelland et al. assessed arthroscopic subacromial decompression +/− ACJ excision using functional measures (64). They found patients returned to driving an average of 28.9 days post-operatively.
Hand surgery
Carpal tunnel release
Five studies assessed driving return post carpal tunnel release; all studies employed a questionnaire (65, 66, 67, 68, 69). Three assessed patients’ responses and two assessed physician’s advice. Patients returned to driving a mean of 7.75 days (0–14) across four studies for leisure and 21 days for work. Murphy et al. advised that guidelines are required, and overarching responsibility lies with the patient.
Upper extremity immobilisation
Guidelines
Two studies reported guidelines on driving returning after upper extremity injury (1, 70). Stock et al. reported that patients should have adequate ROM to lift their foot off the accelerator onto the brake or turn the steering wheel (70). Giddins et al. surveyed insurers about returning to driving and found that doctors should take care when giving patient advice, the insurer would not remove cover if the patient was acting on the clinician’s instructions but would remove coverage if patients were acting of their own volition (1).
Range of motion
Three studies looked at ROM required to drive vehicles (14, 71, 72). Rawal et al. found shoulder flexion, internal rotation, forearm pronation and supination were the key movements in safe driving. Both Latz et al. and Rawal et al. advised against driving in arm casts (14, 71). Pandis et al. found driving conditions to abnormally load supraspinatus, deltoid, and infraspinatus (72).
Immobilisation devices
Sling
Hasan et al. utilised simulated driving circuits to assess driving while immobilised in a sling with the elbow in 90 degrees of flexion (73). They advised against driving with the dominant arm in a sling in an automatic car as the ability to perform evasive manoeuvres is impaired.
Cast
Six articles looked at varying levels of plaster cast immobilisation: below elbow, above elbow, short arm, and thumb spica (74, 75, 76, 77, 78, 79). Differing advice and recommendations were given. Chong et al. designed a randomised higher crossover trial assessing driving ability around a driving course and found that all forms of immobilisation trended towards a worse driving performance, with left thumb spicas being the least safe (74). Jones et al. corroborated these findings during driving courses, advising patients to not drive in a thumb spica cast (75). Stevenson et al. designed a small randomised trial assessing driving ability via a UK driving test to assess safety while driving immobilised (76). They advised that it is safe to drive in a Bennett’s cast and left and right below-elbow neutral casts but to avoid driving in a left above-elbow cast. Blair et al. advised that right-sided Colles’ casts are unlikely to affect driving control in the majority of cases and that if hand brake clearance is adequate it is safe to drive in a left-sided Colles’ cast (77). In contradiction, Kalamaras et al. utilised a driving assessment to assess safety while driving immobilised and advised that all forms of cast are unsafe to drive (78). Finally, Gregory et al. advised on a deterioration of driving ability while the upper extremity was immobilised and advised patients to exercise driving caution (79).
Splint
Three articles assessed safety in driving while wearing a short arm and thermoplastic hand splints (74, 75, 80). Two utilised a driving course as detailed above with the third employing a survey. All advised exercising caution or avoiding driving while splinted, with the onus being on patients.
Trauma procedures
Wrist fracture
Conservative management
Musselwhite et al. looked at below-elbow immobilisation after sustaining distal radius fracture utilising a questionnaire to assess return to driving (81). They found that 18% of patients drove while immobilised. Von Arx et al. sent a survey to orthopaedic surgeons on returning to driving while immobilised and found 50% of surgeons would advise patients in a left Colles’ cast to drive and 42% would advise a patient in a left scaphoid cast to drive (42). Kennedy et al. surveyed patients with wrist fractures and found a minority of patients returned to driving without clinician or insurer advice beforehand (49).
Volar locking plate
Four studies assessed fixation of distal radius fractures using a volar locking plate (82, 83, 84, 85). Three studies assessed driving performance as the main outcome measure for safe return to driving. The mean advised safe return to driving was 4.3 weeks (2.14–7) (82, 83, 84). Jones et al. advised that recommendations should be made on a case-by-case basis (85).
Upper extremity injuries
Three articles assessed return to driving after miscellaneous upper limb injuries (4, 43, 86). Edwards et al. surveyed patients in fracture clinic who sustained upper limb injuries about perceived safety in return to driving and found that patients should not drive while immobilised (86). Chen et al. surveyed orthopaedic surgeons and advised patients to retest prior to starting driving again (4). Surgeons advise their patients to return to driving at 5 weeks for a right-sided wrist fracture, 4.4 weeks for a left-sided wrist fracture, 5.3 weeks for a right-sided elbow injury, 4.8 weeks for a left elbow injury, 5.9 weeks for a right-sided shoulder injury, and 5.3 weeks for a left-sided shoulder injury. Finally, Rees et al. also surveyed orthopaedic surgeons regarding return to driving after certain conditions were met regarding immobilisation, union, and grip status after hand and wrist injury (43). Differing levels of advice were given for these injuries, detailed in Supplementary Table 2.
Discussion
This review highlights key weaknesses in the evidence and current recommendations regarding return to driving after lower or upper extremity injury or elective orthopaedic procedure. The evidence available is heterogeneous with varying degrees of sample size and markedly differing study designs. This has contributed to conflicting recommendations and mostly the onus is on the patient rather than an objective, robust, and validated method to assess safety in return to driving.
Multiple attempts have been made to define protocols for return to driving combining driving authorities, surgeons, and insurers using observational and randomised studies, a consensus has not been reached thus far. It remains unclear where the overarching responsibility lies. The aim of this review was to provide a comprehensive summary of the literature on safe return to driving in upper and lower extremity intervention, in both trauma and elective settings.
Lower extremity procedures allow for the use of measures to quantitatively assess driving performance. Several studies have used TBRT as a surrogate marker of safe return to driving; however, this value is not standardised, with multiple studies utilising a different cut-off time. Furthermore, a component part of TBRT, RT, is increased by concurrent opioid usage (18, 87). Patients who have sustained traumatic injuries are more likely to be discharged on these medications and this is something that should be considered alongside the driving assessment. While TBRT may not be a direct surrogate marker of safe return to driving following upper extremity surgery, concomitant braking alongside sudden steering evasive manoeuvres may be required to avoid danger. Therefore, this marker may have a role in the assessment of return to driving following upper limb injury. Overall, the evidence for the use of TBRT as the primary assessor for evaluation of fitness to drive remains poor. This coupled with differing cut-off time for TBRT worldwide suggests alternative measurements should be formulated or worldwide standardised protocol should be implemented.
From the review of the literature, we can infer the following time frames as safe return to driving: TAA, 6 weeks; soft tissue injuries, 2–7 weeks; hallux valgus correction, 6–8 weeks; ankle arthrodesis, 6–12 months; treated ankle fractures 2–6.6 weeks. However, these timings are based off average return to driving across studies utilising various parameters, including TBRT. Not only are there varying ways to measure TBRT itself, but the different variables also assessed are not generalisable to each other. As already noted, TBRT is not a reliable metric for return to driving given the myriad issues associated with its use. Therefore, it is difficult to determine whether these time frames should be recommended to patients. At present, there is conflicting evidence about driving safety with varying levels of lower limb immobilisation. It is interesting to note that most of the patients recruited in studies had injuries/surgeries to their right lower limb – clearly the right leg performs the safety (braking) as well as locomotion (accelerating) aspects of driving and therefore plays a more crucial role than the left leg; however, none of the recommendations highlight the difference in time frames to return to driving for right versus left lower limb. Similarly, there are likely to be differences between the use of a manual versus automated motor vehicle. It is difficult to draw conclusions about whether driving with an orthosis and restricted weight bearing is possible or safe.
Studies assessing the return to driving protocols for upper extremity injuries are more qualitative in nature. It is noted that in many of these studies, and the current guidelines available, the responsibility falls on the patient to ascertain whether they are safe to drive. In relation to cast immobilisation, there is contradictory material in the evidence base. The majority of studies advise against driving in a manual vehicle with cast immobilisation of the left arm, given the impact this has on the range of motion of the upper limb. The literature also suggests driving while splinted or restrained in a sling is dangerous. Operatively managed wrist fractures are safe to return to driving between 2.14 and 7 weeks while, as previously mentioned, non-operatively managed immobilised wrist fractures should avoid driving until cast removal. A minimum of 6 weeks abstention from driving should be the approach taken in shoulder arthroplasty. For arthroscopic procedures involving the rotator cuff, patients should avoid driving for at least 7 weeks.
The literature available have not assessed confounding variables effect on driving performance and safety. Driving is a complex task not solely relying on functional status and ability to carry out an emergency brake manoeuvre but also requiring cognitive and visuospatial skills (17). For example, opioids can affect cognitive function and proprioception, with many patients discharged on these medications (18). Legislation was passed in the UK in 2015 which classified certain medications, including opioids, and found individuals guilty of breaking the law if their driving was impaired (88). This was overlooked in most studies utilising driving simulators, with 13 excluding opiate users and the rest not mentioning their use. Furthermore, pain is an individualised experience, with patients’ experiences and reactions being vastly different. This may alter individuals’ perceived safety in driving and affect how they respond to potentially hazardous situations. Functionally, drivers not only need to perform emergency braking safely and promptly but also need the ability to get out of the vehicle in a timely fashion if necessitated (e.g. escaping from a vehicle on fire). Another confounder results from the differing driving simulators and assessments used, making it challenging to synthesise and statistically analyse the heterogenous data. While we have collated safe return to driving based on the quantitative measures, the importance of surgeons’ experience through the survey data cannot be overlooked. There is a possibility that surgeons are being cautious with their advice, given the lack of clarity in who has the overarching responsibility in decision making.
One of the key strengths of this review includes the large number of studies analysed and synthesised to highlight recommendations from the literature on safe return to driving. This review includes the largest number of articles assessing return to driving after lower or upper extremity procedures in the current evidence base, excluding hip and knee arthroplasty. As such, a broad spectrum of advice was considered and mean return to driving was inferred across the literature.
Despite this, there were several limitations resulting from the poor methodological quality of the studies assessed. There was a lack of adequately powered, high quality, randomised controlled trials (RCTs) with large sample sizes to assess safe return to driving for differing subset of injuries. The evidence that is currently available is heterogeneous, with low sample sizes, and contrasting methodology. Parameters assessed may not be reliable for determining safe return to driving, specifically TBRT with varying definitions for it in the literature. This means that it is difficult to draw definitive conclusions about safe return to driving for these procedures and injuries.
Many of these studies are resource heavy and expensive. Ultimately, the establishment of simple validated clinical examinations that can be conducted to determine ability to drive should be prioritised in future research. With approximately a quarter of the world’s population driving on a regular basis and the socio-economic role it plays, research in the field needs to be prioritised.
Conclusions
This review highlights the high level of heterogeneity in the evidence base, with differing sample sizes of patients, and divergent study designs. Future research should aim to perform adequately powered, high-quality, randomised controlled trials with large sample sizes to give definitive guidance on safe return to driving for upper and lower extremity procedures.
Supplementary materials
This is linked to the online version of the paper at https://doi.org/10.1530/EOR-23-0117.
ICMJE Conflict of Interest Statement
HGP is a National Institute for Health Research (NIHR) senior investigator. VPG is an NIHR academic clinical fellow. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The authors alone are responsible for the content and writing of the paper.
Funding Statement
This paper presents independent research funded and supported by the NIHR Leeds Biomedical Research Centre (BRC).
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