It may not be your decision
For many people, driving a car is a necessity of everyday life. In areas without public transportation (and even in cities with good public transportation), people drive everywhere. So when something happens—whether it’s a flat tire or a fractured tibia—drivers want it fixed quickly so they can get behind the wheel again.
As Geoffrey S. Marecek, MD, and Michael F. Schafer, MD, write in the November 2013 issue of the Journal of the AAOS, “The inability to drive presents a significant obstacle to patients. … The decision to resume driving after orthopaedic surgery is difficult for both patient and surgeon.”
Recently, AAOS Now spoke with Dr. Marecek about driving after orthopaedic surgery.
AAOS Now: What orthopaedic procedures or surgical sites are most likely to impair a patient’s ability to drive?
Dr. Marecek: 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. Steering and shifting require use of the shoulder, elbow, and wrist. Sitting upright and watching the road require good spine function. In short, driving requires total body coordination.
Based on the available studies, patients who sustain major lower extremity fractures should delay driving the longest—up to 18 weeks in some cases—but nearly every orthopaedic procedure will have some impact on a patient’s ability to safely drive.
AAOS Now: Are there guidelines that orthopaedic surgeons can reference when patients ask about driving after a specific surgery or procedure?
Dr. Marecek: A number of studies have used 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 (Table 1). Although most studies have focused on lower extremity or spine procedures, some studies on the impact of upper extremity procedures are in the works.
The decision to resume driving should be individualized; patients and surgeons need to talk about how the recovery process is proceeding and what impact the procedure may have on driving skills.
However, these discussions should take place early on. For elective surgeries, driving discussions should take place when the decision to schedule the surgery is made. This will enable the patient to make accommodations well in advance. If it’s an urgent situation, such as a fracture, the discussion about driving should take place before the patient leaves the hospital or at the first postoperative visit.
AAOS Now: What challenges do orthopaedic patients face in returning to driving?
Dr. Marecek: 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. Due to the coordinated movements involved in driving, surgery around the hip, knee, ankle, and foot can impair braking function. Any splint, cast, knee immobilizer, or walking boot on the lower extremity impairs braking function, and patients should not drive while wearing any of them.
After a total hip replacement, the ability to sit in a car safely is a concern. If the car seat is low and depending on the surgical approach used, patients may be at risk for hip dislocation.
Taking evasive maneuvers to avoid an accident also causes delays in braking time. Immobilization of any part of the upper extremity for any reason can affect the ability to shift gears and turn the steering wheel. Even highly trained drivers do not drive well while wearing casts. As for removable wrist splints, there are conflicting reports, so patients should discuss their particular circumstances with the surgeon.
AAOS Now: Many orthopaedic patients may be on pain medications. What impact does that have on driving?
Dr. Marecek: Although some evidence suggests 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.”
AAOS Now: Did anything surprise you in your research?
Dr. Marecek: One of the most striking findings was that insurance companies and law enforcement agencies generally 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 a patient is in an accident or receives a ticket.
Despite this, lawsuits have been filed against the physician if a patient under care has an accident while driving. (See “How Far Does Your Obligation Go?” AAOS Now December 2008.) Although these cases may not qualify as medical malpractice, they may be considered negligence. Orthopaedic surgeons should discuss the issue of returning to driving with patients and document that discussion in the medical record.
I advise my patients to think about the neighbor’s child—or their own grandchildren—running into the street. If they could avoid an accident, they may be ready to begin driving again.