Custom 3D printed casts offer a telemedicine solution for some orthopedic injuries

Umpire Pat Hoberg was behind the plate at Citizens Bank Park last July when he was struck by a broken bat. In just the second inning, the Phillies trainer taped Hoberg’s split and bruising hand, allowing him to finish the game. The next day Michael Rivlin, a hand specialist at Rothman Orthopaedics, determined Hoberg’s knuckle was fractured but he didn’t need surgery.

“Dr. Rivlin took X-rays and put me in a splint,” recalled Hoberg, who lives in Phoenix and travels between Major League Baseball cities from March through October. His injury would need monitoring, but during the pandemic, Hoberg was mostly sequestered in his hotel or the stadium due to COVID-19 safety guidelines. So getting back to Philadelphia for regular follow-up visits would be nearly impossible.

Rivlin had an idea. Rothman had been tinkering with a new technology that was still in the trial stages. Through a telemedicine visit with a doctor, a patient could take pictures of their injured body part, upload them to an app or website, and have a custom splint or cast made and mailed to their home.

The patented software and 3D cast technology, registered with the FDA, had been developed by Dimension Orthotics, a San Diego-based company, and Rothman was using it in limited patient situations through a clinical trial.

“It essentially digitizes your hand, and using artificial intelligence, we can recreate your hand in 3D and print a 3D cast or brace,” he said. “Or, we can recommend an off-the-shelf brace that fits you perfectly, without ever meeting you or touching you.”

For Hoberg, that was the ideal solution. While on the road, he took pictures of his hand with his cell phone and sent them to Rivlin. The doctor created a customized 3D splint which he shipped to whatever city Hoberg was working in at the time.

“I was able to treat him remotely for the rest of his recovery, which took about 10 weeks or so,” Rivlin said. “As he was progressing in the treatment, I was able to get him more and more functional splints.”

The pandemic became the perfect time to offer the technology to more patients who were being seen through telemedicine. At the height of the pandemic, total doctor visits per week in the U.S. done through telemedicine increased from just 1% pre-pandemic to 30%, up to about 400,000, according to Joe Kvedar, chairman of the board of the American Telemedicine Association.

Before utilizing this new technology, a doctor would have to guesstimate the appropriate size brace that a patient could get online or from a pharmacy. Some more complex splints, like what Hoberg needed, can only be made by orthotic/prosthetic providers and are not found in pharmacies.

“An incorrectly fit brace can actually cause more damage than good, so we tried to think outside the box,” Rivlin said.

The most common uses have been for wrist and hand injuries, though the casts and braces also have been used on the leg and back. Made of lightweight resin, they have a honeycomb design that allows the skin to breathe through large holes, a benefit traditional casts cannot provide.

Like with all telemedicine, the doctor must make an initial diagnosis to determine if the patient needs to be seen in person or have a diagnostic test such as an X-ray. In some cases, the patient will be sent to an urgent care facility to rule out a break or other problem.

“There is absolutely no substitute for an exam,” Rivlin said.

Now, as more patients are able to be seen in a doctor’s office, Rothman doctors can diagnose the injury in person and make the cast, splint, or brace within a few hours.

Currently, Rothman is concentrating on children, making 3D casts for about half of the kids who have wrist fractures that qualify. These casts do not currently work for patients who need surgery, have an open wound, or severe swelling.

“Kids are most affected by itchy smelly casts and they may not be able to tell if a cast doesn’t fit like adults do,” Rivlin said. “Also, I have found quarters, Lego pieces, pens, and things I would not even imagine stuck inside casts that can pose a real issue if not noticed.”

For a child’s cast, it takes about 10 seconds to make the virtual cast from the pictures the patient has uploaded. It then goes through the 3D printer and can be complete and ready to ship or apply on the patient the same day in most cases.

Rivlin and his team began using 3D casting about four years ago, when his son, Kai, 3 years old at the time, broke his elbow.

“I’ve done many difficult things in my life, but one of the hardest was keeping a toddler’s elbow in a bathtub dry,” he recalled.

The benefits of 3D printed casts and splints go well beyond remote use through telemedicine. A Rothman study comparing treatment of children’s wrist fractures found that the 3D options are waterproof, lightweight, and more durable and comfortable than traditional plaster casts.

“Unlike having a smelly cast in the summer when you cannot shower or go into the pool, these 3D casts are light, very strong and you have the option to go in the pool,” Rivlin said. “They can be more easily cleaned than a waterproof or plaster cast and don’t harbor bacteria in the same way.”

Another benefit is the ability to take an X-ray while in the resin cast, something that can’t be done with a plaster cast. They come with a locking mechanism that makes them easy to remove, not requiring a saw that might scare kids or nick the skin. To prevent kids from removing the cast on their own, Dimension Orthotics is launching a new model with a lock and key, said CEO Stuart Seymour.

“It still baffles me that we are still casting the same way we were 50 years ago,” said Seymour.

Because the technology is relatively new, call your insurer first to determine if 3D casting is covered.

Independence Blue Cross, the largest insurer in the Philadelphia area, said it does not currently have a coverage policy for 3D casts and splints. “It is a new and evolving area of orthopedics that we are in the process of gaining more knowledge and understanding of,” said Patricia Guerra-Garcia, vice president of medical management and medical policy, and a physician.

Hoberg is still healing but is thankful for the care he received in Philadelphia. “Being able to get the splint without having to go somewhere to get fitted was fantastic,” he said. “The convenience of it was off the charts.”