Skin-related complications of casting in children: a systematic review

Abstract

Casting is the most common treatment for pediatric fractures and neuromuscular-skeletal disorders such as cerebral palsy, developmental or neuromuscular dysplasia of the hip, Perthes disease, and scoliosis. Few studies determine the most common causes of skin complications from casting. This study aims to provide a quantitative breakdown of specific skin complications across cast types and offer practical solutions. A literature review, last searched on 17 October 2024, following PRISMA guidelines, identified all cases of pediatric skin-related casting complications and categorized them by cause. These were analyzed to determine the significant causes of complications. Chi-square tests determined whether a given complication accounted for a significant proportion of all complications. AMSTAR 2 was used for an overall appraisal of the review process, and ROBINS-I and RoB 2 were used at the individual study level. Nineteen articles with a total of 11 464 patients were reviewed. There were 599 skin-related complications, comprising 77.99% of all casting complications. The most common skin complications were pressure ulcers (23.7%), unspecified skin irritations (20.4%), wet cast (18.9%), and cast rubbing/fitting issues (18.5%) (P < 0.001). Unspecified etiology skin irritation and wet cast comprise 39.2% of all skin-related casting complications in children; hence, education on cast-covering techniques is essential to decrease these complications. Pressure ulcers and cast-related rubbing/fitting issues account for 42.2% of complications and are addressed by proper molding and padding around pressure points to produce better-fitting casts. In short, a substantial proportion of skin-related casting complications are potentially preventable with proper casting technique and by avoiding wet casts.

Introduction

Studies have shown that up to 40% of girls and 50% of boys sustain a fracture before adulthood^[1–3^]. Casting is a standard nonoperative and postoperative treatment for fractures in the pediatric population. Modern casts are composed of either plaster or fiberglass and are made in different lengths depending on the fracture type. Casts are applied first with a stockinette, a thin fabric placed directly on the skin over the injured area, followed by layers of cotton undercast padding, and then a wet layer of fiberglass or plaster casting material, which hardens over time.

One of the most frequent reasons for emergency room (ER) visits among pediatric patients with cast-related complications is a wet cast, followed by a tight, loose, or painful cast[4]. These visits to the ER create an additional financial burden on the medical system, which is preventable[4]. Skin-related casting complications can include maceration and infection, necrotizing fasciitis, toxic shock syndrome, septic arthritis, compartment syndrome, and osteomyelitis^[5–7^]. Necrotizing fasciitis following casting has even led to amputation[7]. Although prospective and retrospective studies have reported on the causes of cast complications, we sought to compile all available data in a systematic review to provide a quantitative breakdown of specific skin complications across cast types and indications, and to offer practical solutions.

HIGHLIGHTS

• Out of all casting complications in children, the vast majority are skin-related.

• The most common casting complications in children are due to wet casts, skin irritation, and pressure ulcers.

• Patients with neuromuscular disorders have higher casting complication rates.

• Plaster casts have more complications, proportionally, than fiberglass casts.

This article did not use any AI assistance in compliance with the TITAN checklist[8].

Methods

A comprehensive literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol.

Study selection

A literature inquiry was conducted using the electronic databases PubMed and Cochrane Reviews, last reviewed on 17 October 2024. An initial inquiry was conducted to identify studies that quantified and categorized skin complications in pediatric patients after casting. At least two reviewers agreed on the selected studies. The initial inquiry was also limited to peer-reviewed, English-language studies published after 1970, coinciding with the advent of modern fiberglass casting. Search parameters included a combination of the following keywords and Medical Subject Headings (MeSH): (cast complications) OR (splint complications) OR (wet cast). These keywords were used deliberately to yield the most results possible. These keywords pulled up all articles that mentioned the word “cast,” causing an abundance of articles, most of which did not apply to our study. Searching Cochrane and PubMed was deemed sufficient, as many articles were indexed in both databases.

Inclusion criteria

1. Original research articles that quantified and categorized skin complications after casting

2. Patient population < 18 years old

3. Intervention: casting

4. Comparator group: different types of casting complications, patients, and casting materials will be compared to one another.

5. Outcome: type of cast-related complication

6. Peer-reviewed studies published in English after 1970

Exclusion criteria

1. Letters, editorials, or conference abstracts

2. Skin infections due to non-orthopedic complications in the casting process

Data extraction and analysis

Skin complication categories included blisters, wet casts, pressure ulcers, unspecified etiology of skin irritation, foreign objects, self-removal, soilage, insects in the cast, and cast rubbing/fitting issues. These categories were created using the same labels that appeared in the studies, and only studies that mentioned the type of skin irritation were included. Some studies reported casting complications, but they did not describe them, so they could not be categorized and were excluded.

A single reviewer categorized the skin complications, which were then confirmed by another reviewer. Unspecified etiology includes complications categorized with general, non-specific terms such as erythema and skin irritation. Categorical data are presented as a percentage of the entire study selection. Chi square tests were used to determine if a given type of complication made up a significant percentage of all complications using IBM SPSS Statistics (α = 0.05). AMSTAR 2 was used for an overall appraisal of the review process, and ROBINS-I and RoB 2 were used at the individual study level.

All confidence intervals were calculated using the Wilson interval with a denominator of $1+\frac{{\text{Z}}^{\text{2}}}{\text{n}}\left(z=1.96\right)$

A risk of bias assessment was performed for the included articles (Table 1).

Table 1.

Risk of bias assessment.

Study (author, year)	Design	Tool mapped	Randomization/Confounding	Selection of participants	Classification of intervention/exposure	Deviations from intended interventions	Missing outcome data	Measurement of outcomes	Selection of reported results	Overall risk
DiFazio et al, 2017[9]	Interrupted time-series (QI)	ROBINS-I	High	Low	Low	Some concerns	Some concerns	Some concerns	Some concerns	High
DiPaola et al, 2014[10]	Prospective observational cohort (single-arm)	ROBINS-I	High	Low	Low	Low	Low	Low	Some concerns	Moderate
Pisecky et al, 2022[11]	Retrospective case series	ROBINS-I	High	Low	Low	Low	Low	Some concerns	Some concerns	Moderate
DiFazio et al, 2011[12]	Retrospective cohort (case–control analysis)	ROBINS-I	High	Low	Low	Low	Low	Some concerns	Some concerns	Moderate
Iobst et al, 2004[13]	Retrospective case series	ROBINS-I	High	Low	Low	Low	Low	Some concerns	Some concerns	Moderate
Ferrier et al, 2020[14]	Retrospective cohort	ROBINS-I	High	Low	Low	Low	Low	Low	Some concerns	Moderate
Murgai et al, 2018[15]	Retrospective cohort	ROBINS-I	High	Low	Low	Low	Low	Some concerns	Some concerns	Moderate
Sawyer et al, 2010[4]	Retrospective cohort	ROBINS-I	High	Low	Low	Low	Low	Low	Some concerns	Moderate
Cassinelli et al, 2005[16]	Retrospective cohort	ROBINS-I	High	Low	Low	Low	Low	Low	Some concerns	Moderate
Plint et al, 2006[17]	Randomized controlled trial	RoB 2 mapped	Low	Some concerns	Low	Some concerns	Some concerns	Some concerns	Low	Some concerns
Flynn et al, 2004[18]	Prospective comparative cohort	ROBINS-I	High	Low	Low	Low	Low	Some concerns	Some concerns	Moderate
Mansour et al, 2010[19]	Retrospective comparative cohort	ROBINS-I	High	Low	Low	Low	Low	Low	Some concerns	Moderate
Jaafar et al, 2016[20]	Retrospective comparative cohort	ROBINS-I	High	Low	Low	Low	Low	Low	Some concerns	Moderate
Inglis et al, 2013[21]	Randomized controlled trial	RoB 2 mapped	Low	Low	Low	Low	Low	Low	Low	Low
Schuh et al, 2016[22]	Retrospective cohort	ROBINS-I	High	Low	Low	Low	Low	Low	Some concerns	Moderate
Bauer et al, 2019[23]	Retrospective cohort	ROBINS-I	High	Low	Low	Low	Low	Low	Some concerns	Moderate
Hamdy et al, 2025[24]	Randomized controlled trial	RoB 2 mapped	Low	Low	Low	Low	Low	Some concerns	Low	Some concerns
Beck et al, 2023[25]	Randomized controlled trial	RoB 2 mapped	Low	Low	Low	Low	Low	Low	Low	Low
Barnett et al, 2012[26]	Randomized observer-blinded controlled trial	RoB 2 mapped	Low	Low	Low	Low	Low	Low	Low	Some concerns

Results

The initial search in PubMed and Cochrane reviews yielded 1477 potential articles, which were narrowed down to 237 based on date, language, population, and relevance. These 237 articles were then analyzed to ensure they quantified and categorized cast-related skin complications. There were 19 articles that reported the number and cause of their cast-related complications, and these were used for the final analysis. A flowchart of the selection process is shown below (Fig. 1).

Figure 1.

PRISMA flow diagram for the identification of studies via PubMed and Cochrane reviews.

Across all 19 studies, a total of 11 464 patients with short-leg, long-leg, short-arm, long-arm, thumb spica, hip spica, shoulder spica, hand, and A-frame casts were included in this review. These cases came from 3 prospective, 11 retrospective, and 5 randomized controlled trials (Table 2). Causes of casting included fractures treated operatively and nonoperatively, spine immobilization, and musculoskeletal disorders (Table 2).

Table 2.

Thirteen analyzed studies broken down by number of patients, type of cast, study type, and cause of casting.

Study	Number of patients/ casts	Cast type	Study type	Cause of casting
DiFazio et al, 2017[9]	6238	Short leg, long leg	Prospective	“Variety of musculoskeletal disorders” Including fractures, cerebral palsy, and myelodysplasia. Treated surgically and non-surgically
DiPaola et al, 2014[10]	1135	Short arm, Long arm, Thumb spica, Short leg, Long leg	Prospective	Not described
Pisecky et al, 2022[11]	83	Hip spica	Retrospective	Hip reconstructive surgery due to developmental hip dysplasia, neuromuscular hip dysplasia, and Perthes disease
DiFazio et al, 2011[12]	297	Hip spica	Retrospective	Femur fractures treated non-surgically
Iobst et al, 2004[13]	22	Shoulder spica	Retrospective	Hemivertebra excision surgery
Ferrier, Schembri, Hopper, 2020[14]	104	Not mentioned	Retrospective	Tibial fractures treated non-surgically
Murgai et al, 2018[15]	2481	Short leg, Long leg, Spica, A-frame	Retrospective	Lower extremity elective surgery
Sawyer et al, 2010[4]	168	Long arm, Long leg, Short arm, Short leg, Hand, Hip spica	Retrospective	Hand, forearm, elbow, femur, and foot fractures non-surgically
Cassinelli et al, 2005[16]	145	Hip spica	Retrospective	Femur fractures treated non-surgically
Plint et al, 2006[17]	45	Short arm	Randomized Controlled	Distal radius and/or ulna buckle fractures treated non-surgically
Flynn et al, 2004[18]	35	Hip spica	Prospective	Femur fractures treated non-surgically
Mansour et al, 2010[19]	100	Hip spica	Retrospective	Femur fractures treated surgically and non-surgically
Jaafar et al, 2016[20]	94	Hip spica	Retrospective	Femoral shaft fractures treated non-surgically
Inglis et al, 2013[21]	199	Long arm, short arm	Randomized Controlled	Radial and ulnar fractures treated non-surgically
Schuh et al, 2016[22]	50	Short leg	Retrospective	Distal tibia fractures treated non-surgically
Bauer et al, 2019[23]	136	Short leg, long leg	Retrospective	Distal tibia fractures treated non-surgically
Hamdy et al, 2025[24]	84	Hip spica	Randomized Controlled	Femur fractures treated non-surgically
Beck et al, 2023[25]	28	Short Leg	Randomized Controlled	Distal fibula fractures treated non-surgically
Barnett et al, 2012[26]	20	Short leg	Randomized Controlled	Ankle fractures treated non-surgically
Total	11 464

There were 768 cast-related complications among 11 464 patients (6.70%, CI 6.25%–7.19%). Out of all 768 complications, 137 (17.84%, CI: 15.3%–20.7%) were short-leg, 76 (9.90%, CI: 7.8%–11.95%) long-leg, 46 (5.99%, CI: 4.92%–7.90%) short-arm, 39 (5.08%, CI: 3.74%–6.87%) long-arm, 4 (0.52%, CI: 0.18%–1.35%) thumb spica, 312 (40.62%, CI: 37.1%–44.2%) hip spica, 14 (1.82%, CI: 1.10%–3.02%) hand, 16 (2.08%, CI: 1.29%–3.36%) A-frame, and 6 (0.78%, CI: 0.36%–1.68%) shoulder spica. Three studies accounted for 68 of the 768 complications but did not specify how many cast complications were short-leg/arm and how many were long-leg/arm^[14,21,23^]. Skin-related complications constituted 599 of the 768 (77.99%, CI: 74.9%–80.8%; Table 3). Each study categorized its complications differently, and 9 common categories were used in this analysis: blisters, wet cast, pressure ulcer, foreign object, self-removal, soilage, insect in cast, cast rubbing/fit issues, and unspecified etiology skin irritation (Table 3). Unspecified etiology skin irritation was present in most studies (10/19, 52.63%, CI: 31.6%–72.7%), followed by pressure ulcer (9/19, 47.37%, CI: 27.3%–68.4%),– cast rubbing/fitting issues (7/19, 36.84%, CI: 19.4%–58.7%), and wet cast (6/19, 31.58%, CI: 15.6%–53.8%).

Table 3.

Number of cases of skin-related cast complications by category.

Complication	Study	Number
Blisters	Murgai et al, 2018, Barnett et al, 2012	28
Wet Cast	DiFazio et al, 2017, DiPaola et al, 2014, Sawyer et al, 2010, Plint et al, 2006, Inglis et al, 2013, Beck et al, 2023	113
Pressure Ulcer	DiFazio et al, 2017, DiFazio et al, 2011, Murgari et al, 2018, Cassinelli et al, 2005, Flynn et al, 2004, Inglis et al, 2013, Bauer et al, 2019, Hamdy et al, 2025, Barnett et al, 2012	142
Unspecified Etiology Skin Irritation	DiFazio et al, 2017, DiPaola et al, 2014, Pisecky et al, 2022, DiFazio et al, 2011, Iobst et al, 2004, Ferrier, Schembri, and Hopper, 2020, Murgai et al, 2018, Mansour et al, 2010, Jaafar et al, 2016, Schuh et al, 2016	122
Foreign Object	DiPaola et al, 2014, DiFazio et al, 2011, Cassinelli et al, 2005	5
Self-Removal	DiPaola et al, 2014	2
Soilage	DiPaola et al, 2014, DiFazio et al, 2011, Cassinelli et al, 2005, Mansour et al, 2010	75
Insect in Cast	DiPaola et al, 2014	1
Cast Rubbing/ Fit Issues	DiPaola et al, 2014, Pisecky et al, 2022, Iobst et al, 2004, Ferrier, Schembri, and Hopper, 2020, Sawyer et al, 2010, Cassinelli et al, 2005, Mansour et al, 2010	111
	Total Skin-Related Complications	599

Three studies specified the number of plaster casts they used; the rest used fiberglass^[11,17,21^]. The complication rate in the studies with all plaster casts was significantly higher than that in the rest of the studies included in the review (61/217, 28.1%, CI: 22.6%–34.4% vs. 707/11247, 6.3%, CI: 5.86%–6.76%, P < 0.001).

Across all causes of skin-related cast complications, wet cast (113/599, 18.9%, CI: 15.9%–22.2%), unspecified etiology skin irritation (122/599, 20.4%, CI: 17.3%–23.8%), pressure ulcer (142/599, 23.7%, CI: 20.4%–27.2%), and cast rubbing/fitting issues (111/599, 18.5%, CI: 15.6%–21.7%) all constituted significant portions of skin-related complications (P < 0.001). These are also the same complications that were reported in most studies (Table 3). Soilage did not trail far behind, accounting for 75/599 (12.5%; CI: 10.0%–15.4%) of all cases of skin-related cast complications (Fig. 2).

Figure 2.

Causes of skin-related casting complications.

Three studies included patients with neuromuscular-skeletal disorders^[9,11,13^]. The first study involved a variety of musculoskeletal disorders, including patients with cerebral palsy and myelodysplasia, who reported 58 complications overall, of which 20 (34.48%, CI: 23.6%–47.4%) were from patients with cerebral palsy and myelodysplasia[9]. In the second study, hip spica casts were used following hip reconstruction for patients with developmental dysplasia of the hip, neuromuscular hip dysplasia, and Perthes disease[11]. These patients had an overall complication rate of 23/83 (27.71%, CI: 19.1%–38.2%). The third study analyzed patients who were placed in a shoulder-spine spica cast after hemivertebra resection[13], and their complication rate was 6/22 (27.27%, CI: 13.4%–47.7%). The complication rate in patients with neuromuscular-skeletal disorders is higher than the overall complication rate we found in this study (6.70%).

Discussion

In this systematic review, we examined the prevalence and causes of casting complications in 11 464 pediatric patients. We found that 77.99% of casting complications were skin-related, with wet casts, unspecified-etiology skin irritation, pressure ulcers, and cast rubbing/fit issues comprising most cases.

When combined, wet casts and unspecified-etiology skin irritation make up 39.2% of skin-related casting complications. These categories are related since it is possible that wet casts can lead to irritation and erythema without an apparent cause. A common scenario that can lead to this is that the child gets the cast wet, does not tell anyone, develops skin irritation from prolonged wetness, the cast eventually dries, and the child is left with skin irritation without an apparent cause to the examiner. Furthermore, only two of the 10 studies that reported unspecified-etiology skin irritation also reported wet casts as a separate category. It is possible that the studies that did not separate these could have reported skin irritation from the wet cast as unspecified skin irritation. When considered, it is plausible that up to 39.2% of skin-related casting complications are preventable by maintaining a dry cast environment. Given the ease with which this can be accomplished, the most important and simple recommendation a physician can make to their patient is to keep their cast covered when bathing. Multiple independent studies have found that securing two heavy-duty plastic bags around the cast with duct tape is superior to commercially available products and is therefore the most efficacious and cost-effective method for preventing skin-related casting complications^[27,28^]. While this is a practical method for waterproofing casts, the patient should be cautioned that no method is foolproof. Ideally, multiple methods can be combined to cover the cast, including keeping the affected limb out of the shower if possible.

The complication rate in the two studies, which used exclusively plaster casts rather than fiberglass as in the rest of the studies, was significantly higher and showed a predominance of unspecified etiology, skin irritation, and wet casts, similar to the overall systematic review.

Pressure ulcers accounted for 23.7% of skin-related casting complications, and while not entirely avoidable, proper cast padding and patient education can significantly reduce their incidence. Parents must be educated to recognize the signs and symptoms of pressure ulcers. If detected early enough, a window can be cut into the cast, or a cast exchange can be performed early. More importantly, the formation of pressure ulcers can be minimized during the casting process. Pieces of foam can be cut to size and placed over bony prominences during casting. This has been shown to significantly reduce the number of complications in A-frame and long-leg casts[15]. In a similar study, the incidence of cast-related skin complications was reduced from 17.1% to 6.8%, mainly by adding more padding to areas of excessive pressure, such as the heel[9]. Proper cast molding is also crucial to avoid pressure ulcer formation. We found that 18.5% of skin-related casting complications are due to cast rubbing and fitting issues, which likely stem from poorly padded casts; therefore, improved cast molding could reduce 42.2% of all skin-related casting complications.

Three studies included in this review involved patients who underwent casting due to neuromuscular-skeletal disorders^[9,11,13^], and the average complication rate across these three studies for corrective casting due to neuromuscular-skeletal disorders is 29.82%, which is 4.45 times higher than the overall complication rate in this review. One explanation for the higher rate of complications in casting for neuromuscular-skeletal disorders, rather than other conditions, is that many of these patients have associated cognitive disabilities. Cerebral palsy can present with speech impairment as well as musculoskeletal deformities and spasticity[29]. Young children already have trouble communicating effectively, and children with speech impairment from cerebral palsy are at greater risk today due to their inability to communicate any cast-related complaints. Another aspect to consider is the level of surveillance and the length of follow-up, which could account for the higher complication rate in the neuromuscular group. Only one study in the neuromuscular group stated how long the follow-up was (3 months)[11]. We do not have sufficient data to make any claims about surveillance or follow-up contributing to the higher neuromuscular complication rate.

The types of casts that accounted for the most cases of complications in our review were hip spica (40.62%), short-leg (17.84%), and long-leg (9.90%). Hip spica casts cross four joints and have the most ways to cause cast-related issues. All cast types in this study could get wet, become loose, become soiled, or have spots that are too tight, which could cause pressure ulcers. However, hip spica casts are more likely to become soiled with urine and fecal matter than other types of casts. This introduces an additional complication, as these casts require more work to keep clean, with diaper changes needing to be performed within them. Additionally, most neuromuscular, hip conditions, and skeletal disorders that required complex hip reconstructions were treated with hip spica casts post-surgery[11]. So, not only do hip spica casts have the extra risk of soilage, but they are also often applied in cases of neuromuscular-skeletal disorders, which inherently have a higher complication rate. A study has shown that using waterproof hip spica casting for femur fractures can significantly reduce skin complications[30]. The study also noted that patients who received waterproof casting were charged less than those who received traditional spica casts. Therefore, the use of waterproof casting, when available, can reduce both costs and complications.

The biggest strength of this study is that we identified common categories across multiple studies. We compiled data from 19 studies that reported complications in the same categories. The consistency of reporting across studies included in this review allows us to report the trends we found in the data with confidence. Limitations of this study include non-specific data categorization and the use of only two databases in the literature search. The unspecified etiology skin irritation category was not an official category in any study; it is a compilation of skin findings from 10 studies that did not explicitly list a reason for skin irritation. This ended up being a large category, accounting for 20.4% of all complications included in this study. These skin findings can be due to another category in this study or something else that has not yet been reported. It is most likely that these are due to causes present in the other categories in this study, given the wide range of causes we have, which include more obscure factors, such as an insect in the cast. Given the limitation of using only PubMed and Cochrane, we may have missed studies. Another limitation is that when reporting pooled data on types of skin complications, heterogeneity across studies, such as cast type and reason for casting, could have altered the effect estimates. However, as mentioned earlier, if we can substantially decrease the number of wet casts, pressure ulcers, and ill-fitting casts, we can prevent infections and reduce costs associated with reapplying casts, emergency room visits, and treating infections. Also, in all the studies except one, there was no differentiation between casts and splints.

As for risk-of-bias patterns, most of the included studies have some concerns, with moderate concerns for bias. Most of the included studies (10/19) were retrospective cohort studies, and all received a “moderate” risk-of-bias score (Table 1). The next highest category of study included RCTs (5/10), which received a “low” or “some concerns” risk-of-bias assessment. The high number of studies that earn a “moderate” risk score does not invalidate our recommendations, as these are already common-sense practices being adopted nationwide. This study provides the data to support this higher standard of practice.

Clinical correlation

In summary, the majority of skin-related casting complications stem from skin irritation and wet casts (39.2%), as well as pressure ulcers, cast rubbing, and fitting issues (42.2%). The type of cast with the highest percentage of skin complications was the hip spica. Therefore, physicians/providers can reduce these complications by following proper casting techniques, ensuring adequate padding over bony prominences, educating parents/caregivers on the plastic bag and tape method to keep casts dry, and demonstrating to the family how to properly manage a hip spica cast with a diaper. Along with the plastic bag and duct tape method, physicians should also remind patients/parents to perform skin checks after bathing and to avoid using heat sources, such as a hair dryer, to try to dry a cast after it gets wet as a precaution. Another aspect to consider is trying to reduce itchiness under the cast, which leads children to place objects inside the cast. These objects then get stuck and lead to a breakdown. There is evidence that applying calamine lotion before cast placement can reduce skin irritation and itchiness[31]. These practices do not add additional cost to healthcare and do not take much extra time, if any at all. These are summarized in a checklist form (see Fig. 3). They have the potential to save pediatric patients and their families time and money spent on additional hospital visits, pain, and limit prolonged recovery from simple fractures that are so common in our world today.

Figure 3.

Casting Checklist.

Ethical approval

The requirement for ethical permission was waived due to the retrospective, de-identified nature of the data and conclusions synthesized from previous studies.

Consent

The requirement for informed consent was waived due to the retrospective, de-identified nature of the data and conclusions synthesized from previous studies.

Sources of funding

Not applicable.

Author contributions

• Substantial contributions to the conception or design of the work, or the acquisition, analysis, or interpretation of data for the work: Sivashanmugam Raju, William Callahan, and Heidi Israel.

• Drafting the work or revising it critically for important intellectual content: William Callahan, Rashini Jayawardena, Diego Silva-Mendoza, Sahand Fallahi, Adarsh Suresh, and Sivashanmugam Raju.

• Final approval of the version to be published: Sivashanmugam Raju.

• Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: William Callahan, and Sivashanmugam Raju.

Conflicts of interest disclosure

None.

Research registration unique identifying number (UIN)

Research Registry UIN: reviewregistry2011.

Guarantor

Sivashanmugam Raju, MD.

Provenance and peer review

Not commissioned; externally peer reviewed.

Data availability statement

Data available upon request.

Presentation

2024 Latino Medical Student Association National Conference.