Fit to fly? Evaluating airline guidance for passengers with orthopaedic immobilisation

Air travel with cast immobilisation increases the risk of compartment syndrome and venous thromboembolism due to cabin pressure-related tissue swelling and venous stasis. Despite these concerns, guidance on flying with casts is often vague and inconsistent. This study aimed to evaluate the accessibility and consistency of airline travel policies for passengers with casts and to review existing literature regarding cast immobilisation and air travel.

The travel policies of the 30 largest commercial airlines worldwide by available seat miles were reviewed, focusing on restrictions or recommendations related to orthopaedic casts. Airline websites were searched systematically and, where guidance was not readily available, customer service was contacted by telephone. Relevant literature on cast immobilisation, air travel and associated physiological risks was identified through PubMed.

Guidance was not easily accessible for 11 airlines (37%), requiring telephone contact. A 48-hour threshold following cast application was the most common restriction, with 22 airlines (73%) recommending cast splitting for travel within this period. Twelve airlines (40%) required a signed fit-to-fly certificate. Six airlines (20%) imposed additional restrictions for passengers with full-length leg casts, including additional seat purchase or travel in business class, and one airline prohibited travel entirely.

Airline guidance for passengers with casts is inconsistent, difficult to access and poorly standardised. Given that air travel increases soft tissue swelling and intracompartmental pressure, clearer, evidence-based guidance is required. Although limited recommendations exist in the UK, major international aviation authorities provide no explicit guidance, highlighting a significant regulatory gap.