Total Contact Casting

Total contact casting:
• below knee plaster cast; minimal or no padding (total contact); inner layer of plaster of paris bandage (for better contact); outer layers plaster or fibreglass
• perhaps gold standard for off loading pressure on diabetic foot ulcers – while allowing ambulation
• many studies have shown effectiveness
• disadvantages – does limit some activities; increase in joint stiffness; muscle wasting; potential for skin abrasions; inadequate training of staff  improper applications

Indications:
plantar ulcers
Charcot’s neuroarthropathy

Contraindications:
• infection
• ulcer depth greater than width
• excessive oedema
• peripheral vascular disease
• non-compliance
• skin condition that occlusion may exacerbate

Method of application:
importance of experience
prepare foot (nail debridement; emollient application; ulcer debridement; cotton wool between toes to absorb moisture)
stockinette to cover foot and leg (fold dorsally over toes and cut at flex crease at ankle joint – use tape to hold in place)
adhesive felt to protect bony prominences (8-10cm wide strip down anterior aspect of tibial crest and circular pad to cover both malleoli – skive/bevel edges – use adhesive tape to hold in place)
2-3cm foam to cover dorsal and plantar aspect of toes to allow toes to move (tape in place)
10cm x 5m roll of plaster applied – starting at base of toes and moving towards upper leg (make sure foot at 90 degrees to leg; no folds or lumps in plaster
10cm fibreglass roll covers plaster (previous techniques used all plaster, but needed 24 hours to dry sufficiently; fibreglass on needs 30 minutes)
attach plantar walking heel
apply additional layers from 2 rolls of fibreglass, enclosing the toes.

Removal:
As no cast padding is used, removal needs to be with care when using cast saw.

Variations in method of application:
Fracture padding

Instructions to patient:

Complications:

How it might work:
spread plantar pressures over entire plantar surface  reduced pressure on wound
wound oedema
oedema
leg of cat takes weight (ref)
compliance (ref Armstrong removable walkers)

 
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