Diabetic Ulcers And The Total Contact Cast
Second-Place Article, 2015 Paper of the Year Competition

by Michael R. Pare, OTC

Milroy Paul in Sri Lanka first introduced the Total Contact Cast (TCC) in the 1930s for treatment of non-healing ulcer in Hansen’s disease. The TCC was brought to the United State by Paul Brand in the 1960s for treatment of similar patients.

The TCC can be used for a range of treatments, such as: diabetes mellitus, leprosy, back injuries, reduction of lower leg and foot edema, allowance for Charcot foot neuropathy and postoperative adjunct to reconstructive surgery.

The Total Contact Cast is considered the “gold standard” for treatment of diabetic and neuropathic patients for many types of problems. Let’s take a look at these types of patients to see the benefit of a TCC.

The diabetic patient has many underlying effects, such as: neuropathy, vascular disease and diminished response to infection. Neuropathy can cause the foot to become deformed, which may happen for two reasons:

1.The neuropathy can cause paralysis of the small muscle in the foot, causing the toes to claw. The clawing of the toes may cause prominence of the metatarsal heads on the plantar surface of the foot, and also may cause knuckles to do the same on the dorsal foot. The neuropathy can also cause the loss of sensation. As the metatarsal head on the plantar surface is subject to increased pressure and force, the skin will start to hypertrophy and callus. This force will cause the layers of skin to separate and fill with fluid which can become infected. The pressure can cause the primary breakdown of the skin and results in a foot ulcer. Once the breakdown and contamination occurs the foot can become infected, which can cause significant problems.

2.The second type of deformity is known as Charcot foot. This is caused by neuropathy or lack of sensation, which in turn subjects the bones of the foot to trauma and they will actually fracture and disintegrate. The foot will become deformed as a result of ambulation. The middle portion of the foot is the area affected causing prominence of bone in this area, which can cause ulcers in the middle portion of the foot.

The TCC is used to heal diabetic foot ulcers by distributing the weight evenly across the plantar surface of the foot. The cast is applied in such a way as to contour the entire foot, thus the name total contact cast. By removing the pressure on the prominent areas of the foot, the ulcer can heal in the cast if applied in a way that allows the patient to be ambulatory during the treatment. The molding of the cast to the contour of the foot on the plantar surface from the heel to the toes allows the distribution of pressure to be more even across the foot. Pressure to the foot is expressed in terms of pressure (pounds) over an area per square inch. If the area of weight bearing is enlarged, the pressure per square inch is reduced. Doing this allows the weight on the boney prominence to be distributed over the entire plantar surface.

The Total Contact Cast, when used for the described applications, is a very effective treatment. A prerequisite is that the foot must have an adequate blood supply, and therefore, the foot must be monitored quite carefully. The cast must be applied by someone who has experience with the applications and use of this cast. The cast must be changed at regular, short intervals of a week or two. The reason for this caution is that the diabetic who has insensitive feet runs the risk of having other sores or areas of irritation occur under the cast.

When performing a TCC, the supplies used depends upon the size of the patient. Here is a list of supplies used on an average size patient:

Supplies:
1. 1 roll plaster 4”
2. 3 fiberglass rolls – 3” or 4”
3. 6 strips plaster (4”x15”)
4. 3 rolls webril
5. 1 strip of felt, 2 pieces need to be cut from the strip to cover both malleoli
6. 2 – 4” stockinette, to the length of the lower leg allowing enough room (approximately 6”) to twist and pull over the fore foot

Prior to starting the TCC, you need to make sure the ulcer is covered with a thin dressing, which is usually decided by the provider.

1. Use sufficient padding between the toes using folded cast padding to make sure the toes do not rub, which may help create another ulcer area.

2. Tri-fold the cast padding and lay it on top of the distal toes (going from the MTP joint of the great toe to the MTP joint of the 5th) and then continue to roll the padding around the foot twice, going high and then low, which allows some additional padding to the medial and lateral foot area. Once this is done, roll the foot plantar to distal surface folding the padding in as we move up the foot to the toes. Once at the toes fold in a tri-fold padding the cushion the plantar and distal toes.

3. Take the additional padding from the roll and tri-fold it and place it on the heel, rolling around the heel to hold the padding in place.

4. Apply the stockinette, pulling it up to the knee, and let additional stockinette hang over the toes. Twist the stockinette and then pull it over the foot.

5. Cut the stockinette starting at the lateral malleolus across to the medial malleolus making sure there are no folds or creases.

6. Apply the felt over the medial and lateral malleolus and to the anterior tibia from the tibial tuberosity to the distal tibia.

7. Add additional cast padding or felt (a donut) to the ulcer area to help off load around the ulcer area.

8. Take the second roll of cast padding starting at the achillies calcaneus origin and wrap around the heel to across the top of the toes twice going 50% overlay, then go around the dorsal and plantar surface of the foot and work up the lower leg.

9. The third roll of cast padding is used to go up the lower leg to the tibial tubercle. At the top, make several more turns with the padding to thicken the top of the cast.

10. Take the roll of plaster and submerge it in the water to make sure that the whole roll is wet. Make sure to hold the beginning of the roll, so you are not trying to find it when the roll is wet. Squeeze out some of the excess water, but make sure the roll is still wet.

11. Start the plaster at the achillies calcaneus origin and wrap it around the top of the toes. Go around the foot twice with a 50% over lay, then start rolling around the dorsal and plantar surface of the foot. Make sure to fold the plaster over the foot working up to the toes then bring it down to the heel.

12. Once you have finished the heel start up the lower leg. Make sure that the plaster roll goes past the ankle and up the leg around the mid calf area, otherwise you create an escape for the stress at the ankle and the cast will crack.

13. Take the first three strips of plaster and wet them. Put the plaster on the plantar surface of the foot molding it to the contour of the foot. The plaster will overlay the heel and the toes for additional support.

14. Apply the additional three strips of plaster then tri-fold and wet them. Put them on the heel and mold it to the heel. This creates the rocker bottom, which assists with the off loading and allows the patient to walk. Make sure to smooth out all of the plaster, so there are no rough spots in the cast that may create other issues.

15. The first roll of fiberglass is applied the same way as the plaster.

16. Continue with the second roll of fiberglass up to the tibial tubercle. Once at the top work your way down a little to pull down the stockinette. Then, work your way back up to allow a 1” length of cast padding and stockinette at the top for comfort.

17. Apply the third roll of fiberglass around the foot, just like the first roll, for strength and support for the weight bearing patient.

Our clinic uses a combination of plaster and fiberglass, which allows us to mold the plantar foot to the contour of the foot. The plaster strips create more thickness to the plantar surface of the foot which allows you to mold it better. The fiberglass rolls help creates a more rigid cast.

Our success rate with this type of casting is approximately 80-85% and the length of casting varies with each patient but usually 10 -12 weeks. Depending when they come to us, the diabetic is a very complicated patient, as they often times have other health issues that can hinder the healing of the ulcer.

Diabetic patients must spend time each day inspecting and caring for their feet to make sure that there are no complications occurring, which can lead to hospitalization of the patient if left unattended.

***This article shows one method of applying a Total Contact Cast. There is more than one method to apply a Total Contact Cast.

About the Author:
Michael Pare, OTC is a graduate of West Georgia College with a Bachelor’s Degree in Business Administration. He worked in the business field for years, owning several successful businesses before deciding to return to school to pursue a degree in the medical field. Michael attended the Orthopedic Technology Program at Southern Crescent Technical College, graduating in 2011. He received his OTC certification in 2012. Michael is currently employed at Perimeter Orthopaedics in Atlanta, GA and serves as a Board Member for the National Board for Certification of Orthopaedic Technologists (NBCOT).

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