Bricolage IS WRITTEN by Jeff Cable and is based in the United Kingdom.

This blog aspires to provide COHERENT and relevant Material for all cast TECHNICIANS. 

Total Contact Casting

Total contact casting is an advanced casting technique which is used for treating ulcerated feet in diabetic patients. The treatment objective is to off-load the plantar surface of the foot and to spread the loads across the foot and lower leg. The diabetic patient is likely to be subject to neurovascular complications.

Often the patient will have an insensate foot and will not feel when footwear, pressure and shear forces cause sore areas on the plantar surface of the foot. Additionally, they may suffer with anatomical changes in the foot morphology such as the mid-foot collapse; which is seen with Charcot foot.

There are many variants of cast for off-loading the plantar aspect of the damaged foot, where diabetic foot ulceration has begun its depredations. Compliance with treatment has been cited as one of the reasons a total contact cast may be prescribed and applied. The failure to treat people as adults, who are responsible and will take on the responsibility for their own care and treatment, is a sign that we are in danger of over professionalisation of some medical conditions.

In my view, it is preferable to explain what is required and determine (and agree with the patient) the means by which an acceptable and effective treatment will be provided. The patient's own cooperation is assured once they can understand what is required of them and the intended pathway by which an improvement in their condition will be provided.

Chronicity of pain and non-healing wounds may cause the patient to become unwilling to assist with their own treatment. Forcing treatment compliance is an unnecessary and demeaning step and represents a failure to explain and offer the patient an acceptable care plan. The dignity of the patient is compromised by the decision of the treating clinician to remove the patient's ability to have any say in their treatment (and by extension, all staff working for the consultant) and all future cooperation may be imperilled.

Below are images of a total contact cast that has not served the interests of the patient well. The cast was worn for a total of nine days. The patient is diabetic and suffers with peripheral neuropathy secondary to diabetes. The cast had damaged the skin over the anterior tibial spine and the medial malleolus.  The healing of these areas is problematic in healthy patients. There is an additional comorbidity associated with insulin dependent diabetes mellitus and the healing of pressure ulcers which is very well known and delayed healing is the expected outcome.

Front of cast removed showing pre-tibial exudate

Front of cast removed showing pre-tibial exudate

The image above shows the detail of the cast at the point where the anterior tibial spine was subject to a shear force which had abraded the skin. The exudate is the first clue to how the skin is damaged and the smell after just nine days was a second clue. The lack of orthopaedic felt padding to the anterior tibial spine displays a lack of understanding (by the BCC cast technician) about how these iatrogenic injuries are caused.

The thickness of the cast wall (5 layers of casting tape) over the securing casting plates of the Bohler walker shows another misunderstanding of the cast technician. The failure to understand how casting plates are best secured to the cast. They should not require more than two layers of casting tape. No urethane pre-tape was applied over the Bohler walking frame securing plates. This omission had ensured that the Bohler walker was almost impossible to remove because the securing plates were stuck fast under layers of polymer casting tape.

Anterior tibial spine pressure ulcer

Anterior tibial spine pressure ulcer

The pre-tibial pressure ulceration depicted above demonstrates that peripheral neuropathy will prevent an intelligent patient from knowing when a poorly fitted cast is causing a problem. This nine day disaster was only discovered when the patient contacted the plaster room with a problem that could not be described in terms of pain, discomfort or obvious issue. It is the duty of every cast technician to see that patient complaints of cast discomfort are investigated as soon as possible.

Medial malleolar pressure ulcer

Medial malleolar pressure ulcer

The patient was not aware of any uncomfortable feelings around the medial malleolus. The image above demonstrates a pressure ulcer that should have been acutely painful to the patient. 

The image below shows the cast and the Bohler walker attached. The foot is placed in equinus without any clinical prescription to do this. The line of force through the leg was a little too posterior because of the boiler walker placement. 

Detail showing foot in equinus

Detail showing foot in equinus

The image below shows the whole leg with the cast and the Bohler walker in situ. The cast had to be removed by cutting the cast as close as possible to the anterior edge of the securing plates of the Bohler walker along the anterior cast surface. The reverse cuts were made along the posterior surface of the cast. This permitted the lateral and medial sections of the cast to be opened wider, using the Bohler walker legs to bend the cast outwards, and the cast was slipped off the leg. 

Cast and attached Bohler walking frame

Cast and attached Bohler walking frame

The final image demonstrates the thickness of the cast at the malleolus and shows that orthopaedic felt was not used to pad the malleoli. The cast thickness in polymer casting tape looks to be about 6 layers and is far too thick. The plaster of Paris thickness is about double the polymer wall thickness and once again, it is far too thick.

This cast was applied by a BCC qualified cast technician. 

Cast detail showing thickness of cast at malleolus (note absence of felt padding) 

Cast detail showing thickness of cast at malleolus (note absence of felt padding) 

The literature underpins the use of total contact casting to heal plantar ulcers in diabetic patients. There is not much literature to support the creation of iatrogenic pressure injuries in patients who have been prescribed these casts. The risk of pressure injuries under a cast is ever present and cast technicians would do well to understand that our work is a significant vector for creating pressure injuries. 

The work described and depicted above is yet another indictment of the poor training being provided to cast technicians. Our professional tutors need to understand that this very low standard of work is being provided by people who have ostensibly completed the BCC training course and passed the final assessment. Cast technicians MUST do better than this sloppy and unprofessional work. Cast technicians must also be taught that this standard of work is completely unacceptable.   

Advanced Clinical Practices

You Cannot Be Serious!