CHAPTER 5I TOTAL CONTACT CASTING

A. Louis Jimenez, DPM, FACFAS

Total contact casting (TCC) was first introduced in 1930s Extrinsic complicating factors include improper by the orthopedist Milroy Paul in Sri Lanka for of treat- removal of the cast. Over aggressive use of saws and ing non-healing ulcers in Hansen's Disease. Paul Brand scissors can create abrasions and possible new sources of used the technique for similar patients and after several infections and ulcers. Practice in cast removal is modifications, brought the technique ro rhe United States paramount prior to attempting to remove TCC especially in the 1960s. Although variations in materials have in neuropathic patients. Indentations in the casts when occurred, the concepts and principles of TCC are patients ambulate prematurely can create depressions in basically the same. the cast that can become new pressure ulcers. For this reason patients need to wait 30 minutes or longer when INDICAIIONS synthetic cast are used and 24 hours when plaster casts are used prior to placing full weight on them. Indications for TCC are: chronic non-healing ulcers associated with neuropathic disorders of various etiologies BIOMECHANICS including diabetes mellitus, leprosy, back injuries, reduction of foot and lower leg edema, allowance for TCC works because it diminishes pressure on the wound, consolidation of the Charcot foot (neuroarthropathy), increases the surface area on the plantar aspect ofthe foot and postoperative adjunct to reconstrucrive surgery. and limits all muscle-tendon activity. Ulcers on the plantar aspect of the foot are formed as a result of CONTRAINDICAIIONS abnormal stresses, usually from bony prominences. TCC AND COMPLICAIIONS causes the patient to shorten his/her stride length, which in turn reduces gait velociry and therefore reduces vertical Contraindications and complications include active loading forces on the foot. Saggital plane motion at the infection, poor pedal hygiene including onychauxic ankle is eliminated thereby eliminating the propulsive and elongated nail, ischemia, non-compliance, and phase of gait. As a result the vertical loading forces are claustrophobia. \Mith respect to infection, the dark, moist eliminated at the metatarsal heads. Once these forces are and warm atmosphere within this cast is an excellent absent, ulcers in the sub metatarsal head area become environment for bacterial growth. Other forms of unloaded and given a chance to heal. unloading should be used until the infection is resolved Application of casting material to the entire skin surface 1eg creates significant contact before TCC application. Nails should be trimmed, as of the foot and long nails with severe incurvation can cause nail lysis and surface area which can reduce vertical forces at the site of obvious paronychial probiem. Xerotic skin should be the bony prominences and reduce edema significantly. treated rvith emollient lotions to avoid fissuring and Edema reduction can be dramatic in the first mo days. If hyperkeratoses if present, debrided. Circumferential the cast becomes loose, pistoning of the extremity occurs bandages should be avoided . Cutting of the bandage into within the cast, which in turn can cause a new ulcer. The skin can occur reducing blood flow to the foot. As cast therefore needs to be changed. Although compared Kominsky states "It is far more important to be to complete bed rest,. crutches, various shoes, orthoses, concerned with what is taken off of the ulcer, i.e., and pads, TCC reduces the need but does not completely pressure, than what is being put on." eliminate the need for compliance. Prior to cast application the ulcer should be evaluated for width and depth. Ulcers that are deeper than CAST APPLICATION they are wide create a problem since epithelialization may occur before the depth of the wound is adequately healed, Application of the cast should be as quick and smooth as possibly allowing an abscess to form. These ulcers should be possible to avoid lamination and thus weakening of the uncapped, treated with open packing then casted. cast. We find that placing the patient prone is the easiest CI]APTER 51

way to apply rhe casr as this avoids the assistant and/or inches are left past the toes, folded dorsally and held in operator from having to hold the extremiry off the table. position with one-inch tape. Folds are created at the anlde Also the patienr is more comfortable as he/she will not get and the excess marerial is cut away and the ends of the cramps in the thigh or hip. The prone position allows the stockinette are taped with one inch tape (Figure 1D). assistant to hold the appropriate position of the foot to One fourth inch foam is placed over rhe toes and past the the leg, usually ninery degrees to the leg. This position metatarsophalangeal joints dorsally and plantarly to also allows the gastro-soleus complex to shift proximally protect the toes and limit MPJ tendonous motion on the leg thereby removing their bulk allowing for the (Figures 1E, 1F). The assistant stands lateral to the cast to fit more snugly. extremity and holds the foot 90 degrees to the ieg while The assistant is of key importance in successful appli- the knee is flexed 90 degrees. One thin roll of webril is cation of a TCC. Any abnormal movement of the snugly placed over the foot and leg with minimal overlap. extremiq. while the cast is drying can be detrimental as a One or rwo rolls of plaster rolls are placed from the disral new point of pressure may be created, which can cause a aspect of the toes ending just below the fibular head. Note new ulcer. Loss of position can also aiter weightbearing so that the toes should be fully covered with the plaster so that inappropriate pressure is placed on rhe plantar aspect that they do not move once the cast dries (Figure 1G). A of the foot. This is not a procedure for the casual assistantll 5" x 30" splint double folded at the distal 1/3 is now applied plantarly from the toes ending posteriorly on the MAIERIALS AND SUPPLIES leg (Figure 1H). The precur ply,wood is placed on rhe plantar aspect of the foot (Figure 1I). It should at least 3" or 4" stockinette meet the entire plantar aspecr of the foot (Figure 1J). 1- 1 " tape Multiple precut 3" to 4" pieces of plasrer material are used '/n" adhesive fek- 4" wide x 20-30" iong. to fill voids in areas where the foot does not meer rhe 3" or 4" webril wood so that ABSOLUTELY NO ROCKING of the 1-3" roll plaster casting tape wood on the foot is noted (1K). Four-inch synthetic rolls 2-4" rolls plaster casring tape are used to cover the foot and leg. The walking heel is 1-2" roll synthetic casting tape centered in the middle of the foot in a line just distal to l-J" roll synrheric casring rape the long a-xis of the tibia (Figure 1L). The foot and leg are 2-4" rolls syntheric casting tape held in this position for a minimum of 5 minutes to allow 1 walking heel the cast to dry. The patient may now be placed in the silicone (clear-site) prorectors supine position and sits for another 20 minutes while the foam toe protectors cast dries. It is preferred to maintain non weightbearing precut pll.wood foot plate for 24 hours until the cast sets up well. The casr is changed as often as necessary but at least weekly to check PROCEDURE for healing and other ulcer formation.

Total contact casting is a precise procedure that requires CAST REMOVAL skillful application. The surgeon should attend a hands- on course and practice applying 3-4 casts prior to purring Cast removal should be performed by an operator thar is one on a patient. The ulcer is debrided in standard completely familiar wirh cast saws and cast removal. A small fashion and if a dressing has to be applied, it is held in nick on the skin may have severe consequences. A hear,y position with one inch paper tape. Circumferential dress- marking pen may be used to place a line exactly where the ings are not recommended for reasons previously doctor wants the casr to be split (Figures 2A, 2B). discussed. The patient is placed in the prone posirion (Figure 1A). Bony prominences, and the posterior heel SUMMARY and achiiles tendon are padded (Figure 1B). One fourth inch adhesive felt is applied to the leg and foot starting TCC is an excellent procedure for healing foot ulcers. It is anteriorly on rhe tibial tuberosity crossing the ankle, my feeling that any ulcer that has some vascularity can be ending on the dorsum of the foot (Figure 1C). healed with TCC. k is skillfully demanding and requires Alternatively in sensare parienrs, the felt can be applied to practice to expertly apply it. It is preferable to have an the medial and lateral aspects of the leg and foot. assistant that has had hands on experience with application, Stockinette smaller than the size one would normally use , holding and removing of TCC for best results. is placed from the toes to just below the knee. One to nvo 284 CHAPTER5l

Figure 1B. Medial and lateral malleoli, posterior calcaneus, and distal 6 crn. of tendo-achillcs arc padclecl to avoid pressure ulcers. Photo shows Clear Site covcrin€! these areas.

Figure 1A. Patient in prone position. Knee and ankle are flexed 90 degrees . This position is easier for the paticnt ancl surgeon for cast application.

Figure 1D. Stockinette is tblded dorsally over the toes and secured rvith one l " tape. After the fbld on the anterior ankle is removed, 1" tape holds the edges apposed.

Fieure 1C. Angular cuts are placcd in the 1/4" felt which allows lor better contouring lvhen placed on the anterior leg, ankle, and dorsal of the foot. CHAPTER 51 285

Figure 1 F. Lateral vierv showing fbam as in 1 E,

Figure 1E. Plantar view shorving one fourth inch adhesir.e foam placcd or.er the toes ancl MP]'s to avoid pressure.

Figure 1H. 5" x 30" splints folded at rhe distal 1/3 and doubled on itselfand then applied ro the plantar and posterior,rspects ofthe loot and leg.

Figure 1C. The entire fbot;rnd lorver leg lvill be covered rvith plaster.

Figure 1 I. Precut plpvood rvill be appiied to the plantar aspect of the foot 286 CHAPTER 51

Figure 1J. Segments of plaster which wiil be applied to the plantar of the Figure 1K. The precut plpvood applied to the plantar aspect of the foor is pllvood. further stabilized bi, adding portions of plaster rvhere openings are present benvcen the fbot and the pipvood to minimize rnovernenr.

Figure 1L. Lateral vierv of completed cast shorving rvalking heel incorporated into the cast.

Figure 1M. Alterior vierv shou'ing finished cast with walking heel. CHAPTER 51 287

Figure 2A. Dark lines mark the :rreas of cast that rvill Figurc 28. Extremjry after removal from cast be split. The lines lall over the 1/4" felt applied to the leg and foot. Cast is removed eithcr at the solid line or by cutting out a strip as ourlined be thc outer broken

I i nes-

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