On-line CEUs

TIP OF THE MONTH: August/September 2007
Total Contact Casting Technique
Robyn Masseth, OTC

Nearly 35% of diabetics experience ulcers of the foot and ankle at some time in their lives. Because many diabetics experience neuropathy or lack of sensation in their feet, many of them have abnormal pressure distribution when walking. Continuous pressure on the skin for even a short time can cause the skin to breakdown and ulcerate. The dangers of an exposed ulcer can lead to infection, amputation and can also play a factor in the morbidity and mortality of patients.

It seems each year while attending NAOT’s national symposium Total Contact Casting (TCC) seems to be a hot topic. There are many different techniques of TCC that have been shown throughout the years. Differences can include the use of plaster vs fiberglass, some use little or no cast padding, others may or may not enclose the toes.

Since the role of the OTC is so important, they must be open minded to trying new techniques, be willing to practice and become proficient, and to find what works best for them and their patients. After attending the 2006 symposium, I have found a method that, for me, is far above all others in results. Since last August I have had over 30 patients whom I have used this technique of TCC. I have had only one that did not heal and that was due to an underlying infection before the cast was applied.

This technique is specifically for plantar surface and heel ulcers. I did attempt to try this technique on a patient that had a mid-foot amputation where the incision was not healing. This did not gain any improvement. A TCC is designed to reduce the shear forces and off-load pressure from the ulcer, giving the ulcer time to heal. The only way to completely do this is for a patient to be on complete bed rest and not be allowed to put any pressure on the ulcer. However, since most patients cannot do this without it severely affecting their daily lives, a TCC is the next best thing.

Figure 1

In my opinion, the thing I like best about this TCC technique is that it allows patients to still be weight bearing. Patient compliance is now taken out of the equation when using this technique. I haven’t had a single patient who has walked “too much.” At each visit the physicians will want to debride the ulcer of the old calloused skin. He may even choose to use a wound healing product to the area (Figure 1). However, if you do this, do NOT apply gauze dressings or a bandage to this area before the TCC is applied. Make sure any bleeding is stopped but we would still want the ulcer to be exposed, to get “total contact” with the cast.

MATERIALS NEEDED FOR THE TCC:

•4” Stockinette Tape
•1 roll - 3” Cast padding
•1 roll - 4” Cast padding
•1 pkg - 4x30 or 5x30 Primacast
•2 rolls - 3” 3M SoftCast
•2 rolls - 4” 3M SoftCast

For those of you who have never used Primacast, it is a synthetic splint material that has an excellent conformability. It leaves no creases or rough edges, alleviating any chance of causing further pressure areas. It also is extremely strong. For those of you who have never used Softcast, it looks exactly like a fiberglass, however when it is dry it is somewhat flexible.

APPLICATION

Step 1:

Apply the stockinette and cast padding as you would for a short leg cast. Remember to cut out the stockinette at the bend in the ankle, anteriorly, and tape.

Step 2:

Take the Primacast conformable splint and apply this to the posterior of the leg (Figure 2)

Figure 2

Secure the splint using the 4” Softcast from 2 inches behind the knee and rolling downward, wrapping exactly as you would for a short leg cast, using regular fiberglass (Figure 3).

Figure 3

Give the patient a cast shoe for walking and to protect the integrity of the cast (Figure 4). Essentially when you are done, you have a posterior splint secured within a short leg cast. The Softcast combined with the Primacast conformable posterior splint takes the sheer force away, allowing the patient to walk. This gives a rigid enough surface that allows the patient to walk and yet, the flexibility of the Softcast moves with the patient and does not cause any rubbing in other areas.

Figure 4