Background
Total Contact Cast (TCC)
- heal ulcers by reducing pressure
- 1/3 of load is taken by wall of cast & transmitted to the leg
- 45% reduction in forefoot pressure but not heel pressure
Indications
1. Superficial forefoot and midfoot plantar ulceration
2. Eichenholtz stage I or II neuroarthropathic fractures
3. Post operative neuropathic foot surgery
Contraindications
| Heel ulcers | Deep infection | Poor skin quality | Severe arterial insufficiency | Poor compliance |
|---|---|---|---|---|
|
Not effective - ischaemic component & osteomyelitis - TCCs don’t reduce heel pressure |
Abscess, osteomyelitis, gangrene - beware of ulcer with drainage - treat infection with rest in bed / NWB / Antibiotics - if ulcer is deeper than wide - surgically debride to open ulcer - allow deeper layers to heal & convert to superficial ulcer |
ABI < 0.45 Doppler toe pressure < 30mmHg TcPO2 < 30 |
Need regular cast change | |
TCC Application
Technique
Absorbent gauze on ulcer
- enclose the toes with gauze between toes to reduce moisture
- seamless stocking
- felt over bony prominences
- avoid overpadding the cast / increases shear forces
- well moulded POP / fibre glass
Protocol
First 6 weeks
- change weekly
- edema subsides quickly
- photos of ulcer at each change
Biweekly for first 6 months
- until ulcer healed / Stage 2 Charcot
6 months
- change to orthotic
- CROW (Charcot restraint orthotic walker)