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Diabetic Foot Ulcer Treatment Priorities:

Vascular Status Infection control

Wound DebridementOff-Loading/

Pressure Relief

Blood Glucose

Control

Patient Education/

Compliance

Wound Environment

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Neuropathic Foot Ulcers

Pre-ulcerative conditions

Post-operative care

Charcot Neuroarthropathy

Debridement Adequate Vascular Supply Infection Control

Total Contact Cast Application

•The Cast is loose, rubbing or pistoning; causing

pain; gets wet

•The Patient has fever, chills, nausea, vomiting or

claustrophobia

YES → REMOVE THE CASTNO → Cast Change in 2-3 Days

Reassess prior to reapplication Charcot Neuroarthropathy

Change Cast Weekly to Bi-Weekly

Forefoot Ulcers

Change Cast Weekly

Midfoot/Rearfoot Ulcers

Change Cast Twice Weekly to Weekly

Continue Casting for Two Weeks After

Ulcer is Healed

Guidelines for the Management of a Patient

with Neuropathic Foot Complications

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How Does It Work?

•Shorten stride length•Eliminating propulsive phase of gait•TCC decreases plantar pressure by up to 69%1

•Full contact with weekly custom fit cast provides control of shear•Ensures 100% compliance

Wertsch, et al, Plantar Pressures with Total Contact Casting. Jrnl Rehab Rsch & Dev , 32:3;205-209, 1995.

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MISAPPLIED CASTS

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Issue #1: Cast is too long

Problems with this cast:

- Lose the “peg in hole” effect of TCC- Can impact peroneal nerve, which may

lead to foot drop- Stretching the cast may weaken the

strength

Recommendation: Remove and re-apply with proximal edge ending at widest part of the calf muscle

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Issue #2: Cast is too short

Problems with this cast:

- Lose the “peg in hole” effect of TCC- Paddle system will reach above proximal

edge of cast- Ineffective at pressure reduction

Recommendation: Remove and re-apply with proximal edge ending at widest part of the calf muscle

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Issue #3: Cast is not complete

Problems with this cast:

- Open toe can allow unwanted articles to enter into the cast

- Toes are not protected from impact while walking

Recommendation: Remove and re-apply with distal end folded over toe area.

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Issue #4: Cast is not at 90 degrees

Problems with this cast:

- Most common error- Plantar flexed cast will crack at ankle

joint over time- May cause pressure points around the

ankle

Recommendation: Remove and re-apply with ankle at 90°

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Issue #5: Dirty Plantar Surface

Problems with this cast:

- Key sign that the patient is not wearing their boot

- May lead to cast breakdown over time- Reduces offloading effect of system

Recommendation: Re-educate the patient and family around the importance of wearing the boot at all times

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Issue #6: Tight Around the Toes

Problems with this cast:

- Bound toes can lead to additional ulcer development on toes or worse if unchecked

Recommendation: Remove and re-apply cast, leaving adequate space for toes (2 finger breadths between toes and padding)

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WHEN PATIENT IS TOO LARGE OR

FOOT TOO DEFORMED…

MEDE-KAST ULTRA IS READY!

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• Prep1

• Roll2

• Apply3

MedE-Kast

ULTRA

Application

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MedE-Kast ULTRA

Application

Prep Apply Primary Dressing

using paper tape

Apply Stockinette up to knee

fold over toes, tape, cut excess

Apply Tibia/Maleolar Pad

secure maleoli first

Apply Grey Toe Foam

start at sulcus of toes and fold

cut excess at each side

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Roll Roll Patient to Prone

bend knee and ankle to 90˚

Roll Cast Padding

use 2-3 pieces across tibia and dorsum of foot to help removal

Roll Plaster Layer

Wet plaster & roll from toes to calf

stop at widest point of calf

Roll Fiberglass Layer

Wet 3” fiberglass and roll from toes to calf – stop just before plaster edge

MedE-Kast ULTRA

Application

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Apply

Apply first splint

Apply splint from calf – overhang toes

– cut & fill into arch-cut at heel

Apply Grey Foot Plate

place on flat surface of foot

Apply Green Walking Peg

align center cut of peg with tibia

Apply 2nd Fiberglass Splint

Fold splint 1/3 and cut about 3”-4”

apply over walking peg – fold proximal edge

Apply Final Roll of 4” Fiberglass

Wet & roll enclosing toes to complete cast

MedE-Kast ULTRA

Application

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• Identify Padding1

• Cut with Cast Saw2

• Remove Internal Layers3

MedE-Kast

ULTRA

Removal

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MedE-Kast ULTRA Removal

Identify padding along tibia, maleoli

and toes

Identify placement

of cast saw cuts on padding

Five cuts

Two sagittal anterior

Two oblique malleolar

One distal transverse

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Cut cast on padding

Five cuts

Two sagittal anterior

Two oblique malleolar

One distal transverse

MedE-Kast ULTRA Removal

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Remove padding along tibia to

dorsum of foot

Remove stockinette with

bandage scissors cut along tibia

Remove foot from cast

MedE-Kast ULTRA Removal