Problems with totalcontact cast

A 63-year-old female with type 1 diabetes mellitus of 20 years' duration, developed an acute Charcot's osteoarthropathy which was treated in a total-contact cast. She was a very successful milliner who was currently making hats for Royal Ascot Races, and was working from a studio at home with a team of assistants. She failed to attend for her 1-week cast check. We telephoned her and she said that the cast was fine but she was frantically busy making hats and really did not want to come in. We persuaded her to attend. When she came the following day she looked tired and unwell, and the cast was in poor condition with dehiscence of the lamina. Before the cast was removed she volunteered that she 'might have dropped some pins down it'. On cast removal she had a deep necrotic ulcer on the plantar surface of the foot caused by a pin which had penetrated the inner layers of the cast (Fig. 4.6a,b) and punctured her foot. She was admitted to hospital the same day (she booked a private room and continued to direct her team preparing for Ascot over the telephone). She underwent surgical debridement and the foot healed in 2 months.

Key points

• Regular cast inspections are essential

• A patient's report on the condition of the cast may be unreliable

• A patient's occupation may be hazardous without special precautions.

Rarely a total-contact cast causes an eczematous eruption.

Fig. 4.6 (a) Cast in poor condition with pin protruding, (b) Site of ulcer on plantar surface of 5th ray indicating area where pin penetrated the foot.

Fig. 4.6 (a) Cast in poor condition with pin protruding, (b) Site of ulcer on plantar surface of 5th ray indicating area where pin penetrated the foot.

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