North West Podiatry Services

Clinical Effectiveness Group for Diabetes

Guideline for the Provision of Heel Casts for

the Treatment of Heel Ulcers

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Development Group

Andrew Sharpe Advanced Podiatrist and Team Leader, Southport and

Ormskirk NHS Trust and Lecturer Practitioner, University of
Huddersfield

Carol Fletcher High Risk Foot Team Podiatrist, Tameside Hospital NHS
Foundation Trust

Hazel Whitehead Wound Care Specialist Podiatrist, Liverpool Community

Health

Graham Holt High Risk Foot Team Lead, Pennine Acute (Community)

Jenna Tilbury Advanced Podiatrist, Pennine Acute

Dr Jane McAdam Director of Prosthetics & Orthotics and Podiatry,

University of Salford

External Reviewers

Abbie Dagg Clinical Podiatric Lead Rheumatology, Mid Yorkshire NHS

Hospital trust and lecturer in diabetes at Staffordshire
University

Keri Hutchinson Principal Podiatrist (Acute Services), Cwm Taf University

Health Board

Clair Priestley Tissue Viability Nurse, Pennine Acute (Community)

For further information contact:

Andrew Sharpe
Tel: 01695 588452
E-mail: Andrew.sharpe3@nhs.net

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Use of the guideline

The purpose of this guideline is to provide a consensus agreement on the use of

heel casts in practice.

The guideline should be considered in conjunction with:

• NICE NG19 (2015) – Diabetic Foot problems: Prevention and

Management.
• Mental Capacity Act (2005).
• NICE CG119 (2010) – Inpatient Management of Diabetic Foot Problems.
• NICE CG147 (2012) – Lower Limb Peripheral Arterial Disease: Diagnosis
and Management.
• NICE CG179 (2014) – Pressure Ulcers: Prevention and Management of
Pressure Ulcers in Primary and Secondary Care.
• North West Podiatry Service Clinical Effectiveness Group – Guidelines for
the Treatment of the Diabetic Foot (2014).
• Human Rights Act (1998).

Overview

Heel ulcers are often caused or delayed in their healing by some form of external
pressure, either dynamic (walking) or static pressure. To promote wound healing,
heel ulcers require off-loading modalities such as heel casts (Lewis and Lipp,
2013). Although commonly used across the UK, there is currently limited
guidance for the use of heel casts. The evidence for use is low, but practice and
small-scale case studies for heel casts have shown to improve healing times
(Stuart et al, 2008; Dagg, 2013).

As an expert group of practitioners working predominantly in wound care, we

have consolidated current practice, knowledge and evidence to produce a
guideline that offers a consensus agreement on the use and manufacture of heel
casts in practice. It is intended that they will give advice on safe and appropriate
use and method of application for heel casts in relation to heel ulcers.

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CONTENTS
1. Introduction 5
1.1. Aim 6
1.2. Limitations 6
1.3. Definitions 7
2. Review of current evidence 8
2.1. Method 8
2.2. Results 8
3. Indications for use 10
3.1. Informed Consent 10
4. Cautions and contra-indications 12
4.1. Contra-Indications 12
4.2. Cautions 12
5. Cast fabrication 13
6. Key layers 14
6.1. Dressing 14
6.2. Base Layer 14
6.3. Orthopaedic Wool Layer 14
6.4. Heel cast 14
6.5. Retention layer 14
7. Footwear 15
8. Review 15
9. Associated training 16
10. Audit 16
11. Governance 16

References 17
Appendices 18

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1. INTRODUCTION

The North West Podiatry Services Clinical Effectiveness Group (CEG) for
Diabetes have been producing guidelines since 2004 and have used quality, up-
to-date evidence and expert opinion to ensure the best guidance possible.

The main cause of ulceration to the heel is pressure either though dynamic
pressure such as walking or prolonged static pressure, with or without shear and
friction (Nabuurs-Franssen et al, 2005; European Pressure Ulcer Advisory Panel
[EPUAP] and National Pressure Ulcer Advisory Panel [NPUAP], 2014; Lewis and
Lipp, 2013; NPUAP, EPUAP and Pan Pacific Pressure Injury Alliance [PPPIA],
2014). Heel ulcerations occur following localised trauma leading to a breakdown
of skin integrity (Edwards and Stapley, 2010; McGinnis and Stubbs, 2014).
Underlying comorbidities, such as peripheral neuropathy and / or peripheral
arterial disease (PAD), can increase this risk due to altered feedback from
pressure damage or reduced tissue perfusion from external stresses (National
Institute for Care and Excellence [NICE], 2012; 2015).

The heel is particularly susceptible to pressure damage and / or ulceration due to

its anatomical design. The posterior heel is at increased risk of increased peak
pressure and damage from increased force when the body is laid flat because
the heel bone becomes a bony prominence with little subcutaneous fat or soft
tissue on the posterior aspect that protects the area, hence why it is the second
most common site to develop pressure ulcers (Gefen, 2010; McGinnis and
Stubbs, 2014).

In order to understand how to heal ulcers on the heel, the basics of pressure
relief need to be understood. Pressure is force applied over an area, therefore to
reduce pressure force needs to be reduced or the surface area increased, or a
combination of the two. The increase in time or intensity (force time integrity) of
pressure to an area is known to increase the level of damage, hence the national
and international guidelines advocate the removal of pressure (NPUAP, EPUAP
and PPPIA, 2014).

A reduction in pressure and an increase in surface area can be achieved through

the use of focused rigidity casts or heel casts. This is reflected in practice where
there has been increased use of focus rigidity casts to reduce pressure and
therefore treat heel ulcers. The Manchester ‘Martini’ Cast and soft cast heel
protection devices have been shown in small-scale case series studies to
advocate their use in ischaemic and / or diabetic foot ulcers, as well as pressure
ulcers (Stuart et al, 2008; Hutchinson et al, 2010). There is a multi-site
randomised control trial currently ongoing for heel casts being produced by the
Foot Ulcer Trial Unit (FUTU) to assess the effectiveness in diabetic foot ulcers on
the heel (www.futu.co.uk).

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1.1 Aim of guideline
To produce a guideline to offer consensus agreement on the use of heel casts in
practice. Where the evidence base is lacking, agreement on current best practice
will form the basis for the guidance.

The objectives are to:

• Review current evidence for the use of focused rigidity casts for the
treatment of heel ulceration.
• Discuss the indications for use, identify contraindications and cautions.
• Agree principles for heel cast fabrication and application.
• Advise on additional requirements of casting, such as supportive footwear.

1.2 Limitations of guideline

These guidelines are for the use of a casting technique for the heel only (referred
to as heel cast).

Plantar heel ulcers (where they are entirely on the plantar surface) should be
considered for a below knee non-removable Total Contact Cast (TCC) or
removable walker as a first line treatment (Lewis and Lipp, 2013). Plantar
pressures are a major component of the causative factors of ulcers located in this
position, thus modalities other than the heel cast described in this guideline have
been shown to be effective (Armstrong et al, 2001; Lewis and Lipp, 2013). Heel
casts or focused rigidity cast (FRC) may be considered where TCC are not
appropriate (Dagg, 2013).

Heel casts are a development on the principle of the focused rigidity cast (FRC).
They are made from semi flexible polymer casting material where increased
rigidity is applied by adding extra layers of cast material to the site that requires
pressure relief (Dagg et al, 2013). This process provides an ‘external skeleton’
structure to redistribute pressure from a focal site across a wider area to promote
healing and / or pain relief (Hutchinson, 2010). This guideline is focused on the
principle of redistributing pressure from the ulcer site and does not include
methods that involve a ‘cavity’, ‘ballooning’ or ‘recessing’ at the ulcer site, which
have been observed in practice.

These guidelines do not:

1. Make any recommendations on particular casting products. Clinicians
should consider cost-effectiveness, efficiency and safety when selecting
casting tapes.

2. Differentiate between the types or causes of ulceration (e.g. diabetic foot

ulcer, pressure ulcer, ischaemic ulcer).

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1.3 Definitions

Heel cast – A bespoke removable cast with an area of reinforcement overlying

an active or recently healed ulcer that is within the heel region. The cast covers
the medial, lateral, plantar and posterior aspect of the heel, ending below the
malleoli, and can extend along the plantar aspect of the foot ending proximal to
the level of the styloid process.

Heel ulcer – Ulceration of the skin over the calcaneum but below the level of the
malleoli. They may be posterior, medial or lateral. Ulceration that is entirely on
the plantar surface of the foot at the location of the heel would be considered a
plantar foot ulcer. Plantar pressures are the major cause of an ulcer located in
this position.

Total Contact Cast (TCC) – A custom made cast that encloses the entire lower
limb from below the knee. It supports the lower limb and redistributes pressures
across the foot to relieve pressure on the ulcer site. Total contact casts are non-
removable (Lewis and Lipp, 2013).

Focused Rigidity Cast (FRC) – A cast where an area of increased rigidity is

applied at the site that requires support, pressure reduction or offloading by
increasing the number of layers of casting tape (Dagg, 2013).

Slipper cast – A removable cast that encloses the whole of the foot. It is used
like a TCC for ambulatory treatment during the healing phase of foot conditions.

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2. REVIEW OF CURRENT EVIDENCE

2.1 Method
A literature search was undertaken to establish what evidence was available to
support the use of heel casts in the treatment of heel ulceration. Relevant studies
were identified after a comprehensive search of the literature. This was achieved
by identifying key words, the key words were developed using the review group
from the North West Podiatry Clinical Effectiveness Group. See Table 1 for
search terms and databases searched.

Table 1 – Search terms and search databases

Search terms Databases searched
1. [‘foot’ OR ‘feet’ OR ‘heel’] Cumulative Index to Nursing and Allied
2. [‘focus’ AND ‘rigid*’] Health (CINAHL)
3. [‘cast*’] United States National Library of
4. Scoping terms [‘diabetes’ OR Medicine (MEDLINE)
‘pressure ulcer’] British Nursing Index (BNI)
Health Management of Information
Consortium (HMIC)
Search results Manual search
0 results The publications of known clinicians
working within the field. From the
group’s experience and previous work
by Dagg (2013) helped identify three
suitable poster presentation
publications (Stuart et al, 2008,
Hutchinson et al, 2010 and Hutchinson
et al, 2011).

The databases chosen are commonly used by researchers when searching for
health based citations (Mulrow and Cook, 1994). Each database has specific
characteristics and should, therefore, yield a better return. When deciding on the
appropriate electronic databases to search, consideration of the advantages and
disadvantages of each needs to be taken. Collectively, the output from all these
databases should have the net result of ensuring fullness, effectively exhausting
all search parameters (Barton, 2000). To review the evidence, a consensus
group of clinicians working in the field of podiatry and wound care, with the
inclusion of podiatrists working in musculoskeletal management was set up.
Where there are gaps in evidence an agreement of best practise was reached.

2.2 Results
The extent of the evidence for the use of heel casts was limited. Both Hutchinson
et al (2010; 2011) and Stuart et al (2008) have demonstrated their effectiveness
in treating diabetic and pressure heel ulcers even when PAD / ischaemia is

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noted. However, other evidence in casting has excluded the inclusion of
ischaemia (Armstrong et al, 2001; NICE, 2015). As highlighted, total contact
casts remain the gold standard for plantar foot ulcers but there is a currently a
lack of randomised control trials specifically for heel casts, which are a form of
focused rigidity casting (Lewis and Lipp, 2013; Dagg, 2013). Despite the lack of
evidence, heel casts continue to be used in regular practice. It is, therefore,
deemed to be appropriate to give guidance based on current knowledge and best
practice consensus agreement.

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3. INDICATIONS FOR USE

The purpose of a heel cast is to provide pressure relief over fragile, ulcerated or
previously ulcerated sites of the heel. It is indicated for use where pressure,
shear and friction have contributed to the cause of or prevent healing of an ulcer.
In patients where ulcer healing is unlikely, a heel cast may be used for pain relief
or to prevent deterioration. A heel cast is not the first treatment choice for ulcers
that are solely on the plantar heel (see section 1.2 Limitations of Use).

As the heel cast is removable it allows the patient, carer or health care provider
to inspect the foot if required and does not need to be re-made at each dressing
change. In addition, Stuart et al (2008) also demonstrated the cost savings by
reducing the use of more expensive medical devices, speeding up healing times
and perhaps most importantly reducing pain for patients.

3.1 Informed Consent

To enable informed consent for treatment, patients should be made aware of the
intended benefits and potential risks of a heel cast. Where informed consent
cannot be obtained trust policies should be referred to and treatment should be in
the best interests of the patient.

The known benefits and risks are as follows:

Benefits:
• Improved healing times
• Pain reduction
• Improved mobility
• Removal of the cast allows inspection of the foot or ulcer
• Removable
• Provide pressure redistribution
• Light weight
• Cost effective
• Can be made to fit different shapes of heels and feet- custom made
(Stuart et al, 2008)

Risks:
• Wound deterioration
• Pain
• Slip, trip or fall risk
• Abrasion, injury or new ulceration
• Allergic reaction to the material
(Consensus agreement)

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N.B. This is not an exhaustive list and is based on clinical experience. The group
welcomes clinicians to advise of any adverse effects that occur with the use of
heel casts to add to this list as necessary

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4. CONTRAINDICATIONS AND CAUTIONS

4.1 Contraindications
• Patient refusal
• Cast is the cause of deterioration or further ulceration
• Allergy to any of the products used

4.2 Cautions
• Ischaemia
o NB. It is important that these patients have been assessed for
vascular reconstruction as per Peripheral Arterial Disease
guidelines (NICE CG147, 2012). Pain relief should be
addressed in line with local guidelines.
• Non-concordant patients – the cast cannot be made as non-removable
and so is not appropriate for patients who may remove or interfere with the
cast or protective dressings e.g. patients with dementia.
• Lower limb contractures – the potential to cause rubbing from the heel
cast to the opposite limb or the same limb needs to be considered.
• Poor mobility / stability / falls risk – the cast can potentially alter gait and
therefore must be used with caution in patients with poor mobility.
• Oedema – oedema must be monitored as an increase may lead to
constriction from the cast or a decrease may lead to the cast becoming
loose and rubbing.
• Exudate levels and / or incontinence – high levels of exudate or urine /
faeces may soil the cast and increase bacterial risk to the ulcer.
• Footwear – consider patients footwear, ensure it is accommodative for
additional material.
• Plantar heel ulcers.
• An individual risk assessment should be carried out for each patient and
practitioner when undertaking a heel cast. (For example of a Risk
Assessment Form, see Appendix 1)

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5. CAST FABRICATION

This does not constitute instructions for creating a cast. Clinicians should
undertake formal training in casting techniques from a competent
person(s) and demonstrate initial / ongoing competence.

Key principles for making heel casts

• Do not use bulky, non-conformable dressings under the cast.

• Non-elastic stockinette should form the first layer of the cast.
• The distal edge of the cast should extend no further than proximal to the
level of the styloid process.
• The proximal edge of the cast should be below the malleoli.
• The casting tape should have as little overlap as possible without any
gapping in the ‘shell layer’. There should be no more than 50% overlap of
the casting tape.
• The reinforced area provides increased rigidity and can be applied as a
concertinaed ‘slab’ or layered to produce a ‘fan’ style.
• The reinforced area provides redistribution of pressure away from
the ulcer and must be larger than the actual ulcer site.
• 4 – 5 layers of reinforcement should overlie the ulcer
• Contouring the protective / redistributing area is important to
prevent damage to underlying skin.
• The reinforced area should stop before the edge of the overall cast.
• The outer edges of the cast should be a single layer thick where possible
and certainly no more than double layer.
• The internal surface of the cast must be checked to ensure there are no
creases or ridges that may cause trauma.
• Coloured casting material is preferable so that it is not accidently thrown
out with dressings. White material can very easily get lost in the dressing
debris.
• Advice leaflets for patients / carers and health care professionals should
be provided. (For example of Health Care Professional Advice leaflet, see
Appendix 2. For example of Patient advice leaflet, see Appendix 4).
• For example of materials and method used in heel casting, see Appendix
3)

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6. Key layers

6.1 Dressing
Dressings should be appropriate for use with the heel cast. Bulky, non-
conformable dressings may not be suitable. The heel cast is made over the
dressing and if the dimensions of the dressing, limb or foot change significantly,
then a new cast should be considered.

6.2 Base layer

A layer of tubular bandage should be applied over the dressing, this is essential
to prevent the cast coming into contact with the skin. The size of the tubular
bandage should be appropriate to the limb and should fit well without excess
material that may crease or be too tight and cause compression. Tubigrip or
similar products must not be used.

6.3 Orthopaedic wool layer (NOT RECOMMENDED)

Review of the evidence and consensus agreement is that an additional layer of
orthopaedic wool is not recommended. An additional layer may cause friction,
and further delay wound healing. The purpose of orthopaedic wool is to provide
limb uniformity in compression bandaging and does not appear to have any
evidence in preventing rubbing.

6.4 Heel cast

The cast is made by applying casting tape on top of a layer of tubular bandage. It
should be applied under slight tension to ensure conformity. There should be no
gaps in the cast and minimal overlapping of the casting tape is recommended for
conformity. A ‘slab’ or ‘fan’ technique is applied over the ulcerated area using 4 –
5 layers of casting tape. Where indicated, a splint casting material may be used
to reinforce the cast. The distal and proximal edges of the cast should avoid the
malleoli and styloid process; however, in some cases the cast may be taken over
the malleoli to secure the cast. Casts are bespoke and patient dependant.

6.5 Retention layer

The cast should be secured to the foot over the stockinette with a retention layer
of tubular bandage to ensure the cast does not shift. Use of bandages with
elastic characteristics should be avoided as they could cause compression,
particularly in ischaemic patients

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7. FOOTWEAR

In mobile patients or those who sit out of bed, the heel cast should be used with
protective footwear. This will depend on the dressing regime, the number and
type of layers used with the cast. The choice of footwear should not compromise
the effectiveness of the cast nor exacerbate the risks of using the cast.

The cast can be used with the patient’s own footwear. An assessment of fit and
function with the dressing and cast in place should be made to ensure other sites
on the foot are not put at risk of damage. Post-operative sandals are a good
alternative to the patient’s own footwear. The risk of ulceration to other sites on
the foot should be assessed before providing the sandal.

The ability of the patient to walk safely in the cast and any alternative footwear
provided should be assessed. It may be appropriate for assistive devices (e.g.
walking stick, crutches) to be provided to enhance patient stability and
confidence.

Locally agreed protocols should be followed when providing assistive devices. A

difference in leg length may be created by the provision of alternative footwear,
thus addressing this should also be considered as part of the treatment
approach.

8. REVIEW

After the cast is initially applied, it must be reviewed by a suitable person in a

timely manner as per a management plan. It is the responsibility of the person
applying the cast to ensure the cast is reviewed. During this period, the cast and
protective dressing will need to be removed for skin inspection at least once a
week as a minimum.

The use of the heel casts post-healing is believed to prevent newly intact skin
from re-ulcerating (consensus agreement). This guidance advises that a heel
cast can be used for up to a further four weeks to protect newly intact skin but
there should be a skin check either by patient, carer, or health professional at
least once a week.

Appropriate long-term pressure relief should be addressed during this period

after healing if not already in place.

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9. ASSOCIATED TRAINING

Formal training should be undertaken by professionals prior to providing heel

casts in practice, and the practitioner should retain proof of training. In order to
demonstrate competence it is recommended this should be delivered by a
competent professional and includes ongoing peer review and reflective practice.
(For an example of peer based competence assessment see Appendix 6)

10. AUDIT

It is recommended that the safety and efficacy of heel casts are audited to ensure
patient safety and continually improve patient care. (For example of audit data
sheet, see appendix 7)

Areas that should be considered when auditing are:

• Adverse events – undertake an investigation to establish underlying cause
• Healing times
• Outcomes
• Pain reduction
The name of the person casting should be included in the audit to identify any
training needs as early as possible.

11. GOVERNANCE

As with all patient interventions, heel casting should have a robust governance
structure to ensure safe and effective interventions. It is the recommendation of
these guidelines that the following should be in place:
• Risk assessment
• Casting competencies
• Patient information leaflet
• Process for auditing outcomes and adverse events
• Standard operating procedure (SOP) (For example of an SOP, see
Appendix 5)

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References
• Armstrong D, Nguyen H, Lavery L, Carine H et al (2001) Off-loading
The Diabetic Foot Wound. A randomised Clinical Trial. Diabetes
Care 24(6): 1019–22
• Barton S (2000). Which Clinical Studies Provide The Best Evidence? The
Best RCT Still Trumps The Best Observational Study. BMJ 321(7256):
255–6
• Dagg A (2013). What Is A Focused Rigidity Cast? Where Do They Come
From And What Is The Evidence? Wounds UK 9(2): 12
• Dagg A., Chockalingam N, Brainthwaite H, (2013). Focused Rigidity Casts
- An Overview. Journal of Wound Care 22 (2)
http://dx.doi.org/10.12968/jowc.2013.22.2.53
• Edwards J, Stapley S (2010). Debridement Of Diabetic Foot Ulcers.
Cochrane Database Syst Rev (1):CD003556
• European Pressure Ulcer Advisory Panel and National Pressure Ulcer
Advisory Panel (2009). Treatment Of Pressure Ulcers: Quick Reference
Guide. Available at:
http://www.epuap.org/guidelines/Final_Quick_Treatment.pdf (accessed
26.04.2016)
• Gefen A (2010). The Biomechanics Of Heel Ulcers. Journal of Tissue
Viability. 19(4): 124 –31
• Hutchinson K, Alexander R, Cawley S (2010). Audit Results Of The Use
Of Soft Cast Heel Protection Devices On Patients With Heel Pressure
Ulceration. J Foot Ankle Res 3 (Suppl 1): 12
• Hutchinson K, Goulding V, Cawley S, Alexander R (2011). Results Of A
Year-Long Service Evaluation Into The Use Of Heel Casts To Treat
Pressure Ulcerations And Lesions. Poster presented at: Society of
Chiropodists and Podiatrists Annual Conference, Harrogate
• Kosiak M (1959). Etiology And Pathology Of Ischemic Ulcers. Archives Of
Physical Medicine And Rehabilitation. Arch Phys Med Rehabil 40(2): 62–9
• Lewis J, Lipp A (2013). Pressure-Relieving Interventions For Treating
Diabetic Foot Ulcers. Cochrane Database Syst Rev 1: CD002302
• McGinnis E, Stubbs N (2014). Pressure-Relieving Devices For Treating
Heel Pressure Ulcers. Cochrane Database Syst Rev 2: CD005485
• Mulrow C, Cook D (1994). Systematic Reviews. Synthesis Of Best
Evidence For Health Care Decisions. American College of Physicians,
Philadelphia
• Nabuurs-Franssen M, Sanders A, Sleegers R et al (2005). Total Contact
Casting Of The Diabetic Foot In Daily Practice: A Prospective Follow-Up
Study. Diabetes Care 28(2): 243–7
• National Institute for Health And Clinical Excellence (2012). Peripheral
Arterial Disease: Diagnosis And Management. CG147. Available at:
https://www.nice.org.uk/guidance/cg147/resources/peripheralarterial-
disease-diagnosis-and-management-35109575873989
(accessed 26.04.2016)
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 • National Institute For Health And Care Excellence (2015). Diabetic Foot
Problems: Prevention and Management (NG19). Available at:
https://www.nice.org.uk/guidance/ng19 (accessed 6.04.2016)
• National Pressure Ulcer Advisory Panel, European Pressure Ulcer
Advisory Panel And Pan Pacific Pressure Injury Alliance (2014).
Prevention And Treatment of Pressure Ulcers: Quick Reference Guide.
Available at: http://www.npuap.org/wp-content/uploads/2014/08/Quick-
Reference-Guide-DIGITAL-NPUAPEPUAP-PPPIA-Jan2016.pdf (accessed
26.04.2016)
• Petty A, Wardman C (1998). A Randomised Controlled Comparison Of
Adjustable Focused Rigidity Primary Casting Technique With Standard
Plaster Of Paris / Synthetic Casting Technique In The Management Of
Fractures And other Injuries. Journal of Orthopaedic Nursing 2(2): 95–102
• Stuart L, Berry M, Wiles P (2008). The Manchester ‘Martini’ Cast – Any
Time, Any Place, Anywhere! Poster 27 presented at the Diabetic Foot
Study Group, Lucca, Italy. Abstract available from: http://bit.ly/Q2ERgc
(accessed 03.06.2015)

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 Appendix 1

RISK ASSESSMENT FORM

Hospital Site ANON Division Diagnostics and Clinical Support Department Orthotics and
Podiatry

Date October 2013

Source of Risk (reason for risk assessment, e.g. Incident report, inspection, Routine Assessment etc)
Routine Assessment, previous incident

Work Activity (Describe work processes)

Providing podiatry treatment/interventions. Lifting and supporting the patients lower limb. Use of cast
saw, cast scissors, the nail clippers and scalpels.

Persons Affected/Those at Risk

Podiatry Staff

Risk Description
Injury to staff during treatment of patients. Injury to staff whilst using equipment.

Hazards Identified (list here)

Bending/stooping to assess and treat foot complaint if patient is immobile and/or presents with
retracted limbs. Lifting of heavy limbs. Manufacturing a TCC without an assistant. Working in a
restricted space. Working in poor light. Lack of maintenance of equipment. Lack of equipment.

Risk Assessment process (Likelihood X Consequence = Risk Rating)

Likelihood: Possible
Consequence: Minor
Risk Rating: Moderate

Controls in Place (list here e.g. training, Trust Gaps in Controls: (Identify weakness in control and
policy, Equipment etc) these must be addressed in action Plan)

1. Trust manual handling policy 1. Staff ignoring risk assessment in place e.g.
manufacturing a TCC without an assistant.
2. Mandatory manual handling training
3. Professional training
4. Patients individually risk assessed
5. Staff individually risk assessed e.g. pregnancy
5. Expert advice from manual handling trainers
6. Use of aids/equipment to support lower limb
e.g. foot wedge.
7. Assistant to support limb when manufacturing a
TCC
Control Effectiveness (None, Uncertain, Weak, Some weaknesses, Satisfactory):
Some weakness

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Residual Risk Rating (Control Effectiveness X Risk Rating from above)
Moderate
Further Controls/Actions:
(If the residual risk is HIGH or SIGNIFICANT the action plan overleaf must be completed.
The action plan should include interim actions already taken or proposed to reduce the risk;
whilst working towards implementation and/or funding of the ultimate action plan to remove
the risk or reduce it to an acceptable level.)
Signed Samantha Davies Designation Clinical Specialist Podiatrist

Review Date October 2014

RISK REMOVAL/REDUCTION ACTION PLAN

Action Description of Action * Priority** Responsibility*** Cost**** Due Date

No. Date Completed

The importance of following

1 the risk assessment to be
discussed at the next team
meeting.

* Description of actions should include interim actions already taken as well

as those planned that will reduce the risk prior to the final action identified.
** Priority should be HIGH, MEDIUM or LOW.
*** Responsibility is the individual, group or management team responsible
for the action.
**** Cost should be the estimated total cost of implementing the identified
action

Dates should be realistic and achievable; where interim actions have already
been taken then the date they were implemented should also be included in the
‘Date Completed’ column.

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Appendix 2

Softcast Information Sheet

Patient Surname………………..…………..NHS
Number………..……………………….
Patient Forename…………………………..Date of
Birth……..…………………………..
Address…………………………………………………………………………………….
..…
Ethnicity………………………………………………………………………………..…
……

The cast is made individually for the patient using a semi-rigid casting tape. This
is a polyurethane resin.
The cast is made to be flexible but is reinforced with extra casting tape over the
site of ulceration. The rigidity of the cast in this area reduces pressure/ sheering
and friction forces.
The casts can be used for both immobile and mobilising individuals.
The cast will be labelled LEFT/RIGHT FOOT and heel casts will be labelled
LEG/TOES to ensure correct application.
The cast is re-usable, and can be re-applied when the wound is redressed.

Type of Cast Supplied eg heel cast, slipper cast

Right Foot……………………………………Left foot………………………………
Rationale (delete as appropriate)
The cast has been made to:

1. To reduce pressure, sheering or friction forces affecting an area of

ulceration.
2. To reduce pain, improve comfort, and improve quality of life.
3. To provide pressure relief to reduce the risks of ulceration or to prevent re-
ulceration occurring.
Other (please specify)……………………………………………………………………
………………………………………………………………………………………………

Application Instructions
Under no circumstance should the cast come into direct contact with the skin due
to risks of causing skin damage.
The cast should be applied as follows:
• Undertake skin inspection
• Dress wound according to management plan
• Apply lightweight tubular bandage ideally toe to knee.
• Apply wool bandage, toe to knee.

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 • Apply cast- check the cast is applied to the correct foot and is the right
way up.
• Apply retaining bandage.
• Apply tubular bandage.
• Appropriate footwear if patient is mobilising.
The cast should be kept dry; use of waterproof dressing protectors can facilitate
showering.

Name……………………
………………….Designation…………………………………
Signature…………………………………...Date………………………………………
…..
Developed April 2013, Podiatry Service, Liverpool Community Health. Review date April 2014.
Page 1 0f 2

Patient Surname………………..…………..NHS
Number………..……………………….
Patient Forename…………………………..Date of
Birth……..…………………………..

Special application instructions eg when cast is used in addition to

compression
bandages…………………………………………………………………………………
…
………………………………………………………………………………………………
..
Precautions
Applied correctly there is a small risk of the cast causing further skin damage.
Check skin for any signs of rubbing/ damage before applying bandages and the
cast.
• Ensure sufficient wool bandage is applied to protect skin (if using).
• The cast may not fit properly and may be ineffective if too much wool
bandage is applied.
• Incorrect application of the cast will increase the risks of tissue damage
and wounds.
• The effectiveness of the cast may be reduced if the cast becomes wet
either from excessive wound exudate or from external sources
(showering/ incontinence).
• The casts are NOT washable
• The cast may also become ineffective if there is significant change in the
level of oedema.
• The cast will only give protection to the area covered by the thickest part
of the cast. Other areas of the foot may remain at risk from pressure
damage.

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 • Assess risks for patients with concordance issues
Please remove the cast if:
• It causes pain or discomfort
• You notice deterioration in the wound which you think may be related to
the cast
• You notice any sign of rubbing
• You notice any increase in the swelling of the foot.
• The cast is excessively soiled.
Please state reason if cast is discontinued
………………………………………………………………………………………………
….
………………………………………………………………………………………………
….
………………………………………………………………………………………………
.....
Discontinued by:
Name……………………………………….Designation………………………...……
……Signature…………………………...………Date…………………………………
…………
Please report any problems, as soon as possible to:
Podiatry Service Manager

Name…………………… …………..…….. Designation………………………………

Signature………………………..…….……Date…………………………......…………

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Appendix 3

Materials required for application:

1 roll of 5cm or 7.5cm Soft Cast Casting Tape. Choice of tape size will depend on the size of the lesion.
2 lengths of 5cm stockinette
1 roll of 10cm undercast padding
Soft cast scissors
Shears or padding scissors
Elasticated bandage
Gloves
Aprons

Casting preparation:
The heel lesion must be covered with an
appropriate dressing for the current
conditions of the lesion

Heel cast method

1. Apply 1 layer of 5cm stockinette to 2. Create a slab of soft cast tape 3. Apply the slab over the area of the 4. Immediately apply a wet bandage

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the foot extending from the malleoli
distally to the styloid process. Lay a
sausage made from folded undercast
padding on the dorsum of the foot for
protection during removal. Apply a
second layer of 5cm stockinette.
5. Mould the cast around the malleoli,
across the flexor surface and into the
Achilles tendon. This can be done
with the patient prone or standing.
Ensure the other shoe has been
removed if moulding is done in a
standing position.
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large enough to cover the lesion by
folding a section into 3 to 4 layers
6. Cut the cast along the dorsum of
the ankle and remove from the
patient and remove the undercast
padding.
lesion and secure in place by
wrapping the tape 3 to 4 times
around the ankle ensuring a 50%
overlap on each turn.
7. Mark the cast under the malleoli
and radiating proximal on the Achilles
tendon. Continue the line along the
anterior edge of the heel. Trim along
the cut lines.
with slight tension to hydrate and
assist in good lamination of the cast.
This also ensures the cast is
moulded to the contours of the limb.
After the cast has set the bandage is
removed.
8. Bandage the cast into place using
a suitable secondary dressing such
as Soffban and/or Comfifast. Provide
a temporary sandal and the advice
leaflet.
Appendix 4

Flexible Casting Advice

A flexible cast has been put on your foot.

This cast has been applied to reduce pressure at different points on your foot. Normally the cast is
applied when you have a foot ulcer or areas of very high pressure.

Wearing the cast

For the cast to be most effective you need to wear it whilst you are awake and moving. In some cases
you may be asked to wear the cast during the night especially if you have an ulcer on your heel.

Apply the cast as you have been shown ensuring that you follow the labels on the cast so that it is
worn the correct way.

Do not wear the cast next to your skin; it must be worn over socks or bandages. The cast will rub and
cause sores if worn directly next to your skin.

Examine your feet regularly.

Stop wearing the cast if it causes you pain or discomfort, you notice it rubbing or causing
blisters or sores and contact the podiatrist on the number below.

Cleaning the cast

Do not wash the cast as this will cause it to fall apart. If you need to clean it, wipe it with a damp cloth.

Any problems, questions or concerns please contact your Podiatrist on

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 Appendix 5
Standard Operating Procedure (SOP) for:
Podiatry Service use of Focussed Rigidity Cast/ ‘Softcast’

Version: 1
Effective from : 1 Sept 2012
Review date: 1 Sept 2013
Replaces: No previous documentation

Author: Hazel Whitehead

Role: Podiatrist, Band 7

Authorisation:

Role:
Signature:

Date:
Abbreviations: HCP= healthcare practitioner: cast/softcast = focussed rigidity cast: HPC = health
professions council: CPD = continuing professional development

Purpose and Objective:

To ensure safe and effective use of focussed rigidity casting on the foot for the population served by
Liverpool Community Health.
To enable trained staff to structure decision making when using focussed rigidity casts.
To promote safe, effective and equitable service provision.

1: Podiatry service: Roles & responsibilities

1:1 Ensure Liverpool Community Health podiatry service has a duty of care for
the patient
1:2 Ensure referral to service is complete and appropriate
1:3 Ensure clinician is trained, competent and supported in the use and
development of casting

2: Casting clinician: Roles & responsibilities

2:1 Manditory Holds current professional registration: HPC
2:2 Has attended formal training for use of cast
2:3 Has undertaken peer reviewed competencies for focussed rigidity casting
2:3 Participates in ongoing peer review of casting issues/ case studies/
discussion groups/ reflective log as part of CPD
2:4 Ensures any pre-visit arrangements are confirmed eg special arrangements
for time/double-up required etc
2:5 Undertakes full holistic assessment in line with current guidance
2:6 Ensures consent obtained or issues are addressed in line with current
guidelines
2:7 Completes or reviews any formal risk assessments eg Waterlow/MUST
2:8 Is competent and confident in wound-care provision, including dressing
selection and sharp debridement, if appropriate
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2:9 Undertakes brief assessment of mobility and manual handling needs of
clinician and patient in regards to accessing wound ie does pt need to be
lying in bed/ are two clinicians required, does the patient walk?
2:10 Is aware of manual handling/lifting and other pressure relieving equipment,
aware of pathways to request it
2:11 Understands why the cast is being used and clearly states its purpose in the
patient’s care plan
2:12 Formulates a realistic management plan in collaboration with the patient,
and other care providers

3: Patient selection: these indicators will help aid risk assessing a patient’s suitability for a cast.
Use of a cast, like any equipment or device, presents a risk of injury, but this is to be balanced against the
benefits of its use, within the knowledge base as it currently stands.
Decision to use, or not use, a cast must always be made in conjunction with holistic judgement for the
individual
3:1 Cast is used on the Current practice suggests grade 2-4 pressure ulcers benefit from use of
foot to: reduce cast. Casts are not indicated for Grade 1 PU or sites which have not yet
pressure sheer and ulcerated. These are usually best managed with other methods but are not
friction, reduce excluded if clinical judgement indicates.
trauma to vulnerable Other wounds, such as trauma or diabetic foot ulcers may also benefit from
site, or relieve cast.
symptoms Ulcers on the maleolus often have aetiology other than pressure or trauma
(ie may be best treated as a leg ulcer), so use of cast may be limited use,
but are not excluded if clinically indicated
3:2 * Cast cannot be used to resolve any underlying wound that is inherently
unable to heal due to patient’s poor health or vascular status.
The wounds may continue to deteriorate even with best management.
If use of cast is indicated, ensure close liaison with appropriate care
providers to agree specified aims and expected outcomes
3:3 * When treating patients that have already been declared as palliative or for
conservative management only, make best efforts to confirm this in writing
from the appropriate medic at the earliest opportunity, wherever possible
3:4 * If using cast in patients with ischaemia, casts will not resolve the underlying
condition, but may be used to alleviate symptoms
3:5 If the use of cast will impact more on the patient’s quality of life than the
condition being treated, consider other options
3:6 If making or using a cast will cause the patient undue distress or pain,
consider other options
3:7 If there is any doubt as to the patient’s psychological status which may
cause the use of cast to increase risk, consider other options
3:8 If making, or using, the cast has such inherent manual handling difficulties,
that it cannot be done safely for the clinician or the patient, consider other
options
3:9 If using cast on a patient who is severely contracted, use of other equipment
to aid positioning of the limb and/or patient as a whole, needs to be
considered. If this cannot be achieved, the cast may be of limited use
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3:10 Cast may be used in combination with other pressure relieving/
repositioning, lifting and handling devices, and compression

4: Use of cast: NB these points are NOT a substitute for training. The technique used is following method
described and demonstrated by Louise Stuart – Consultant Podiatrist MCH NHS M’cr. The principle used
is that for ‘total contact casting’.
4:1 Wound-care Undertake a wound assessment.
Sharp debride, if appropriate.
Dress wound in line with wound competencies
4:2 Bandaging Usually goes from base of toes (Metatarsal-phalangeal joints) to knee to
reduce risk of oedema in the leg developing or being impacted upon.
Occasionally this can be reduced to toe/ankle bandaging if required and
appropriate
4:3 Apply lightweight tubular bandage to foot and leg
4:4 Apply sufficient wool bandage to prevent the cast coming into direct contact
with the skin, but not so much that fit of cast is impaired
4:5 Apply tubular bandage over the foot ensuring the area requiring cast is
covered
4:6 Apply cast tape in spiral fashion to area required, then re-enforce as
appropriate, using further ‘Softcast’ or ‘Prima’
4:7 Apply wet bandage over cast to ensure rapid setting and good cohesion of
re-enforced area.
Wait a few minutes until set
4:8 Cut cast down front/side to allow removal.
Trim cast to enable ease of re-application and ensure risk of injury to rest of
the foot is minimised.
Label.
Re-apply and retain with appropriate tape/ bandages
4:9 Recesses Use of a recess may be employed cast to achieve increased offloading of a
particularly vulnerable site or on smaller bony projections where good
conformity may be difficult.
4:10 Each cast must only be used for the patient intended
4:11 Each cast must be applied correctly as indicated by label stating
‘’RIGHT/LEFT’’ and ‘’TOE/LEG’’
4:12 Each cast must be applied correctly as retention regime indicates ie
bandaging regime (see information sheet)
4:13 Initial manufacture of cast will determine which sites are protected.
It will be made to allow repeated use is as effective and efficient as possible.
A cast is made with re-enforcements to affected site/s only. It is not
designed to offer effective protection to other sites

5: Mobility: casts are designed for use in patients with differing mobility needs such as: fully mobile, limited
mobility, rehabilitation needs, full, partial, no weight-bearing, or 24 hrs a day in bed.
The mobility needs of the individual may impact on the manufacture or application of cast and retention
methods
5:1 Full/partial mobile Consider footwear needs, existing footwear may not accommodate
bandaging and cast.
If required, order stock post-op shoes from GP eg ‘’Kerraped’’
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5:2 Notches may be cut into the cast edges to reduce risk to moving
joint/tendon prominences and allow rehabilitation or mobilisation
5:3 A more robust level of retaining bandage/tape may be required to hold cast
in place
5:4 partial/non mobile Ensure liaison with appropriate multi-disciplinary team/ other HCP to
request review for other pressure-relieving equipment eg mattress/ pressure
cushions/ slide sheets/ turning regime.
Ensure any risk to contra-lateral limb from cast is minimised by effective
positioning/ other equipment, this is especially pertinent for very contracted
patients

6: Special dressings
6:1 Compression When using in combination with compression therapy, the casting clinician
must examine and assess the wound prior to compression being applied
6:2 After compression bandaging has been applied, make the cast on the
outside of the compression bandage.
It is good practice for the caster to protect the compression from damage
during removal of cast on 1st fitting. This is achieved by placing a roll of wool
down the front/site where cast will be cut and tubular bandage over
compression, or double layer tubular bandage, this ensures the cast can be
made removable without damaging compression
6:3 The cast then is re-applied outside the compression bandage each time
compression is changed, retained with appropriate bandage and/or tape
6:4 If the dimensions of the limb and foot change significantly, a new cast is
required
6:5 Topical negative The TNP applied as standard, bridge the connector to a site where the
pressure finished cast will not cover, eg dorsum foot/leg.
Bandage over the activated dressing (ie TNP is switched on) tubinette &
wool as standard.
If the pipe/connector not under finished cast, there are no special
precautions.
The cast can be made over the connector and/or pipe in the initial stage if
needed (bearing in mind that does run the risk of damage to the pipe during
cutting of cast on 1st making).
If pipe/connector do have to lie under cast, the problem is that the cast will
mould to this and so the positioning of this may be difficult without making
new cast
6:6 Larval therapy Apply the cast over the larvae and dressing as standard
(maggots)

7: Removal of the cast: The majority of patients tolerate casts well, some to such an extent, it may be
difficult to persuade them to stop using it.
Casts are not intended to be a long term method of pressure relief. As a general rule, alternatives should
be sought post healing.
As with any intervention, there maybe some patients for whom it does not suit
7:1 Remove & contact Patient refusal
Podiatry asap
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7:2 Remove & contact Cast definitely cause of increased in pain or discomfort.
Podiatry asap Cast definitely cause of deterioration of wound.
Injury/ rubbing from the cast on any area of foot.
Increase in swelling of the foot
7:3 The general current practice is ‘ulcer healed plus 4 weeks’. The bandaging
and cast will still need to be removed for skin inspection at least once a
week as minimum.
This can be reduced if:
the skin is of good quality and the underlying cause has been resolved or
reduced to manageable level, and/or if patient/carers request it.
7:4 If underlying causative factors cannot be resolved, some patients may
benefit from prolonged use of cast. This must be decided on clinical risk
basis, consider if:
-other equipment/devices can be used for long term care
-pt and care provider responsible for changing underlying bandages and/or
routinely checking cast is in agreement
-risk of ceasing cast increases risk of potential impact and this is thought to
be greater than ongoing use (this may be difficult to judge and all involved
need to be aware that relapse may occur)
-financial cost of ongoing visits to the pt’s home or clinic can be justified
compared to cost of potential relapse
7:5 If nothing else suitable can be found for long term pressure relief AND
pt/carers have been risk assessed as suitable, then use of ‘’sock system’’
can be instigated, ie pt wears a thick sock/cast/2nd sock on the affected foot

8: Review dates
8:1 After 1st fit Review of a new cast will be by a podiatrist within two weeks except in
exceptional circumstances (eg hospital visits/pt request) to assess if: safe,
suitable and effective.
If no issues arise at this point, the case-load holder podiatrist must ensure
effective liaison with other HCP regarding ongoing reviews.
There may be input from other HCP before this time, if any problems occur
prior to this, contact podiatry immediately for advice.
If unable to resolve any problems, remove cast from wound (do not dispose
of it). A review by cast-competent podiatrist will be arranged as soon as
possible.
8:2 Ongoing reviews The minimum cast check by podiatry is 1mthly intervals for wounds being
actively treated.
Patients for whom ongoing cast use is the only or best option, will require a
minimum check by podiatry 3mthly.

9: Documentation
9:1 Patient information leaflet to be given to patient or carer
9:2 Ensure a HCP information leaflet is available to anyone involved in the
dressings.
It includes the basic application of the cast when redressing, any special
precautions for that individual and a contact telephone number, if advice is
required
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9:3 Ensure electronic records are complete
9:4 Complete written records in line with record keeping policy; ensure details of
cast, with rationale are included.
Include any liaison and written/verbal advice given

10: Trouble shooting

10:1 Wetness Casts are not designed to be washed.
The integrity of cast may be compromised if wet through with
exudate/incontinence, in these circumstances, the cast may need replacing.
For very wet wounds, consideration needs to be taken if frequent casting is
cost-effective
10:2 Bathing/showering Bathing aids such as ‘’Sealtight’’ or ‘’Limbo’’ can be requested from the GP
or purchased from larger chemist stores
10:3 Soiled Casts do not come into direct skin/wound contact, so do not represent a
significant infection risk (think of it in the same way as a patient’s slipper)
but if soiling is offensive, excessive or odorous, the cast needs replacing
10:4 Incorrect use Ensure all parties involved in use/application of cast have been given written
information sheet on its use as a minimum.
Ensure the labelling is clear, and unambiguous.
Ensure any special instructions, which may vary from standard use, are
written on the information sheet.
Consider the need to report incorrect use as a clinical incident (IR1).
Consider the need to report incorrect use to Safeguarding team
10:5 Not responding Ensure the aim for use of cast is realistic (see 2:12, 3:2, 3:3, 3:4)
Ensure correct use (see 10:4)
Ensure dressings appropriate (see 2:12)
Ensure additional equipment correct and being used appropriately (see
3:10, 5:4)
Re-consider underlying aetiology: are pressure/shear/friction or trauma the
significant factors?
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Appendix 6
Competencies framework for use of heel casts
Name………………………….…Role…………………………Mentor..….................................Date…………………..

competency indicators method ksf min. Initial assessment Final assessment

level
Understands competency Aware of trust / professional guidelines. Discuss. Core2 3
required to make and fit cast Demonstrates ability to reflect on own Evidence in 5 2
practice and discuss issues portfolio
constructively

Understand principles of Understands risks/benefits, aware of Discuss Core2 3

casting and how it affects other types of casts and offloading HWB9 2
mobility techniques, aware of footwear issues
Understands how pressure relief fits in
the overall jigsaw of wound
management.
Able to undertake a holistic Understands psychosocial impact of Discuss. Core1 3
assessment and identify using cast. Able to assess if not suitable Evidence in 6 2
suitability for cast. Understand for cast. Able to undertake any pt records HWB
how casting impacts on necessary assessment prior to & post eg ref 6 3
management cast manufacture. Able to identify letters or
relevant people involved in overall forms
management plan
Able to identify issues of Understands how consent may impact Discuss. Core1 3
consent on management. How to overcome Evidence in
barriers such as refusal or those unable portfolio
to consent. Up to date with relevant
consent training

Formulate realistic Able to explain to patient/carers Discuss. Core1 3

management plan in decisions around plan and be clear Evidence in 6 2
partnership with patient/carers about aims, clearly explain pt records 6 3
risks/benefits and alternatives if
appropriate. Ability to compromise if
required
Implement prescribed treatment Demonstrate ability to: Practical HWB6 3
appropriately • prepare equipment needed 7 3
• apply bandaging correctly 9 2
• apply casting tape correctly,
checking for overlap/gaps sharp
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 edges or areas of potential hazard
• ensure re-enforced area correctly
sized, placed, applied
• apply wet bandage correctly and
allow time for setting to occur in
required position;
• remove cast safely
• trim and label correctly
• ensure retained in situ effectively

Knowledge of infection control Up to date with infection control training. Evidence in Core 3 2
issues in relation to combining Demonstrate hand-washing and gel portfolio.
wound-care with casting use, discuss how, which and when to Practical.
techniques use, correct use of PPE and disposal of discuss
waste. Understands when cast needs
replacing
Anticipate areas which may Ensure verbal and written info sheet Discuss. Core 3 2
cause problems, recognise shared with all relevant parties. Ensure Evidence in HWB6 3
actual problems as they arise concordance issues documented and pt records
and indicate ways to resolve discussed with aim to resolve. Ensure
and/or seek advice contact details available to relevant
parties. Recognise if cast not working
for whatever reason
Have knowledge of referral Understands of when and how to refer Discuss. Core1 3
pathways to other services if required, especially Evidence in 5 2
in event of deterioration of limb; pt records
vascular/ orthopaedics/ GP
services/falls team and mobility
assessments/ skin services/ DN/ other
therapies or podiatry services. Ensure
effective communication

Comprehensive, Up to date with recordkeeping training. Evidence in Core1 3

contemporaneous and accurate Recording of a systematic assessment portfolio. 5 2 (3)
record keeping in line with trust process, identification of underlying Evidence in IK1 1
policies. Able to demonstrate factors, clear management plan, assign pt records
sound rationale of aims and roles within any MDT management incl. risk
outcomes plan. Ensure effective written and verbal assess
liaison within that MDT. forms
Give clear guidance on review dates
and roles/responsibilities. Ensure pt
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 held record notes complete, if
appropriate.
Contributes towards the Understands the changes to services discuss Core 4 2
development of services bought about by the use of casting.
Participation in any audit or surveys
required to bring about effective change

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Competencies framework for use of flexible removable casts to the foot/lower limb

Name………………………….…Role…………………………Mentor..….................................Date…………………..

Discussion session to direct ideas, training

learning needs/ areas of good practice/ areas which require more support or evidence
Current level Action plan

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Appendix 7

Audit of clinical outcomes for PCT Podiatry Dept patients who are fitted with pressure relieving casts

Aim

This audit is to assess the clinical effectiveness of different casting techniques fitted by the High Risk
Foot Team Podiatrists for patients presenting with ulceration and/or Charcot foot pathology. In theory,
casts provide pressure relief and support to promote healing, reduce the risk of amputation and
reduce the risk of further foot deformity and is an essential component of NICE Guidelines of care of
the Diabetic Foot.

Method

The High Risk Foot Team completed a spreadsheet to collect the appropriate data of all patients
within NHS TRUST fitted with a cast. This included:

• Referral date and access to service within 1 week from referral

• Number of patients attended and number of patients failed to attend (DNA)
• Referral source
• Presenting condition
• Intervention (type of pressure relief provided)
• Outcomes
• Causes of any worsening of foot condition
• Referrals made post cast

Audit Criteria & Standards

Audit criteria and standards are as follows:

Criterion
1. Access to treatment
2. Outcomes of treatment
3. Causes of worsening
Standards
80% to be seen within 1 week from
referral
70% percent of patients with
resolution or improvement
70% caused by infection or
concordance
30% Cast faults

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Results

Based on all patients fitted with casts:

50 Number of patients fitted with casts

50 Number of patients seen within 1 week from referral
0 Number of patients DNA

0 Number of patients referred by Consultants

47 Number of patients referred by Podiatrists
3 Number of patients referred by GP/Nurses

34 Number of patients with ulcers

11 Number of patients with Charcot foot pathology

1 Patients fitted with Below Knee Cast (BKC)

7 Patients fitted with BKC padded
1 Patients fitted with BKC removable
2 Patients fitted with Slipper Cast
2 Patients fitted with Slipper cast padded
16 Patients fitted with Slipper Cast removable
17 Patients fitted with Slipper cast removable padded
2 Patients fiited with Walker

Outcomes:

22 Condition resolved
9 Condition improved
10 Condition static
5 Condition worse: 2 cast fault, 2 infection, 1 concordance

TOTAL NUMBER OF TREATMENTS INITIATED 2008-09 = 50

TOTAL NUMBER OF OUTCOMES INDICATED 2008-09 = 46

Discussion

All patients (100%) referred to the casting clinic were seen within 1 week from referral. A number of
different casts were provided; all patients presenting with Charcot were initially fitted with a below
knee cast or walker. Patients presenting with ulceration were fitted with various types of off-loading
casts. Outcome indicators revealed the following. 62% of patients resolved or improved with casting.
Of the 10% of patients where there was deterioration, 60% of these were due to infection or
concordance, 40% due to cast fault. Standard 1 (access to service) was met, 2 (outcomes) was 62%
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as opposed to the target of 70%, 3 (causes of worsening) was 60/40 as opposed to the target of
70/30.

Recommendations

As a result of this audit the High Risk Foot Team are recommending the following:

1. To carry out a minimal biomechanical assessment of all patients prior to casting to

identify best type of cast used to optimise outcomes (Standard 2)
2. If wound is static to identify possible causes (eg raised blood
glucose/ischaemia/activity) (Standard 2)
3. If wound deteriorates due to cast fault identify fault to ensure minimal risk of re-
occurrence.

In order for these recommendations to be carried out, further training may be required
(recommendation 1) and the audit updated accordingly (recommendations 2 & 3). In the case of cast
faults further training may be required for staff to develop and/or update their casting skills
(recommendations 3)

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