System and methods for applying a total contact and offloading cast

Some implementations of the described invention relate to systems and methods for applying a total contact cast to a patient for treatment of a wound on an appendage, such as a leg or foot. While the cast system can comprise any suitable component, in some cases, it includes a clam-shell cast, a foot support defining (or customizable to define) an offloading hole, and a cast underlayment (such as a compression sock, a padding sock, and/or additional padding). In some implementations, a first length of the clam-shell cast is applied to a patient's calf, a second length of the cast is applied to across a patient's foot, and a third length is folded up over the patient's foot to extend up a portion of the patient's calf. In some cases, a strap or wing is used to attach the first and the third lengths together. Other implementations are also described.