Cut off excess bandage … Assuming that arterial insufficiency is ruled out, let us look at the types of compression. Compression therapy remains the mainstay of treatment for venous leg ulcers. 1997;26(1):132-7. Short stretch bandages, traditionally, are manufactured of 100% cotton and depend a good degree on the weave of the product to produce the tension and hence compression. Limited Range of motion is a significant factor in venous ulceration. A good working knowledge of compression therapy options is essential to achieve the best outcomes. Nelson EA, Mani R, Vowden K. Intermittent pneumatic compression for treating venous leg ulcers. European Wound Management Association (EWMA) position document. Ostomy Wound Manage. Does the next person applying know how hard he or she is pulling? Above 25cm the pressure exerted by standard bandage systems are somewhat reduced, therefore bandages with a greater degree of elasticity need to be used. Several companies make high compression elastic bandages that have rectangular or square markings along the bandage to ensure a constant tension during application. This creates difficulties for practitioners and purchasers who have to make decisions about which system to use. Application of compression bandages All types of compression … In the UK bandages are applied using a spiral or figure-of-eight technique and run from the base of the toes … They consist of an absorbent core of hydrophilic fibers that are … So patients with impaired arterial circulation are generally safer with inelastic, then short stretch products, when they lie down, as opposed to long stretch, IF compression is safe be applied at all depending on the situation. Abstract. Long stretch would generally provide the most compression when lying down (and the least potential for high working compression when vertical). However, they are unable to sustain consistent compression for prolonged periods of time.23 The inelastic characteristics of these types of bandages do not allow for contouring of the bandage to the leg circumference once the edema has decreased. Sign in or Register a new account to join the discussion. With decreased ankle-brachial indices, less pressure is recommended.16. 1997;12(6):374-83. 1. It is important that practitioners are aware of the requirements for effective and safe application of bandages because of the consequences for the patient of bandages that are not applied correctly. 32. Measurement is simple but essential. Bandaging technique has changed little over the years. World Wide Wounds. Christopoulos D, Nicolaides AN, Cook A, Irvine A, Galloway JM, Wilkinson A. Pathogenesis of venous ulceration in relation to the calf muscle pump function. The first step is to remove any debris or dead tissue from … Clark M. Compression bandages: principles and definitions. Dr. Wu is the Director of the aforementioned CLEAR at the Scholl College of Podiatric Medicine. Leg ulcers arising from venous problems are called venous (or varicose or stasis) ulcers. Plebolymphology. Venous leg ulcers have a high recurrence rate and many clinicians consider compression therapy to be the gold standard in the management of venous ulcerations. An experienced eye will be able to spot the gaps along the bandage that indicate poor alignment, which leads to a loss in the continuity of the pressure gradient and therefore lack of healing. 39. In other words, a “class II” sock may represent 20 to 30 mmHg for one manufacturing company and 30 to 40 mmHg for another. (It is sometimes referred to as a poor man's pump.) Clinicians should place initial orders for compression socks prior to ulcer closure as many insurance companies will not pay for compression hose if no active ulcer exists. 41. 1993;17(2):414-9. 1. One last point. Compression Bandaging: There are short stretch (inelastic) and multilayer long stretch (elastic) options for compression bandaging. Compression bandages or stockings versus no compression for treating venous leg ulcers To assess the effects of using compression bandages or stockings, compared with no compression, on the healing of venous leg ulcers … Wear a compression bandage. [2] For a detailed review of the anatomy of the veins of the lower leg and the causes of ulceration, see Negus 1991. The sub-bandage pressure (see glossary) is measured in mmHg: 8 Type 3a: light … The ability to achieve a reliable effective outcome is a matter of supervised practice associated with an understanding of the principles involved. 1987;295(6610):1382. Chronic venous insufficiency and venous ulceration. 4. 27. J Wound Care. A product that is inelastic applied and just barely snug would apply a low resting compression when vertical, but very little, if any, when lying down. Phlebology. Patients are often tempted to look for cheaper alternatives via mail order or online catalogues. Most will provide doctors’ offices with special order forms to facilitate the process. Patients can launder and reuse many of these bandages. 2003;15(4):107-22. They accommodate the shape of the leg and sustain high pressures during both ambulation and relaxation.5 The table “An Overview Of Compression Products For Venous Ulcers” (above) lists examples of elastic or long stretch bandages. Patients can also reuse and wash these bandages according to the manufacturer recommendations. When clinicians apply a compression bandage to a normally shaped leg, the narrower ankle, when wrapped with the same bandage at the same tension with a consistent 50 percent overlap, will have a higher sub-bandage pressure than the wider thigh. Br J Com Nurs. Ostomy Wound Manage. Your Venous Leg Ulcer Wound Home Skills Kit: Venous Leg Ulcers and Lymphedema | Your Venous Leg Ulcer 4 Venous Leg Ulcers A venous leg ulcer is an open wound between the knee … Br Med J (Clin Res Ed). The Internet Journal of Dermatology. 3. Compression therapy in patients with peripheral arterial occlusive disease: A prospective clinical study with the 3M Coban 2 Layer Lite Compression System for ABPI >/= 0.5. 7. Venous ulcers: pathophysiology and treatment options. 42. 2nd ed. Many insurance agencies will only pay for 30 to 40 mmHg stockings. The wrong compression product can lead to complications from skin necrosis to severe ischemia.1,2 Inappropriate application and lack of consideration for the individual needs of the patient can lead to ineffective therapy and diminished quality of life. One can apply the Unna boot directly over the wound bed or over another primary wound dressing. One should initiate patient education regarding the necessity for compression — both for ulcer treatment and for lifelong maintenance — at the first visit. Fifty per cent overlap is usually recommended. Treating leg ulcers. 11. 1999;135(8):920-6. However, this service seems to be less frequently available. Despite these possible disadvantages, the European Wound Healing Society recommends multi-layer bandages as first line therapy in both mobile and immobile patients.16. The short stretch generally allows for more consistent low resting compression and higher working compression levels (working like a pump when the patient ambulates when properly applied). Your doctor or nurse will give you a compression device to wear over your dressing. 2008(2):CD001899. Br J Surg. The recommended application for inelastic bandages is a spiral wrap from the base of the toes to two fingerbreadths below the patella with a 50 percent overlap, consistent tension and avoidance of wrinkles and folds. Beidler SK DC, Berndt DF, Keagy BA, Rich PB, Marston WA. They depend upon a higher working compression to reduce/control edema. Approach to leg edema of unclear etiology. Application. Once venous ulcers heal, one needs to consider the use of maintenance therapy to prevent recurrence. Dr. Wu is also an Associate Professor in the Surgery Department and the Associate Dean of Research at the aforementioned Scholl College of Podiatric Medicine. These venous pumps have preset and prescribed graduated intermittent compression. Cochrane Database Syst Rev. J District Nursing. The guidelines available in the UK state that a competent practitioner should apply the bandages (RCN Institute, 1997; NHS Centre for Reviews and Dissemination, 1997) (Box 1). Ostomy Wound Manage. Kunimoto B, Cooling M, Gulliver W, Houghton P, Orsted H, Sibbald RG. Care needs to be taken when applying compression bandages because an even pressure gradient is required along the length of the bandage between the ankle and the knee. Having a clinic assortment of application aids can help determine which would be most helpful. Stacey et al (2002) see ultrasonography and plethysmography as fundamental methods of assessing the state of the arterial and venous systems of the lower leg. 5. Apply graduated compression bandaging: The key to healing a venous leg ulcer is to treat the underlying cause (i.e. The stretch allows for better functionality over joints. There have been a number of reviews of compression bandaging systems (NHS Centre for Reviews and Dissemination, 1997; Cullum et al, 2001; Eagle, 2001). Hafner J, Botonakis I, Burg G. A comparison of multilayer bandage systems during rest, exercise, and over 2 days of wear time. Angiology. 40. I don't believe inelastic products are historically considered to be products with 30 to 70% stretch. Labels such as mild, moderate, firm and strong may also represent different strengths between companies. Collaboration with the patient’s medical team and ensuring a thorough cardiopulmonary assessment prior to initiation are important to ensure cardiac stability and avoid decompensation from an increased preload.34. However, one must encourage patients to be cautious regarding these entities as compression gradients may not be validated or even specified, there may be fewer options in size available, and the quality of the material may not be as durable. Venous Disease is associated with an impaired range of ankle movement. 1. An adequate pressure and stiffness is needed in order for the treatment to be successful. Podiatrists frequently encounter venous ulcerations and chronic venous insufficiency in the clinical setting. The standard of care for management includes graduated compression therapy. Retrieved from http://www.worldwidewounds.com/2001/march/Vowden/Doppler-assessment-and… on December 1, 2011. With all compression bandage systems, padding using orthopaedic wool is used to redistribute pressure from bony prominences and to help provide even distribution of pressure under the compression bandages where the shape of the leg may militate against even graduated pressure. However, treatment evolves and changes. 13. As a clinical example, in a chair-bound nursing home resident, a truly inelastic product that is properly applied might apply very little resting compression (or if too tight could be a tourniquet). MEP Ltd., London, 2003:2-4. Short stretch would apply more resting compression than inelastic when lying down. Given the relatively common incidence of venous insufficiency and the high likelihood of recurrence with venous leg ulcers, these authors offer a thorough review of the literature and share their insights on compression modalities ranging from inelastic (short stretch) bandages to intermittent pneumatic compression therapy. Ostomy Wound Manage. 1994;20(6):872-7; discussion 8-9. Referral criteria for problematic leg ulcers includes allergy, inability to tolerate compression, uncontrolled pain, no reduction in ulcer size in one month, ulcer duration greater than six months, cellulitis unresponsive to treatment and frequent recurrence (Stacey et al, 2002; RCN Institute, 1998). 37. 4. Ms. Rivera is an instructor at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science in Chicago. 2001;47(2):34-46, 8-50. J Vasc Surg. Cullum N, Nelson EA, Fletcher AW, Sheldon TA. Nicolaides AN, Hussein MK, Szendro G, Christopoulos D, Vasdekis S, Clarke H. The relation of venous ulceration with ambulatory venous pressure measurements. Sieggreen MY, Kline RA. These stockings are made for patients who are non-ambulatory, non-mobile or bedridden to prevent venous thrombus. This can be done by bandaging, compression hosiery (socks, stockings or tights) … Bandages are applied … A new app, developed by Abbott’s UK-based nutrition business, has already seen…, Please remember that the submission of any material is governed by our, EMAP Publishing Limited Company number 7880758 (England & Wales) Registered address: 7th Floor, Vantage London, Great West Road, Brentford, United Kingdom, TW8 9AG, We use cookies to personalize and improve your experience on our site. Bandage technology has developed somewhat since compression was first used. A Guide To Compression Dressings For Venous Ulcers, http://www.worldwidewounds.com/2001/march/Vowden/Doppler-assessment-and…, COVID-19 Coagulopathy and Limb Salvage: What You Should Know, Key Considerations With Primary Repair Of Osteochondral Lesions, An Essential Guide To Treating Cavus Foot Deformities, Midfoot Fusions: How To Address The Complications, When An Elderly Patient Presents With Blistering Skin Lesions On His Feet And Legs, Keys To Deltoid Ligament Repair After Ankle Fracture, Protocols for the Prevention and Treatment of Pressure Injuries: Sustaining Outcomes at the Point of Care, Modern Techniques to Manage Infected Wounds in the Diabetic Patient: Integrating Advanced Technologies to Optimize Healing, Biologically Clearing the Barriers to Wound Healing: Changing the Wound Healing Environment through Debridement, Foot and Ankle Surgery: Building Blocks for Success. Capillary‐action dressings. 1997. This is due to the development of elastomers which enable bandages to be designed for specific performance, giving accurate sub-bandage pressures. ACE wraps are intended for short-term use, not for the treatment of chronic venous insufficiency. Full leg. Some bandages have a line running along the middle of the bandage to guide the practitioner’s hand. In other countries other patterns of application may be used. Additionally, several studies have shown that compression bandages may restrict ankle range of motion and gait capacity.21,31 This may place the patient at an increased fall risk and further decrease calf pump function. Addition of the elastic outer layer also creates a bandage with a more consistent working pressure and a higher resting pressure.23 Often, it is necessary to apply a middle layer of gauze or cast padding to absorb wound drainage. Anti-embolic stockings are not appropriate for treating chronic venous disease. This can be overcome by noting their presence and adding padding as appropriate to reduce pressure. 24. If a product with less than 15% stretch, as an example, is applied, there are several issues. Int Wound J. Stacey et al (2002) define compression bandages as follows: - Sustained compression - this includes any bandage system that can maintain sub-bandage pressures for a least one week; - Multi-layered (elastic) compression - this group includes bandages with more than 50% stretch; - Multi-layered (inelastic) compression - this group includes bandages with less than 50% stretch; - Reduced compression - this group contains systems that deliver 15-25 mmHg sub-bandage pressure for patients with narrow ankles or an ankle brachial pressure index (ABPI) between 0.8 and 0.5; - Compression stockings - primarily used for prevention of recurrence or in the care of varicose veins; - Intermittent pneumatic compression - systems capable of delivering high compression for short periods of time. Compounding this situation are the realities that comorbidities of musculoskeletal problems, neurological problems, fragility and lack of significant other assistance also increase with age.5 Although assistive donning devices are available, they are generally not covered by insurance carriers. 26. 21. It usually consists of measuring the lower leg length and calf and ankle circumference. Products with this amount of stretch don't work terribly well over joints, such as the anterior ankle, and this can cause ulcerations. There is a degree of paperwork (including a letter of necessity) involved. Coban 2 compression bandage system (3M) is a multilayer compression bandage for treating venous leg ulcers. The effect of compression bandaging can be summarised by La Place’s law (Box 2), which demonstrates the relationship between the pressure exerted on the leg and the parameters involved in creating that pressure (Moffatt and Harper, 1997). Khachemoune A KC. 2007;94(9):1104-7. When discussing bandaging in association with leg ulcers we generally mean venous ulcers that are primarily caused by problems associated with deep vein thrombosis and varicose veins, both of which lead to chronic venous insufficiency, this in turn leading to ulceration. In order to help simplify the problems associated with assessment, diagnosis and treatments an expert panel recently devised an algorithm or management pathway for leg ulcers (Stacey et al, 2002). 2009;49(4):1013-20. 33. Araki CT, Back TL, Padberg FT, Thompson PN, Jamil Z, Lee BC, Duran WN, Hobson RW, 2nd. 1995;22(5):519-23. A bandage with too high an elasticity will also provide a high resting pressure that may vary along the length of the leg. Venous insufficiency is very common and is the most likely cause of lower extremity edema.38 However, it is imperative to consider other causes of edema, especially in a population with multiple significant comorbidities.39,40 Prior to initiating compression therapy, one must ensure adequate arterial circulation. Continued reinforcement at every visit is essential. While there are a myriad of compression alternatives available on the market, there is not a one-size-fits-all answer when choosing the type of product to use. 1999;86(8):992-1004. This bandage type is recommended for patients who are immobile, have a fixed ankle joint or an inadequate calf pump.16 They are not intended for use in patients with arterial insufficiency. Principles of best practice: Compression in venous leg ulcers. The main treatment is the application of a firm compression garment (bandage … Compression bandages are useful if there are active ulcers as once the wound is cleaned and dressed the bandage can be easily wrapped around the leg from the toes to the calf. Moffatt C, Kommala D, Dourdin N, Choe Y. Venous leg ulcers: patient concordance with compression therapy and its impact on healing and prevention of recurrence. Venous ulcer prevalence increases with age. Risk factors associated with the failure of a venous leg ulcer to heal. Agu O, Hamilton G, Baker D. Graduated compression stockings in the prevention of venous thromboembolism. The cornerstone of venous leg ulcer treatment is compression therapy, which increases venous return and reduces venous hypertension.1 However, dressings are important because they can provide symptom control and optimise the local wound environment to promote healing. In: Understanding Compression Therapy. 2005;56(1):19-23. In order to achieve this even tension has to be applied to the bandage while it is being applied. European Wound Management Association (EWMA) position document. 2. 2011:8;1-8. A short stretch product with elastic fibers would apply some sustained resting compression with the potential for higher working compression when properly applied. Compression for venous leg ulcers. Addressing this issue at the initiation of therapy will assist with maintaining a safe environment for the patient. By starting at the base of the toes there is less chance of the bandage trapping interstitial fluid produced by normal systemic hydrostatic and osmotic pressure. If, however, a product with short (limited or low) stretch AND elastic fibers was used, the compression would not fall off as quickly and the performance would be hybridized with other elastic compression garments. Typically to protect the skin, clinicians use a layer of tube gauze or stockinette over the primary wound dressing. Franks PJ. World Wide Wounds. Clinicians may employ compression stockings for the treatment of smaller ulcers with manageable drainage instead of multi-layer bandages. Graduated compression bandages apply pressure to the lower leg to improve the blood flow back to the heart. Br J Nurs. This is because the high elasticity will allow the bandage to flex excessively with each leg movement rather than support the calf pump. 20. J Am Board Fam Med. Conversely, if a patient had poor arterial circulation, the provider may opt to apply a product that is "inelastic" with very little tension applied because a lower resting compression has a lower potential to block arterial circulation, but still has the potential to provide a higher working compression to help reduce/control edema. Margolis DJ, Knauss J, Bilker W. Medical conditions associated with venous leg ulcers. Clinicians may employ short stretch bandages to decrease edema. Helping the Ulcer Heal Walk regularly to help your leg ulcer heal more quickly. Back TL PF, Araki CT, Thompson PN, Hbson RW. The inelastic or short stretch bandages have limited absorptive qualities and may not be optimal in wounds with heavy or excessive drainage. Replace these bandages every few months. Customized fit stockings may be necessary for some patients. 36. The measurement of ankle circumference is vital to safe compression bandaging. The product can shrink some if the leg decreases in size, limiting slippage and the need for adjustments. Slip-on inelastic devices with adjustable Velcro straps are also options. It is important to note that greater elasticity does not always equate to better efficacy. 2004;22(4):181-9. 3. Alpagut U, Dayioglu E. Importance and advantages of intermittent external pneumatic compression therapy in venous stasis ulceration.